Every finding on record at Hosanna's Home Health Agency, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/26/24. No deficiencies cited.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 09/26/24. Standard level deficiencies cited. Abbreviations: POC=Plan of Care SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined in 2 of 7 (Pts. #2 and 4) clinical records reviewed, the Agency failed to ensure staff provided services as ordered by the Physician and/or indicated on the POC. 2. Pt. #4 was admitted to the Home Health Services on 04/13/24 with the diagnoses of: Weakness. The clinical record was reviewed on 09/24/24. The clinical record contained POC orders dated 03/25/24, that required PT and OT visits 2-3 times a week for 4-6 weeks . The OT failed to visit 04/15/24 and 04/17/24. The PT failed to visit on 06/10/24 and 06/12/24. 3. The findings were confirmed during the interview with the Administrator, designated Administrator and Clinical Manager/Director of Nursing, on 09/25/24 between 10:30 AM and 12:00 PM. Findings include: 1. Pt. #.2 Was admitted to Home Health Services on 09/05/19 with the diagnosis of Weakness. The clinical record was reviewed on 09/23/24. The record included the POC for the certification period of 08/14/24 to 10/12/24 required, "Skilled Nursing 1-2Xwk”. The record lacked documentation the SN provided service during the weeks of 08/25/24 to 08/31/24 and 09/01/24 to 09/07/24.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview it was determined in 1 of 7 (Pt. #1) clinical records reviewed, the Agency failed to include all orders in the plan of care. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 09/28/16 with the diagnosis of heart failure. The clinical record was reviewed on 09/23/24. The clinical record included an SN visit note dated 07/24/24 with a list of medications written on the back. During an interview with the Clinical Manager/Director of Nursing on 09/25/24 at 10:45 AM, she stated the updated list was from the hospital visit, and she called the patient's physician to confirm the medications. The clinical record lacked documentation of updated medication orders. 2. The findings were confirmed during the interview with the Administrator, designated Administrator and Clinical Manager/Director of Nursing, on 09/25/24 between 10:30 AM and 12:00 PM.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness Plan and policies biannually. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:00 PM. The Plan lacked the date it was developed and/or initiated, reviewed and updated. As of 8/16/21, the Agency lacked any documentation, indicating the Agency had reviewed and revised the Plan every 2 years. 2. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the above finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan was based on a risk assessment. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:00 PM. The Plan contained a form titled, "Hazard Vulnerability Assessment" which was left blank. As of 8/16/21, the Agency lacked documentation its Emergency Plan was developed from a facility and community-based, all-hazards approach risk assessment. 2. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the Emergency Preparedness Plan lacked a risk assessment.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to include volunteers in its Emergency Plan, and establish a policy for the use of volunteers. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:00 PM. The Plan lacked the names and contact information of volunteers, and a policy regarding the duties and responsibilities of volunteers. 2. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the Emergency Preparedness Plan lacked any volunteers and a policy for the use of volunteers.

Development of Communication Plan CFR(s): 484.102(c) (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its communication plan and policies biannually. This has the potential to affect all Pts. who receive service from the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:00 PM, and contained a communication plan. The communication plan lacked the date the Agency last reviewed and updated the plan. As of 8/16/21, the Agency lacked any documentation, indicating the Agency had reviewed and revised the communication plan every 2 years. 2. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the Agency failed to review and update its communication plan and policies biannually.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, staff Inservice folder and staff interview, it was determined the Agency failed to conduct Emergency Preparedness testing exercises biannually. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:00 PM. The Plan lacked documentation the Agency conducted any testing of its Emergency Preparedness Plan after 2018. 2. The Agency's staff "Inservice" folder for 2019, 2020 and 2021 was reviewed on 8/17/21 at 10:05 AM. The binder and folder lacked documentation the Agency conducted any testing exercises. 3. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the Agency failed to conduct Emergency Preparedness testing exercises biannually.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 8/19/21. Standard level deficiencies written. Abbreviations: / = per & = and x = times wk = week # = number AM = morning s/p = status post SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients LPN = Licensed Practical Nurse PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist COVID-19 = Coronavirus disease 2019 HHA/HHAs = Home Health Agency/Agencys CDC = Centers for Disease Control and Prevention CMS = Centers For Medicare & Medicaid Services

