Every finding on record at Integral Home Health Agency, Inc

During the recertification survey conducted on 03/04/2025 to 03/06/2025 at Integral Home Health Agency, a Home Health Agency, Emergency Preparedness was reviewed. Integral Home Health Agency is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 03/04/2025 to 03/06/2025 at Integral Home Health Agency. A Home Health Agency Provider. The provider was in non-compliance with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed termination summary including the reason for admission to home health care, type of services being provided, frequency of services, lab data (as applicable) care and out comes meeting goals and medication list for 2 out of 5 Sampled Patients (SP), SP #4 and SP #5. Findings include: Closed record reviews of Sample Patient (SP) #4 and SP #5 were conducted on 03/04/2025 to 03/06/2025. The clinical record for SP #4 contained a discharge summary from the agency with a discharge date of 12/19/2024: SP#5 contained a discharge summary from the agency with a discharge date of 09/05/2024. The discharge summaries of SP #4 and SP#5 omitted information such as reason for admission to home health care, type of services being received, frequency of services, Lab Data (as applicable), care and outcomes meeting set goals and medications at the time of the discharge. Interview conducted on 03/06/2025 with Director of Nursing/Alternate Administrator and Administrator at 10:00am, they acknowledged the summaries for Sp #4 and SP #5 were incomplete, missing the required notations as previously mentioned.

During the recertification survey conducted on 10/11/2021 to 10/14/2021 at Integral Home Health Agency Inc., a Home Health Agency, Emergency preparedness was reviewed. Integral Home Health Agency Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.22, Condition of Participation for Home Health Agencies. The following is a description of the non-compliance:

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based record review and interview, the Home Health Agency failed to develop an emergency preparedness training and testing program that is based on its emergency preparedness, that included strategies and procedures on the identified risks. Findings Include: Review of Staff A, Staff B, Staff C, Staff D, Staff E and Staff F, Staff H, Staff I and Staff J's personnel files conducted on 10/11/2021 revealed that the agency did not develop a federal emergency preparedness training and testing program that is based on its emergency plan that included strategies and procedures on the identified risks and a completed communication plan. During an interview conducted on 10/11/2021 at 3:30 PM, the Administrator and the Director of Nursing reviewed the employees' personnel files and they both acknowledged that the agency did not develop a federal emergency preparedness training and testing program that is based on its emergency plan that included strategies and procedures on identified risks and a completed communication plan.

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 record review and interview, the Home Health Agency failed to conduct training on its emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement consistent with their expected roles. Findings Include: Review of Staff A, Staff B, Staff C, Staff D, Staff E, Staff F, Staff H, Staff I and Staff J's personnel files conducted on 10/11/2021 revealed that the agency did not conduct training based on its a federal emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement consistent with their expected role during an emergency. During an interview conducted on 10/11/2021 at 3:30 PM, the Administrator and the Director of Nursing acknowledged that the agency did not conduct training on its emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement consistent with their expected roles.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and 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 PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization 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 PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE 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 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 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 PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE'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 HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a 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 every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA 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 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 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 HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA'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. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to conduct exercises to test its federal emergency preparedness plan and participated in a full-scale exercise that is community-based and/or an individual facility-based exercise. Findings Include: Record review conducted on 10/14/2021 revealed no documentation showing that the agency conducted exercises to test its federal emergency preparedness plan and participated in a full-scale exercise that is community-based and/or an individual facility-based exercise. Further record review revealed two forms titled “Annual emergency management drill” dated 09/21/2018 and 04/23/2021 respectively. Additional record review revealed that the form titled “In-service attendance record” was blank and did not contain the title, the date and time of the training, the name of the instructor nor the names/ signatures of the participants. During an interview conducted on 10/14/2021 at 1:39 PM, the Administrator and the Director of Nursing acknowledged that there was no documentation to show that the agency conducted exercises to test its federal emergency preparedness plan nor participated in a full-scale exercise that is community-based and/or an individual facility-based exercise. In addition, both parties also acknowledged that the form titled “In-service attendance record” was blank and did not contain the title, the date and time of the training, the name of the instructor nor the names/ signatures of the participants.

