Every finding on record at Integrity Home Health, LLC

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed on 09/09/21.

EP Training Program CFR(s): 484.102(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 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 review of agency documents and staff interview, the agency failed to train staff on emergency preparedness. This has the potential to affect all 25 patients. Findings include: Review of the agency's emergency preparedness documents revealed a lack of training or staff education. On 09/09/21 at 3:38 PM, Staff A stated he/she could not locate any documentation of staff education on the agency's emergency preparedness plan.

Partial Extended Recertification Survey The following deficiencies are based on the Partial Extended Recertification survey completed on 09/09/21. Integrity Home Health, LLC 368400, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies. An entrance conference was conducted on 09/07/21 at 10:00 AM with administrative personnel, and an exit conference was completed on 09/09/21 at 4:15 PM with administrative personnel.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care. This affected five of seven medical records reviewed (Patients #1, #2, #4, #6, and #7). The agency census was 25. Findings include: 1. Review of the medical record for Patient #1 revealed a plan of care dated 06/03/21 to 08/01/21 with orders for home health aide services 42 hours per week. The medical record contained documentation of only 20.5 hours of home health aide services the week of 08/08/21. The medical record lacked documentation of physician notification that services were not provided as ordered. 2. Review of the medical record for Patient #2 revealed a plan of care dated 06/07/21 to 08/05/21 with orders for home health aide services 21 hours per week. The medical record contained documentation of only 19 hours the week of 06/27/21 and 20 hours the week of 07/04/21. The medical record lacked documentation of physician notification that services were not provided as ordered. 3. Review of the medical record for Patient #4 revealed plans of care dated 05/26/21 to 07/24/21 and 07/25/21 to 09/22/21 with orders for 84 hours of home health aide services per week. The medical record contained documentation of only 74 hours of home health aide services the week of 07/04/21. The medical record contained documentation of 85 hours of home health aide services the week of 08/22/21. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. 4. Review of the medical record for Patient #6 revealed a plan of care dated 03/19/21 to 05/17/21 with orders for home health aide services 49 hours per week. The medical record contained documentation of only 35 hours of home health aide services the week of 04/04/21. The medical record contained documentation of 51 hours of home health aide services the week of 03/21/21. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. 5. Review of the medical record for Patient #7 revealed a plan of care dated 04/07/21 to 06/05/21 with orders for home health aide services 20 hours per week. The medical record contained documentation of only eight hours of home health aide services the week of 04/11/21. The medical record lacked documentation of any home health aide services from 04/07/21 to 04/12/21 or after 04/17/21. The patient was discharged on 05/30/21. The medical record lacked documentation of physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 09/09/21 at 2:05 PM.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days 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 medical record review and staff interview, the agency failed to ensure patients not receiving skilled care received an on-site supervisory visit at least every 60 days while the aide was providing care. This affected two of four non-skilled medical records reviewed (Patients #2 and #3). A total of seven medical records were reviewed. The agency census was 25. Findings include: 1. Review of the medical record for Patient #2 revealed a plan of care dated 06/07/21 to 08/05/21 with orders for home health aide services 21 hours per week. The supervisory visits dated 06/06/21 and 08/05/21 were completed without the aide present. 2. Review of the medical record for Patient #3 revealed a plan of care dated 06/29/21 to 08/27/21 with orders for home health aide services 24.5 hours per week. The supervisory visits dated 06/28/21 and 08/27/21 were completed without the aide present. The findings were verified in an interview with Staff A on 09/09/21 at 2:05 PM.