Every finding on record at Interim Healthcare Services Inc

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 25 through February 27, 2026, Interim Healthcare Services, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 25 through February 27, 2026, Interim Healthcare Services, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 upon review of agency policy/procedure, clinical records and the Centers for Medicare/Medicaid Services (CMS) system database, and based on interview with the registered nurses/Clinical Managers (RN/CM-Employees #8 and #9) and the Administrator (Admin-Employee #10), the agency failed to ensure Outcome and Assessment Information Set data (OASIS-Medicare mandated data collection for adult patients receiving skilled home health services) was transmitted to the CMS iQIES system for two (2) of three (3) active patients for whom OASIS data was collected. (Patients #1 and #4) Findings include: On February 27, 2026 at approximately 2:45 PM, review of the agency policy titled "Care Planning Process & Comprehensive Assessment" revealed the following under "Procedure": XI. Within 30 days of M0090 (OASIS Data Set Element-Date Assessment Completed), OASIS data elements must be encoded and transmitted through the CMS iQIES system. Patient #1: Between February 25, 2026 at approximately 10:35 AM and February 26, 2026 at approximately 12:07 PM, review of the clinical record revealed the start of care date was 06/19/2024 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for 3 of 3 certification periods between 08/13/2025 through 02/08/2026. Review of SN documentation revealed comprehensive SN reassessments, including OASIS data collection, were completed on 10/22/2025 and 12/12/2025. There was no documentation in the clinical record which provided evidence the OASIS data collected during the aforementioned comprehensive SN assessments had been transmitted to the CMS iQIES system. Patient #4: On February 25, 2026 at approximately 2:46 PM, review of the clinical record revealed the start of care date was 07/08/2013 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the recertification period of 11/02/20254 through 12/31/2025. Review of SN documentation revealed a comprehensive SN reassessment, including OASIS data collection, was completed on 12/01/2025. There was no documentation in the clinical record which provided evidence the OASIS data collected during the aforementioned comprehensive SN assessment had been transmitted to the CMS iQIES system. On February 25, 2026 at approximately 11:16 AM, review of the CMS system database failed to reveal that OASIS data collected during the above referenced comprehensive SN reassessments had been transmitted to iQIES for the above identified patients. During interview conducted on February 27, 2026 at approximately 2:56 PM, the Admin and RN/CM's (Employees #8 and #9) confirmed there was no documentation in the clinical record which provided evidence the OASIS data collected during comprehensive SN reassessments had been transmitted to the CMS iQIES system for the above identified patients.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based upon review of agency policy/procedure and clinical records and based on interview with the registered nurses/Clinical Managers (RN/CM-Employees #8 and #9) and the Administrator (Admin-Employee #10), the agency failed to ensure Outcome and Assessment Information Set data (OASIS-Medicare mandated data collection for adult patients receiving skilled home health services) was collected during the comprehensive skilled nursing (SN) reassessment for three (3) of four (4) active patients for whom orders for SN services were included on the "Home Health Certification and Plan of Care". (Patient #1, #3 and #4) Findings include: On February 27, 2026 at approximately 2:45 PM, review of the agency policy titled "Care Planning Process & Comprehensive Assessment" revealed the following under "Procedure": IV. Update of the comprehensive assessment: The comprehensive assessment must be updated and revised (including OASIS) as frequently as the patient's condition warrants...but no less frequently than...A. The last five 5 days of every 60-day episode beginning with the SOE (start of episode) date... Patient #1: Between February 25, 2026 at approximately 10:35 AM and February 26, 2026 at approximately 12:07 PM, review of the clinical record revealed the start of care date was 06/19/2024 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for 6 of 6 certification periods between 06/19/2024 and 06/13/2025. Review of clinical record documentation revealed the patient's payor source is Medicaid as evidenced by details included on a plan summary dated 05/04/2024. Review of SN documentation revealed comprehensive SN reassessments were completed on 08/14/2024, 10/16/2024, 12/18/2024, 03/07/2025 and 05/22/2025, There was no documentation in the