A recertification survey was conducted on October 11, 2021 to October 14, 2021 at Integral Home Health Agency Inc. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Licensed Practical Nurse conformed with the physicians' orders for 1 out of 10 Sampled Patients (SP). SP#1 Findings Include: Review of SP#1's record revealed that she was admitted on 05/24/2019. Further review of SP#1's record revealed the following order dated 09/07/2021 “SN to prepare/ administer: Novolog Mix 70-30 24 units subcutaneously in AM injection.” Further review of SP#1's Skilled Nursing (SN)’s notes dated 09/06/2021, 09/08/2021, 09/10/2021, 09/13/2021, 09/15/2021, 09/17/2021, 09/20/2021, 09/22/2021, 09/24/2021, 09/27/2021, 09/29/2021, 10/01/2021, 10/04/2021, 10/06/2021 and 10/08/2021 revealed that Staff E visited the patient in the afternoon instead of the morning and administered 12 units of Novolog Mix 70-30 instead of 24 units, which differs from the physician’s order. During an interview conducted on 10/13/2021 at 1:37 PM, the Director of Nursing (DON) reviewed the SN notes and acknowledged that Staff E did not conform to the physician’s order. In addition, the DON acknowledged that Staff E changed the visit time from morning to afternoon and administered 12 units of Novolog Mix 70-30 instead of 24 units on 09/06/2021, 09/08/2021, 09/10/2021, 09/13/2021, 09/15/2021, 09/17/2021, 09/20/2021, 09/22/2021, 09/24/2021, 09/27/2021, 09/29/2021, 10/01/2021, 10/04/2021, 10/06/2021 and 10/08/2021.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that two Registered Nurses (RN) prepared Skilled Nursing (SN) notes for 2 out of 10 Sampled Patients (SP). SP#3 and SP#4 Findings Include: On 10/11/2021 at 11:30 AM, SP#3’s and SP#4’s records were requested from the Director of Nursing (DON). A review of SP#3’s record conducted on 10/12/2021 revealed that she was admitted on 03/10/2020. Further review of SP#3’s record revealed no documentation to show that the agency provided SN services to the patient subsequent to 09/25/2021. During an interview conducted on 10/13/2021 at 2:29 PM, the DON reviewed SP#3’s record and acknowledged that it did not contain documentation to show that the agency provided SN services to the patient subsequent to 09/25/2021. A review of SP#4’s record conducted on 10/12/2021 revealed that he was admitted on 04/22/2021. Further review of SP#4’s record revealed no documentation showing that the agency provided SN services to the patient subsequent to 09/18/2021. During an interview conducted on 10/13/2021 at 2:45 PM, the DON reviewed SP#4’s record and acknowledged that it did not contain documentation to show that the agency provided SN services to the patient subsequent to 09/18/2021.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to maintain documentation that demonstrates that 1 out of 5 staff reviewed completed 75-hours of home health aide training. Staff C Findings Include: Record review conducted on 10/11/2021 revealed that Staff C was hired as a Home Health Aide (HHA) on 06/07/2021. Further review of Staff C’s record revealed no documentation that she completed a 75-hour training in home health aide. Additional record review revealed that Staff C is actively providing HHA services to SP#8. During an interview conducted on 10/11/2021 at 3:15 PM, the Administrator and the Director of Nursing reviewed Staff C’s personnel file and acknowledged that it did not contain documentation to demonstrate that the employee completed the 75-hour of home health aide training as of 10/11/2021.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to evaluate 3 out of 4 Home Health Aide (HHA)'s performances while carrying out the following task with a patient or pseudo-patient. (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; (iii) Reading and recording temperature, pulse, and respiration; (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: (A) Bed bath;(B) Sponge, tub, and shower bath;(C) Hair shampooing in sink, tub, and bed;(D) Nail and skin care;(E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation;(xi) Normal range of motion and positioning. Staff A, Staff C and Staff D Findings Include: Review of Staff A’s personnel file revealed that she was hired on 03/03/2021. Further review of Staff A’s personnel file revealed that the form titled “Orientation checklist: Professional Staff” was blank and contained only two signatures. Further record review revealed that Staff A is actively providing patient care. Review of Staff C's personnel file revealed that she was hired on 06/07/2021. Further review of Staff C's personnel file revealed that the forms titled “Orientation checklist: Professional Staff; Orientation checklist: Paraprofessional Staff; Job physical requirements; Glucometer Competency Evaluation; Occult Blood Test Competency Evaluation; and Urine Dipstick/ Ketones Competency Evaluation” were blank and contained the employee’s name/ signature and the agency’s representative signature. Continued record review revealed that Staff C is providing HHA services to SP#8. Review of Staff D’s personnel file revealed that she was hired on 05/06/2020. Further review of Staff D’s personnel file revealed that the form titled “Orientation checklist: Professional Staff” was blank and only contained the employee’s signature. Further record review revealed that Staff D is actively providing patient care. Additional review of Staff A, Staff C and Staff D’s personnel files revealed no documentation that the agency evaluated the HHAs’ performances while carrying out the following task with a patient or pseudo-patient. (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; (iii) Reading and recording temperature, pulse, and respiration; (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: (A) Bed bath;(B) Sponge, tub, and shower bath;(C) Hair shampooing in sink, tub, and bed;(D) Nail and skin care;(E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation;(xi) Normal range of motion and positioning. During an interview conducted on 10/11/2021 at 3:20 PM, the Administrator and the Director of Nursing reviewed Staff A, Staff C and Staff D's personnel files and they both acknowledged that they did not contain documentation to demonstrate that the agency evaluated the employees’ skills of the tasks mentioned above prior to assigning them to provide patient care.