Every finding on record at In Home Healthcare, Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 4, 2022 through April 7, 2022. Representing the Department: Surveyors: 35183 and 44841 Census: 31 Unduplicated Admissions: 73 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(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: Based on interview and record review, the agency failed to review and update its Emergency Plan annually, for 15 of 15 months reviewed, in a universe of 31 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the Governing Body (GB) meeting minutes from January 2019 to April 6, 2022, was conducted. There was no documented evidence to show the Emergency Plan had been reviewed and updated. During an interview with the Administrator (Admin) on April 6, 2022, at 11:57 AM, the Admin stated she was a member of the GB and responsible for the agency’s Emergency Preparedness Program. The Admin stated she did not have documentation to show the Emergency Preparedness Plan had been reviewed and updated by the GB. A review of the agency’s policy and procedure titled “Emergency Operations Plan and Policies,” dated January 2020, indicated, “The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least every two years.”

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for 15 of 15 months reviewed, in a universe of 31 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to inform emergency management services about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s policy and procedure titled “Emergency Operations Plan and Policies,” dated January 2020 was conducted. There was no documented evidence to show a policy and procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the Emergency Management Binder dated 2020 to 2022 was conducted. There was no documented evidence to show a method to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 15-month time period reviewed. During an interview with the Administrator (Admin) on April 6, 2022, at 2:35 PM the Admin stated she was responsible for the agency’s Emergency Preparedness Program. The Admin stated she had not developed a policy and procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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 facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for 15 of 15 months reviewed, in a universe of 31 patients. This failure had the potential to place the agency’s patients at risk when the agency did not implement a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications failure. A review of the agency’s policy and procedure titled “Communication Plan and Policy for Emergency Operations Plan (EOP),” dated February 2021 indicated the following: “Procedure: … Primary and alternate means for communicating with Agency’s staff, federal, state, tribal, regional and local emergency management agencies: During an emergency, staff will primarily communicate by telephone or cellular phone. When no internal or external means of communication exists, available staff should report to the command structure at the Agency as soon as feasible for assignment. … If telephone and cellular telephones cannot be used, alternate means of communication may include: …Amateur Radio Operators (HAM Radio) Systems, satellite telephone, … and in-person coordination with applicable emergency management agencies by the Administrator or Director of Clinical Services.” A review of the Emergency Management Binder dated 2020 to 2022 was conducted. There was no documented evidence to show the agency implemented their alternate means of communication with federal, state, tribal, regional and local emergency management agencies. There was no documented evidence to show an agency staff person had taken a HAM Radio in-service and received the HAM Radio codes from an emergency management office. There was no documented evidence to show a contract for a satellite telephone service. During an interview with the Administrator (Admin) on April 6, 2022, at 2:55 PM the Admin stated she was responsible for the agency’s Emergency Preparedness Program. The Admin stated she did not have documentation to show an alternate means of communication with emergency management agencies had been implemented.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide training to all staff, as well as contracted staff, on the agency’s Emergency Preparedness Program, for 15 of 15 months reviewed, in a universe of 31 patients. This failure had the potential to place the agency’s patients at risk when the agency’s staff, as well as contracted staff were not trained on what to do during an emergency or disaster. During an interview with a Certified Home Health Aide (CHHA 1) on April 5, 2022, at 10 AM, CHHA 1 stated she did not remember receiving an in service on the agency’s Emergency Preparedness Plan. During an interview with a Physical Therapy Assistant (PTA 1) on April 5, 2022, at 3:15 PM, PTA 1 stated he remembered being told to call the agency and let them know he was safe. PTA 1 stated he did not know how to contact the agency if the telephone lines and cellular phone towers were down. A review of the agency’s in-service binder from January 2020 to April 6, 2022, was conducted. There was no documented evidence to show a training on the agency’s Emergency Preparedness Plan had been offered or attended. During an interview with the Administrator (Admin) on April 6, 2022, at 3:40 PM the Admin stated she was responsible for the agency’s Emergency Preparedness Program. The Admin stated she did not have documentation to show an in-service on the agency’s Emergency Preparedness Plan had been provided to all staff including contracted staff. A review of the agency’s policy and procedure titled “Emergency Operations Plan (EOP) Training Program,” dated February 2021 indicated the following: “Policy: The Agency will ensure that all staff are appropriately trained regarding their roles in the EOP. Training will be documented. Procedure: 1. The Agency has developed and maintains as emergency preparedness training program that is based on the EOP, risk assessment, policies and procedures and the communication plan. 2. … 3. The Agency will do the following: Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers, (if applicable) consistent with their expected roles.”