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the RN complete a comprehensive assessment at the SOC. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 8/16/21 at 11:30 AM to 8/17/21 at 1:00 PM, and lacked a SOC comprehensive assessment. Pt. #1. SOC 6/25/20. Pt. #2. SOC 12/24/15. Pt. #3. SOC 9/28/16. Pt. #4. SOC 9/5/19 Pt. #5. SOC 7/17/21. Pt. #6. SOC 3/24/20. Pt. #7. SOC 1/31/20. 2. The Agency's policy titled, "Comprehensive Client Assessment" was reviewed on 8/18/21 at 9:10 AM. The policy required: "A thorough, well-organized, comprehensive and accurate assessment, consistent with the clients immediate needs will be completed in a timely manner..." 3. During the entrance interview with the Backup Administrator and DON on 8/16/21 at 10:00 AM, the DON stated the RN conducts the SOC visit. 4. During an interview with the Backup Administrator and DON (Administrative Staff) on 8/17/21 at 1:30 PM and 8/18/21 at 9:30 AM, the DON confirmed the Agency lacked a comprehensive assessment form, and the RN failed to complete a comprehensive assessment during the SOC.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the RN complete a comprehensive assessment, within the last 5 days of the 60-Day certification period. This was found in 6 of 6 (Pts. #1, 2, 3, 4, 6 and 7) clinical records reviewed, wherein service was provided after the initial 60-Day certification period. Findings include: 1. The following clinical records were reviewed from 8/16/21 at 11:30 AM to 8/17/21 at 1:00 PM, and lacked documentation a comprehensive assessment was completed after the initial 60-Day episode. Pt. #1. SOC 6/25/20. SN service provided after the initial 60-Day episode. Pt. #2. SOC 12/24/15. Home Health Aide services provided after the initial 60-Day episode. Pt. #3. SOC 9/28/16. PT and OT services provided after the initial 60-Day episode. Pt. #4. SOC 9/5/19. SN services provided after the initial 60-Day episode. Pt. #6. SOC 3/24/20. SN services provided after the initial 60-Day episode. Pt. #7. SOC 1/31/20. SN, PT and OT services provided after the initial 60-Day episode. 2. The Agency's policy titled, "Comprehensive Client Assessment" was reviewed on 8/18/21 at 9:10 AM. The policy required: "A thorough, well-organized, comprehensive and accurate assessment, consistent with the clients immediate needs will be completed in a timely manner..." 3. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM and 8/18/21 at 9:30 AM, the DON confirmed the Agency lacked a form to update and revise the comprehensive assessment, and failed to ensure the RN completed a comprehensive assessment within the last 5 days of the 60-Day certification period.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service/treatment as ordered by the Physician, and indicated in the POC. This was found in 4 of 7 (Pts. #3, 4, 5 and 6) clinical records reviewed. Findings include: 1. Pt. #3. SOC 9/26/16. Primary Diagnosis: Right Foot Drop Secondary to L5 Radiculopathy. The clinical record was reviewed on 8/16/21 at 3:00 PM. The record contained the revised POC dated 7/20/21 requiring: "Home PT... 2x/week for 6 weeks". The PT evaluation was dated 7/23/21. The record lacked documentation the PT provided any service during the week of 8/1/21 to 8/7/21. The same POC dated 7/20/21 required: "Home OT for home safety evaluation... 2x/week for 6 weeks". As of 8/16/21, the record lacked any documentation the OT evaluated the Pt. 2. Pt. #4. SOC 9/5/19. Primary Diagnosis: Heart Failure. The clinical record was reviewed on 8/17/21 at 9:30 AM. The record contained POC effective 7/27/21 requiring: "Skilled Nursing Orders... Assess systems..." The SN visit note dated 7/30/21 lacked documentation the SN assessed the patient's blood pressure, respirations, pulse and temperature. 3. Pt. #5. SOC 7/17/21. Diagnosis: s/p Right Knee Total Knee Arthroplasty and Presence of Other Specified Devices. The clinical record was reviewed on 8/17/21 at 10:15 AM. The record contained the POC effective 7/15/21 requiring: "12 Physical Therapy visits..." The PT evaluation dated 7/15/21 required the PT to provide: "Frequency 2x/ week for 6 weeks". The record lacked documentation the PT provided a second visit during the week of 8/1/21 to 8/7/21. 