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to show that 2 out of 5 Home Health Aides (HHA) received at least 12 hours of in-service training during each 12-month period. Staff B and Staff D Findings Include: Review of Staff B's personnel file conducted on 10/11/2021 revealed that she was hired as an HHA on 11/20/2015. Further review of Staff B’s personnel file revealed that she completed 24 hours of in-services in September 2020. Additional record review revealed no documentation that Staff B completed any in-services subsequent to September 2020. Continued record review revealed that Staff B is actively providing HHA services to SP#6. Review of Staff D's personnel file conducted on 10/11/2021 revealed that she was hired as an HHA on 05/06/2020. Further review of Staff D's personnel file revealed that she completed 13 hours of in-services in August 2020. Additional review of Staff D's personnel file revealed no documentation that she completed any in-services subsequent to August 2020. Continued review of Staff D’s personnel file revealed that she is actively providing patient care. During an interview conducted on 10/11/2021 at 3:25 PM, the Administrator and the Director of Nursing reviewed and acknowledged that Staff B and Staff D’s personnel files contained in-services that expired in September 2020 and August 2020 respectively.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that onsite Registered Nurse (RN) supervisory visits were conducted to evaluate the care rendered by the Home Health Aide (HHA) at a minimum of every 2 weeks for 1 out of 7 Sampled Patients (SP) receiving skilled care and Home Health Aide Services. SP#6 Findings Include: Review of SP#6's record revealed that she was admitted on 12/16/2019. Further review of SP#6's record for the certification period of 10/06/2021 to 12/04/2021 revealed that the patient is receiving Skilled Nursing (SN) and Home Health Aide (HHA) services from the agency. Further review of SP#6’s record revealed that the agency supervised Staff B on 09/03/2021. Additional review of SP#6's record revealed no documentation that a Registered Nurse or Registered Physical/Occupational Therapist supervised Staff B subsequent to 09/03/2021. During an interview conducted on 10/13/2021 at 2:23 PM, the Director of Nursing (DON) reviewed SP#6's record and acknowledged that it did not contain documentation to demonstrate that a Registered Nurse or Registered Physical/Occupational Therapist supervised Staff B subsequent to 09/03/2021. During an interview conducted on 10/14/2021 at 2:12 PM, the DON and the Administrator acknowledged the above findings.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Registered Nurse (RN) or other appropriate skilled professional made an annual on-site visit to the location where a patient is receiving care to observe and assess 2 out of 5 Home Health Aides (HHA). Staff B and Staff D Findings Include: Review of Staff B's personnel file conducted on 10/11/2021 revealed that she was hired as an HHA on 11/20/2015. Further review of Staff B's personnel file revealed two forms titled "Employee Performance Evaluation Home Health Aide/CNA)” and “Home Health Aide/CNA On-site Competency Evaluation” dated 02/17/2020. Additional record review revealed that Staff B is actively providing HHA services to SP#6. Continued review of Staff B's personnel file revealed no documentation to demonstrate that an RN or other appropriate skilled professional made an annual on-site visit to the location where patients received care to observe and assess the employee subsequent to 02/17/2020. During an interview conducted on 10/11/2021 at 3:19 PM, the Administrator and the Director of Nursing reviewed Staff B's personnel file and they both acknowledged that it did not contain documentation to demonstrate that an RN made an annual on-site visit to the location where patients received care in order to observe and assess Staff B subsequent to 02/17/2020. Review of Staff D's personnel file conducted on 10/11/2021 revealed that she was hired as an HHA on 05/06/2020. Further review of Staff D's personnel file revealed two blank forms titled "Employee Performance Evaluation Home Health Aide/CNA)” and “Home Health Aide/CNA On-site Competency Evaluation” which only contained the employee’s signature. Additional record review revealed that Staff D is actively providing patient care. Additional review of Staff D's personnel file revealed no documentation to demonstrate that an RN or other appropriate skilled professional made an annual on-site visit to the location where patients received care to observe and assess the employee as of 10/11/2021. During an interview conducted on 10/11/2021 at 3:19 PM, the Administrator and the Director of Nursing reviewed Staff D's personnel file and they both acknowledged that Staff D’s "Employee Performance Evaluation Home Health Aide/CNA)” and “Home Health Aide/CNA On-site Competency Evaluation” were blank and only contained the employee’s signature.