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 4, 2022 through April 7, 2022. Representing the Department: Surveyors: 35183 and 44841 Census: 31 Unduplicated Admissions: 73 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid Services) within 30 days of completing the assessment for three of seven sampled patients (Patients 1, 6 and 7). This failure caused missing and delayed information to CMS with the potential to result in inaccurate reimbursement calculation and quality measurement. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 28, 2022, with a recertification period of March 29, 2022, to May 27, 2022. Patient 1 had diagnoses that included diabetes mellitus (a disease that causes high blood sugar levels). A review of Patient 1’s OASIS Admission Assessment dated January 28, 2022, was conducted. The OASIS Admission Assessment indicated a visit completion date of January 28, 2022. A review on April 6, 2022, of Patient 1’s OASIS submission report, undated, indicated Patient 1’s OASIS Admission Assessment had been submitted to and accepted by CMS on March 25, 2022. Fifty-six days had passed before the transmission of Patient 1’s OASIS Admission Assessment to CMS. A review of Patient 1’s Resumption of Care Assessment dated February 17, 2022, was conducted. The OASIS Resumption of Care Assessment indicated a visit completion date of February 17, 2022. A review on April 6, 2022, of Patient 1’s OASIS submission report, undated, indicated Patient 1’s OASIS Resumption of Care Assessment had been submitted to and accepted by CMS on April 5, 2022. Forty-seven days had passed before the transmission of Patient 1’s OASIS Admission Assessment to CMS. 2. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 3, 2022, with a certification period of January 3, 2022, to March 3, 2022. Patient 6 had diagnoses that included a left hip fracture (break). A review of Patient 6’s OASIS Discharge Assessment dated February 15, 2022, was conducted. The OASIS Discharge Assessment indicated a visit completion date of February 15, 2022. A review on April 6, 2022, of Patient 6’s OASIS submission report, undated, indicated Patient 6’s OASIS Discharge Assessment had been submitted to and accepted by CMS on April 5, 2022. Forty-nine days had passed before the transmission of Patient 6’s OASIS Discharge Assessment to CMS. 3. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of October 20, 2021, with a certification period of October 20, 2021, to December 18, 2021. Patient 7 had diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). A review of Patient 7’s OASIS Discharge Assessment dated November 5, 2021, was conducted. The OASIS Discharge Assessment indicated a visit completion date of November 5, 2021. A review on April 6, 2022, of Patient 7’s OASIS submission report, undated, indicated Patient 7’s OASIS Discharge Assessment had been submitted to and accepted by CMS on April 5, 2022. One hundred and fifty-one days had passed before the transmission of Patient 7’s OASIS Discharge Assessment to CMS. During an interview with the Director of Patient Care Services (DPCS) on April 6, 2022, at 2:08 PM, the DPCS stated she was responsible for reviewing, approving and getting patient assessments to billing for submission to CMS. The DPCS stated she was unable to stay on top of the OASIS submission due to an overwhelming workload. The DPCS stated she was aware the OASIS submissions were due within 30 days of the assessment. The DPCS verified Patient 1’s admission and resumption of care assessment had not been submitted within 30 days. The DPCS verified Patient 6 and 7’s discharge assessments had not been submitted within 30 days. A review of the agency’s policy and procedure titled “Reporting of OASIS Information,” dated February 2021, indicated, “Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the System.”