4. Pt. #6. SOC 3/24/20. Diagnoses: Weakness. The clinical record was reviewed on 8/17/21 at 10:50 AM. The record contained the POC for the certification period of 5/15/21 to 7/13/21 which included, an addendum dated 6/7/21 requiring: "PT... 1-2x/ week for 6 weeks. The PT evaluation dated 6/9/21 required the Pt. to provide service "2wk6". As of 8/17/21, the record lacked documentation the PT provided any service after 7/10/21. 5. During an interview with the Backup Administrator and DON on 8/17/21 at 1:50 PM, the Administrative Staff confirmed the SN and PT failed to provide service/treatment as ordered by the Physician, and indicated in the POC.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: 4. Pt. #3. SOC 9/26/16. Primary Diagnosis: Right Foot Drop Secondary to L5 Radiculopathy. The clinical record was reviewed on 8/16/21 at 3:00 PM. As of 8/16/21, the record lacked documentation that staff screened the Pt. for the Pneumococcal Pneumonia vaccine during or after the SOC, and whether the Influenza vaccine was arranged or administered after 2016. 5. Pt. #4. SOC 9/5/19. Primary Diagnosis: Heart Failure. The clinical record was reviewed on 8/17/21 at 9:30 AM. The record contained the undated "Influenza / Pneumonia Vaccine Consent" form completed by the SN and signed by the Pt. The form included the question: "Are you interested in receiving the Influenza... Pneumonia Vaccine?" The Pt. responded "Yes" for both vaccines. The record lacked documentation the Agency referred or arranged for Pt. #4 to receive the vaccines in 2019 or 2020. 6. The Agency policy titled, "Vaccinations" was reviewed on 8/18/21 at 10:40 AM. The policy required: "...Agency shall annually administer or arrange for administration of a vaccination against Influenza and Pneumococcal Pneumonia to each client/patient... 6) The following shall be considered to be documentation approaches. A. Individual client/patient record entries identifying the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow-up activities. B. Standardized check-off form recording client/patient specific information, including the assessment for the need of vaccination..." 7. During the entrance interview with the Backup Administrator and DON on 8/16/21 at 10:00 AM, the DON stated during the SOC visit the SN inquire whether the Pt. had, need or decline the Influenza and Pneumococcal Pneumonia vaccines. This information is documented on a vaccine form contained in the clinical record. The DON also stated the Agency does not administer the Influenza and Pneumococcal Pneumonia vaccines. 8. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM and 8/18/21 at 9:30 AM, the DON confirmed the SN failed to assess and/or document the patient's Influenza and/or Pneumococcal Pneumonia vaccine status, as required by the Agency. . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure immunization screening status was updated, documented and the Agency referred or arranged for vaccine administration. This was found in 5 of 7 (Pts. #1, 2, 7, 3 and 4) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/25/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 8/16/21 at 11:31 AM. The record included the Influenza/Pneumonia consent dated 6/25/20, where the Pt. answered interested in receiving both vaccines. As of 8/19/21, the record lacked documentation the vaccines were administered or arranged for the Pt. 2. Pt. #2. SOC 12/24/15. Primary Diagnosis: Age-Related Cognitive Decline. The clinical record was reviewed on 8/16/21 at 2:30 PM. The record included the Pt. Influenza Vaccine Consent/Declination form dated 12/24/15. As of 8/19/21, the record lacked documentation the Pneumonia vaccine was offered, arranged or administered, and whether the Influenza vaccine was administered or arranged for the Pt. after 2015. 3. Pt. #7. SOC 1/31/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/17/219 at 1:00 PM. The record included the Influenza/Pneumonia consent dated 1/31/20, where the Pt. answered interested in receiving both vaccines. As of 8/19/21, the record lacked documentation the vaccines were administered or arranged for the Pt.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, Infection Control program and staff interview, it was determined the Agency failed to ensure staff screened Pts. for COVID-19, prior to providing Pt. care and service. This was found in 5 of 7 (Pts. #3, 4, 5, 6 and 2) clinical records reviewed. Findings include: 1. Pt. #3. SOC 9/26/16. Primary Diagnosis: Right Foot Drop Secondary to L5 Radiculopathy. The clinical record was reviewed on 8/16/21 at 3:00 PM. The record contained the PT evaluation dated 7/23/21, and PT visit notes dated 7/24/21, 7/27/21 and 7/29/21 which lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to providing care and/or service, as required by the Agency. 2. Pt. #4. SOC 9/5/19. Primary Diagnosis: Heart Failure. The clinical record was reviewed on 8/17/21 at 9:30 AM. The record contained the SN visit notes dated: 6/23/21, 6/30/21, 7/7/21, 7/14/21, 7/20/21, 7/28/21 which lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing care and/or service. 