Every finding on record at Integrity Nursing Services, Inc.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care RN = Registered Nurse SN = Skilled Nurse AM = Morning PM = Afternoon, Evening COVID-19 = Coronavirus 2019

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline. This was found in 5 of 5 (Pts. #1, 2, 3, 4 and 5) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 8/15/22 at 1:15 PM to 8/16/22 at 11:00 AM: Pt. #1. SOC: 11/15/21. Pt. received SN and Physical Therapy services. Pt. #2. SOC: 11/16/21. Pt. received SN and Physical Therapy services. Pt. #3. SOC: 11/17/21. Pt. received SN and Physical Therapy services. Pt. #4. SOC: 11/23/21. Pt. received SN and Physical Therapy services. Pt. #5. SOC: 01/12/22. Pt. received SN and Physical Therapy services. The records lacked documentation that at the SOC, the Pt. or their representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Administrator, Alternate Administrator/Secretary, and Director of Nursing on 8/17/22 beginning 10:30 AM, it was confirmed the Agency failed to ensure Pts. were informed, and/or participated in determining the frequency of visits provided by each discipline.

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: A. Based on personnel COVID-19 vaccination record review, Agency policy, and staff interview, it was determined the Agency failed to implement its employee COVID-19 vaccination policy to ensure that all direct care staff are vaccinated. This was found in 1 of 5 (E #1) employees reviewed for compliance with COVID-19 vaccinations. Findings include: 1. The personnel file of E #1 (Home Health Aide, Date of Hire: 8/6/15) was reviewed on 8/16/22 at 10:30 AM. The file lacked documentation of COVID-19 vaccination status. 2. The Agency policy titled “COVID-19 Policy and Procedures” was reviewed on 8/16/22 at 11:00 AM. The policy requires: “1. All field staff employed with (Agency) before September 19. 2021 must be fully vaccinated by November 1, 2021.” 3. During an interview with the Alternate Administrator/Secretary on 8/16/22 at 10:40 AM, it was stated that as of 8/16/22, E#1’s vaccination status could not be established. 4. During an interview with the Administrator, Alternate Administrator/Secretary, and Director of Nursing on 8/17/22 beginning 10:30 AM, the above findings were confirmed.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure discharge summaries were sent to the Physician within 5 days of discharge from the Agency. This was found in 4 of 5 (Pts. #1, 3, 4, and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 11/15/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 8/15/22 at 1:15 PM. The record included a discharge summary, completed by the RN on 5/12/22, the day of the Patient’s discharge. The record lacked documentation this discharge summary was sent to the Physician within 5 days of discharge from the Agency. 2. Pt. #3. SOC 11/17/21. Primary Diagnosis: Disorder of Thyroid, Unspecified. The clinical record was reviewed on 8/16/22 at 11:00 AM. The record included a discharge summary, completed by the RN on 5/13/22, the day of the Patient’s discharge. The record lacked documentation this discharge summary was sent to the Physician within 5 days of discharge from the Agency. 3. Pt. #4. SOC 11/23/21. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 8/15/22 at 2:00 PM. The record included a discharge summary, completed by the RN on 5/20/22, the day of the Patient’s discharge. The record lacked documentation this discharge summary was sent to the Physician within 5 days of discharge from the Agency. 4. Pt. #5. SOC 1/12/22. Primary Diagnosis: Open Surgical Wound. The clinical record was reviewed on 8/16/22 at 10:00 AM. The record included a discharge summary, completed by the RN on 5/9/22, the day of the Patient’s discharge. The record lacked documentation this discharge summary was sent to the Physician within 5 days of discharge from the Agency. 5. During an interview with the Administrator, Alternate Administrator/Secretary, and the Director of Nursing on 8/16/22 at 10:30 AM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure medical record documents were complete. This was found in 5 of 5 (Pts. #1, 2, 3, 4, and 5) clinical records reviewed. Findings include: 1. The following clinical records were reviewed, beginning 8/15/22 at 1:15 PM to 8/16/22 at 11:00 AM: Pt. #1. SOC 11/15/21. Pt. #2. SOC 11/16/21. Pt. #3. SOC 11/17/21. Pt. #4. SOC 11/23/21. Pt. #5. SOC 1/12/22. All of these records included a document titled “Advance Beneficiary Notice of Non-coverage (ABN),” which was signed by the Pt.; however, the sections of the form including the items/services Medicare doesn’t pay for, the reason Medicare doesn’t pay for the items/services, the estimated cost of these items/services, which items/services the Pt. still wants, and the date were all left blank. 2. During an interview with the Administrator, Alternate Administrator/Secretary and Director of Nursing on 8/17/22 beginning at 10:30 AM, the above findings were confirmed.