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patients’ rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to one of three sampled patients (Patient 3). This failure had the potential to cause a reduced ability of patients to lodge a complaint, resulting in continued delivery of substandard care by the agency. Findings: A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 15, 2022, with a recertification period of March 15, 2022, to May 13, 2022. Patient 3 had diagnoses that included Pressure- induced deep tissue damage (a form of pressure injury = Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear is usually over boney prominence) of left heel During a home visit and on April 5, 2022, at 4:05 PM, to Patient 3’s home accompanied by a physical therapist (PT 1) indicated Patient 3’s home notebook (a paper folder containing home health agency and Patient 3’s medical information) had not been provided. There was no documented evidence to show the state free home health telephone hot line and supporting information had been provided. The Physical therapy (PT) 1 verified there was no state free home health telephone hot line with supporting information. During an interview with Patient 3 on April 5, 2022, at 4:10 PM, Patient 3 confirmed consent was signed upon admission and she stated only wrote the agency phone number [agency phone number] on her personal notebook. Furthermore Patient 3 stated no home notebook had been provided to her by the agency contained the state free home health telephone hot line with supporting information and she also stated she did not know about the right to file a complaint with the state. During an interview with a Director Patient Care Services (DPCS) on April 6, 2022, at 9:38 AM, the DCPS stated the admitting nurse should have made sure the home notebook left in the patient’s home included the hot line information at admission, and it should be in the home. The DPCS stated, “I do not know why it is not.” A review of the agency’s policy and procedure titled, “Patient Bill of Rights and responsibilities” revised February [no date indicated], 2021, indicated the following: “Purpose: The agency protects and promotes the right of each individual in its care. Procedure: Patient have right: To be advised of the telephone number and hours of operation of the state's Home Health Agency hotline, that receives complaints or questions about local home care agencies. The hours are 24 hours a day, seven (7) days a week and the telephone number is [no phone number indicated]. The hotline also receives complaints about advance directives.” A review of the agency’s policy and procedure titled, “Patient Admission Criteria” revised February [no date indicated], 2021, indicated the following: “…13. During the initial visit, the admitting professional will: …Explain and provide a copy of the Patient’s Bill of rights/Responsibilities…Provide the copy of the agency’s scope of service, office hours and how to access the on-call system.”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of three sampled patients (Patients 1 and 3) when: 1. For Patient 1: two medications the patient was taking were not indicated on the Medication Profile (MP-a current list of all medications prescribed for a specific patient). 2. For Patient 3: one medication the patient was not taking was indicated on the MP and one of medication indicated on the MP scheduled on as needed basis medication had been expired for 2 years and 7 months. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 28, 2022, with a certification period of March 29, 2022, to May 27, 2022. Patient 1 had diagnoses that included unspecified atrial fibrillation (= is a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). During a home visit on April 5, 2022, at 10:15 AM with Certified Home Health Aide (CHHA 1) and in the presence of Patient 1, an observation of Patient 1’s actual medication bottles available in the home were compared with Patient 1’s most current Medication Profile (MP). During an observation on April 5, 2022, at 10:35 AM, in the presence of CHHA 1, checked a bottle of Tamsulosin Hcl (used to relaxes the muscles in the prostate and/or bladder neck, making it easier to urinate) 0.4mg (milligram-a unit of measure) 1 capsule by mouth daily and a bottle of Methenamine Hipp (used to prevent urinary tract infections due to bacteria) 1g (gram-a unit of measure) 1 tablet 2 times daily. Patient 1’s MP has no indication of the order of Tamsulosin Hcl 0.4mg 1 capsule by mouth daily and Methenamine Hipp 1g 1 tablet 2 times daily. Patient 1verified Patient 1’s bottles of Tamsulosin Hcl and Methenamine Hipp has no record on MP. During an interview on April 5 10, 2022, at 11:45 AM, with Patient 1, Patient 1 stated, “I’ve been taking Tamsulosin Hcl and Methenamine Hipp since February, 2022. My doctor is aware of it.” During an interview on April 6, 2022, at 9:10 AM with the Director of Patient Care Services (DPCS), the DPCS stated, “Nurses should have been reviewing and updating medication profile on their visits.” 2. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 15, 2022, with a recertification period of March 15, 2022, to May 13, 2022. Patient 3 had diagnoses that included Pressure- induced deep tissue damage (a form of pressure injury = Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear is usually over boney prominence) of left heel During a home visit on April 5, 2022, at 3:40 PM with Physical Therapy Assistant (PTA 1) and in the presence of Patient 3 an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current Medication Profile (MP). During a concurrent observation and interview on April 5, 2022, at 3:40 PM, in the presence of PTA 1, checked a bottle of Potassium CL ER (is a mineral supplement used to treat or prevent low amounts of potassium in the blood) 10 MEQ (milliequivalents-a unit of measure) 1 tablet by mouth daily. Patient 3’s MP indicated “Potassium Chloride ER, 10 MEQ, 1 tablet 2x/day, Oral”. Patient 3 stated, “I stopped taking the medication when my doctor told me that my potassium level was high, I never take it since I got home from nursing home.” During a concurrent observation and interview on April 5, 2022, at 3:50 PM, in the presence of PTA 1, checked a bottle of Nitroglycerin (are used to prevent chest pain in people with a certain heart condition) sublingual (=you will put it under your tongue) 0.3mg (milligram-a unit of measure) indicated “EXP 08 19” [Expired August 2019 (medication had been expired for 2 years and 7 months)]. Patient 3’s MP indicated “Nitroglycerin, 0.3 Milligram, 1 tab [tablet], as needed for chest pain, sublingual.” Patient 3 stated “yes, I know, I am trying to get it refill.” During an interview on April 6, 2022, at 9:45 AM with DPCS, DPCS stated, “Nurses should have been reviewing and updating medication profile on their visits, medication ordered. The nurse should be more proactive. I do not know why it is not” A review of the agency’s policy and procedure titled “Medication profile,” revised March [no date indicated] 2018, indicated the following: “Policy: The agency provides a mechanism for documentation of patient prescriptions, nonprescription (over the counter) medications and home remedies, including vitamin and herbs. Procedure: …4. The nurse or therapist will add all new/changed medication(S) to the medication profile. Discontinue (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur. 5.When the Skilled Nursing is ordered, the RN and LPN review the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effect, storage and administration of all medication.” A review of the agency’s policy and procedure titled, “Medication Reconciliation,” undated indicated the following: “Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy. Purpose: To define the medication reconciliation process. Procedure: … Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated.”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to follow agency policy and procedure to ensure the comprehensive assessment was updated by a discharge assessment and summary within two calendar days for one of seven sampled patients (Patients 4), when the discharge assessment and summary not completed after 29 days. This failure had the potential to cause unsafe and ineffective transition of care for Patient 4. Findings: 1. A review of Patient 4’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 22, 2021, with a certification period of February 20, 2022, to April 20, 2022. Patient 1 had diagnoses that included heart failure unspecified (a condition in which the heart can't pump enough blood to meet the body's needs). A review of Patient 4’s electronic clinical chart titled “Physician order “dated March 9, 2022, indicated “Transfer to in patient facility – not discharge.” A review of Patient 4’s clinical record from February 20, 2022, to April 20, 2022, was conducted. There was no documented evidence to show an OASIS (Outcome and Assessment Information Set-a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality) discharge assessment had been conducted. There was no documented evidence to show a discharge summary had been completed. During an interview with the Director of Patient Care Services (DPCS) on April 7, 2022, at 10:00 AM, DPCS stated it was a Registered Nurse (RN) supposed to conduct the OASIS discharge assessment and complete a discharge assessment for Patient 4. The DPCS stated the OASIS discharge assessment and discharge summary had not been done for Patient 4. A review of the agency’s policy and procedure titled, “Discharge Criteria and Planning”, revised February [no date indicated] 2021, indicated the following: “Policy: Patients are discharged by Agency based on specifically defined criteria. During the Public Health Emergency, CMS is waiving the requirements to provide detailed information to the patient and caregiver in selecting a post-acute provider by using and sharing data that includes quality measures and other resource measures for another Home Health Agency, Skilled Nursing Facility, Inpatient Rehabilitation Facility and Long-Term Care Hospital. Purpose: To establish guidelines for discharge of patient from agency. Procedure: 1.Patient will be discharged from services as follows: Discharge is necessary for the patient's welfare because the Agency and the physician/practitioner who is responsible for the home health plan of care agree that the Agency can no longer meet the patient's needs, based on the patient's acuity. The Agency will arrange a safe and appropriate discharge to other care entities when the needs of the patient exceed the Agency's capabilities. … Services can no longer be provided safely and/or effectively in the patient's place of residence (patient's physician/practitioner will be consulted for alternative follow up care and/or referral).” A review of the agency’s policy and procedure titled, “Reassessments/Update of the Comprehensive Assessment”, revised February [no date indicated] 2021, indicated the following: “Policy: Each patient will have appropriate reassessments performed and documented. Purpose: To define the scope and intensity of reassessments. Procedure: Transferred to inpatient facility - not discharged from Agency: within 2 calendar days of the discharge/transfer/death date or knowledge of a qualifying transfer to inpatient facility.”

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to maintain an infection control program, in a universe of 31 patients when: 1. The staff COVID 19 vaccination rate was 78.4% 2. The agency failed to track 21 staffs' vaccination status (Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26) 3. The agency did not in-service un-vaccinated staff on mitigation strategies of wearing an N95 mask and testing twice a week. This failure had the potential to cause the spread of the COVID 19 virus among patients and staff, leading to serious illness, debility and death. 1. During record review on April 7, 2022, a comparison between the agency’s staff roster, undated, and the agency’s “Staff COVID 19 Vaccination Tracking Form,” undated, was conducted. The agency’s staff roster indicated a total of 93 staff and the “Staff COVID 19 Vaccination Tracking Form” indicated the following: a. Sixty-eight staff had received the COVID 19 vaccination b. Five staff had received an exemption from the COVID 19 vaccination (Staff 1, 2, 7, 22, and 25) c. Twenty-one staff had not been tracked and 20 staffs’ COVID 19 vaccination status was unknown. (Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26) The following calculation was conducted: 68 Completely Vaccinated + 5 (five) Granted Exemption + 0 (Zero) Temporarily Delayed (divided by) 93 Total Staff X (times) 100 = 78.4 % (percent). During an interview with the Director of Patient Care Services (DPCS) in the presence of the Administrator (Admin) on April 7, 2022, at 12:17 PM, the DPCS stated she was responsible for the COVID 19 staff vaccination program. The DPCS stated she was aware that agency was required to have 100% compliance with staff COVID 19 vaccinations by February 26, 2022. The DPCS stated the vaccination status for Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 24, and 26 was unknown. The Admin stated the agency has been short staffed and the DPCS had not received the assistance needed to ensure the staff COVID 19 vaccination program was properly done. The DPCS stated the staff COVID 19 vaccination program had not been thoroughly implemented because her workload was too heavy, and she could not attend it properly. 