3. Pt. #5. SOC 7/17/21. Diagnosis: s/p Right Knee Total Knee Arthroplasty and Presence of Other Specified Devices. The clinical record was reviewed on 8/17/21 at 10:15 AM. The record contained the PT evaluation dated 7/15/21 and PT visit notes dated 7/17/21, 7/22/21, 7/24/21, 7/29/21, 7/30/21 and 8/5/21. These visit notes lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to providing care and/or service. 4. Pt. #6. SOC 3/24/20. Primary Diagnosis: Weakness. The clinical record was reviewed on 8/17/21 at 10:50 AM. The record contained the PT visit notes dated 6/23/21, 6/30/21, 7/8/21 and 7/10/21. These visit notes lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to providing care and/or service. 5. Pt. #2. SOC 12/24/15. Primary Diagnosis: Age-Related Cognitive Decline. The clinical record was reviewed on 8/16/21 at 2:30 PM. The record included documentation the Home Health Aide provided services 5 days a week from 5/13/21 to 8/19/21. The record lacked documentation that the Pt. was screened for COVID-19, prior to the visits indicated above. 6. The Agency's "Infection Control" program was reviewed on 8/16/21 at 12:19 PM, and contained the CMS memorandum: "QSO-20-18-HHA" dated 3/10/20 which included, "...Subject: Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)... "How should HHAs screen patients for COVID-19" When making a home visit, HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following: 1. International travel... 2. Signs or symptoms of a respiratory infection... 3. In the last 14 days, has had contact with someone with or under investigation for COVID-19... 4. Residing in a community where community-based spread of COVID-19 is occurring..." 7. During an interview with the DON on 8/16/21 at 12:15 PM, the DON stated staff are required to screen Pts. for COVID-19. "Staff call the morning... or day before the visit, and ask the COVID screening questions... this information is added to the visit note or the questionnaire in the (patient's) record." 8. During an interview with the Backup Administrator and DON on 8/17/21 at 1:50 PM and 8/18/21 at 9:30 AM, the Administrative Staff confirmed the field staff failed to screen Pts. for COVID-19, prior to providing Pt. care and service.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Infection Control program and staff interview, it was determined the Agency failed to establish an Infection Surveillance Program for the Pts. and staff relative to COVID-19. This has the potential to affect all Pts. that receive services by the Agency. Findings include: 1. On 8/16/21 at 10:00 AM, a request was made to review the Agency's infection surveillance plan and policies. A binder labeled, "Infection Control" was presented and reviewed on 8/16/21 at 12:19 PM. The Agency's "Infection Control" program lacked a plan and policy pertaining to surveillance of Pts. and staff exposed or confirmed with COVID-19. 2. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM, the Administrative Staff confirmed the Agency lacked an Infection Surveillance Program, for persons under investigation for COVID-19.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the RN supervised the LPN. This was found in 4 of 4 (Pts. #1, 7, 4 and 6) clinical records reviewed, wherein the LPN primarily provided the SN services. Findings include: 1. Pt. #1. SOC 6/25/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 8/16/21 at 11:31 AM. The record included the LPN visit notes for services provided 2 times a week from 6/17/21 to 8/15/21. As of 8/19/21, the record lacked documentation the RN conducted any LPN supervision between 6/17/21 to 8/19/21. 2. Pt. #7. SOC 1/31/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 8/17/21 at 1:00 PM. The record included the LPN visit notes for services provided 1-2 times a week from 7/14/21 to 8/17/21. As of 8/19/21, the record lacked documentation the RN conducted any LPN supervision between 7/14/21 to 8/17/21. 3. Pt. #4. SOC 9/5/19. Primary Diagnosis: Heart Failure. The clinical record was reviewed on 8/17/21 at 9:30 AM. The record contained the LPN visit notes for June 2021 (2 times a week from 6/4/21 to 6/30/21), and July 2021 LPN visit notes (2 times a week from 7/2/21 to 7/30/21). As of 8/17/21, the record lacked documentation the RN supervised the LPN in June and July of 2021. 4. Pt. #6. SOC 3/24/20. Primary Diagnosis: Weakness. The clinical record was reviewed on 8/17/21 at 10:50 AM. The record contained the LPN visit notes for June 2021 (2 times a week from 6/9/21 to 6/30/21), and July 2021 LPN visit notes (2 times a week from 7/2/21 to 7/30/21). As of 8/17/21, the record lacked documentation the RN supervised the LPN in June and July of 2021. 5. During an interview with the DON on 8/18/21 at 10:05 AM, the DON stated the RN is required to supervise the LPN "monthly", and documentation of the supervision is entered into the clinical record. 6. During an interview with the Backup Administrator and DON on 8/17/21 at 1:30 PM and 8/18/21 at 9:30 AM, the DON confirmed the above findings.