Licensed Practical (Vocational) Nurse CFR(s): 484.115(e) Standard: Licensed practical (vocational) nurse. A person who has completed a practical (vocational) nursing program, is licensed in the state where practicing, and who furnishes services under the supervision of a qualified registered nurse. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Licensed Practical Nurse (LPN)'s file contained a current and valid license. Staff E Findings Include: A review of Staff E’s personnel file revealed that he was hired as a Licensed Practical Nurse (LPN) on 01/07/2020. Further review of Staff E’s personnel file revealed that it contained an LPN license that expired since 07/31/2021. Continued record review revealed that Staff E is actively providing Skilled Nursing care to SP#1. During an interview conducted on 10/11/2021 at 2:59 PM, the Director of Nursing (DON) and the Administrator reviewed Staff E’s personnel file and acknowledged that it contained an LPN license that expired since 07/31/2021.

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Registered Nurse (RN) who is actively providing patient care had a current and valid license in her personnel file. Staff G Findings Include: A review of Staff G’s personnel file revealed that she was hired as a Registered Nurse (RN) on 02/04/2019. Further review of Staff G’s personnel file revealed that it contained an RN license that expired since 04/30/2021. Continued record review revealed that Staff G is actively providing Skilled Nursing care to SP#3 and SP#4. During an interview conducted on 10/11/2021 at 2:59 PM, the Director of Nursing and the Administrator reviewed Staff G’s personnel file and acknowledged that it contained an RN license that expired since 04/30/2021.