2. During record review on April 7, 2022, a comparison between the agency’s staff roster, undated, and the agency’s “Staff COVID 19 Vaccination Tracking Form,” undated, was conducted. a. The agency’s staff roster indicated the following staff: Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26. b. The agency’s “Staff COVID 19 Vaccination Tracking Form,” did not indicate a COVID 19 vaccination status for Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26. During an interview with the Director of Patient Care Services (DPCS) in the presence of the Administrator (Admin) on April 7, 2022, at 12:17 PM, the DPCS stated the COVID 19 vaccination status had not been tracked for Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26. The DPCS stated the vaccination status for 20 of the 21 staff not tracked (Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 23, 24, and 26) was unknown. The DPCS stated she was aware it was required for all staffs’ COVID 19 vaccination status to be tracked. 3. During record review on April 7, 2022, a comparison between the agency’s staff roster, undated, and the agency’s “Staff COVID 19 Vaccination Tracking Form,” undated, was conducted. The agency’s staff roster indicated a total of 93 staff and the “Staff COVID 19 Vaccination Tracking Form” indicated the following: a. Sixty-eight staff had received the COVID 19 vaccination b. Five staff had received an exemption from the COVID 19 vaccination (Staff 1, 2, 7, 22, and 25) c. Twenty-one staff had not been tracked and 20 of the 21 un-tracked staffs’ COVID 19 vaccination status was unknown. (Staff 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, and 26) During an interview with a Registered Nurse (RN 1/Staff 7) on April 7, 2022, at 11:45 AM, RN 1/Staff 7 stated she had qualified for a non-medical exemption to the COVID 19 vaccination. RN 1/Staff 7 stated the agency had in-serviced her on wearing an N95 mask and getting a COVID 19 test once per week. During an interview with a Physical Therapist (PT 1/Staff 25) on April 7, 2022, at 2 PM, PT 1/Staff 25 stated he had qualified for a non-medical exemption to the COVID 19 vaccination. PT 1/Staff 25 stated he had not received an in-service from the agency on additional COVID 19 precautions. PT 1/Staff 25 stated he wore whatever mask he had available, sometimes it was an N95 and sometimes it was not. PT 1/Staff 25 stated he received COVID 19 testing one time a week. During an interview with the Director of Patient Care Services (DPCS) in the presence of the Administrator (Admin) on April 7, 2022, at 12:17 PM, the DPCS stated she had in-serviced RN 1/Staff 7 on additional precautions for COVID 19, wearing an N95 mask and getting tested once per week. The DPCS stated the agency’s “COVID-19 Vaccination of Personnel for Medicare and Medi-Cal Providers,” undated, had not been updated to reflect the requirement for un-vaccinated staff to be tested twice per week. The DPCS stated she had not in-serviced Staff 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26 on additional COVID 19 precautions. A review of the agency’s policy and procedure titled “COVID-19 Vaccination of Personnel for Medicare and Medi-Cal Providers,” undated, indicated the following: “Policy: This organization, a Medicare and Medi-Cal certified provider, is required to have all current and future employees vaccinated against COVID-19 as mandated in the CMS [Centers for Medicare and Medicaid Services] Omnibus [compilation] COVID-19 Health Care Staff Vaccination Interim Final Rule. Procedure: … The Attachment to CMS QSO [Quality, Safety & Oversight]-22-07-ALL requires all staff, as defined in the definition section, to have achieved the vaccination status (at minimum) required for each time period of the memorandum prior to providing care, treatment, or services for the organization and/or its patients. … The organization will ensure all staff are educated on the vaccination requirements contained within this policy. The organization will ensure all staff the education and implementation of additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19. … Contingency plans for staff who are not fully vaccinated or un-vaccinated for COVID 19: … Requiring at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement is met, regardless of whether the facility or service site is located in a county with low to moderate community transmission, in addition to following CDC [Centers for Disease Control] recommendations for testing the un-vaccinated in facilities located in counties with substantial to high community transmission. Requiring staff who have not completed their primary vaccination series to use a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients. … Tracking and documentation of vaccination status: This organization will document and track the vaccination status of all employees including staff who are contracted, volunteers, or students. …”