clinical record which provided evidence the aforementioned comprehensive SN assessments included OASIS data collection. Patient #3: Between February 25, 2026 at approximately 1:55 PM and February 27, 2026 at approximately 2:40 PM, review of the clinical record revealed the start of care date was 07/26/2024 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the 3 of 3 certification periods between 07/21/2025 and 01/16/2026. Review of SN documentation revealed comprehensive SN assessments were completed on 09/13/2025, 11/18/2025 and 01/13/2026. There was no documentation in the clinical record which provided evidence the aforementioned comprehensive SN assessments included OASIS data collection. Patient #4: On February 25, 2026 at approximately 2:46 PM, review of the clinical record revealed the start of care date was 07/08/2013 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the 3 of 3 certification periods between 07/05/2025 and 12/31/2025. Review of SN documentation revealed a comprehensive SN reassessment was completed on 09/04/2025. There was no documentation in the clinical record which provided evidence the aforementioned comprehensive SN assessment included OASIS data collection. During interview conducted on February 27, 2026 at approximately 2:56 PM, the Admin and RN/CM's (Employees #8 and #9) confirmed there was no documentation in the clinical record which provided evidence the comprehensive SN reassessment included OASIS data collection for the above identified patients.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based upon review of agency policy/procedure and clinical records and based on interview with the registered nurses/Clinical Managers (RN/CM-Employees #8 and #9) and the Administrator (Admin-Employee #10), the agency failed to ensure a comprehensive skilled nursing (SN) reassessment was completed in accordance with agency policy/procedure for four (4) of five (5) active patients. (Patients #1, #3, #4 and #5) Findings include: On February 27, 2026 at approximately 2:45 PM, review of the agency policy titled "Care Planning Process & Comprehensive Assessment" revealed the following under "Procedure": IV. Update of the comprehensive assessment: The comprehensive assessment must be updated and revised...as frequently as the patient's condition warrants...but no less frequently than...A. The last five 5 days of every 60-day episode beginning with the SOE (start of episode) date... Patient #1: Between February 25, 2026 at approximately 10:35 AM and February 26, 2026 at approximately 12:07 PM, review of the clinical record revealed the start of care date was 06/19/2024 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the following certification periods: 12/16/2024 through 02/13/2025, 02/14/2025 through 04/14/2025, 04/15/2025 through 06/13/2025, 06/14/2025 through 08/12/2025, 08/13/2025 through 10/11/2025, 10/12/2025 through 12/10/2025 and 12/11/2025 through 02/08/2026. There was no documentation in the clinical record which provided evidence a comprehensive SN reassessment had been completed during the following recertification periods: 12/16/2024 through 02/13/2025, 06/14/2025 through 08/12/2025 nor 08/13/2025 through 10/11/2025. Review of SN documentation revealed the comprehensive SN reassessment was conducted prior to days 56 through 60 during the following recertification periods: 02/14/2025 through 04/14/2025, 04/15/2025 through 06/13/2025, 10/12/2025 through 12/10/2025 and 12/11/2025 through 02/08/2026. Patient #3: Between February 25, 2026 at approximately 1:55 PM and February 27, 2026 at approximately 2:40 PM, review of the clinical record revealed the start of care date was 07/26/2024 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the following certification periods: 07/26/2024 through 09/22/2024 and 03/23/2025 through 05/21/2025. There was no documentation in the clinical record which provided evidence a comprehensive SN reassessment had been completed during the following recertification periods: 07/26/2024 through 09/22/2024 and 03/23/2025 through 05/21/2025. Patient #4: On February 25, 2026 at approximately 2:46 PM, review of the clinical record revealed the start of care date was 07/08/2013 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the following certification periods: 07/05/2025 through 09/02/2025, 09/03/2025 through 11/01/2025 and 11/02/2025 through 12/31/2025. There was no documentation in the clinical record which provided evidence a comprehensive SN reassessment had been completed during the following recertification period: 07/05/2025 through 09/02/2025. Review of SN documentation revealed the comprehensive SN reassessment was conducted prior to days 56 through 60 during the following recertification periods: 09/03/2025 through 11/01/2025 and 11/02/2025 through 12/31/2025. Patient #5: Between February 26, 2026 at approximately 1:24 PM and February 27, 2026 at approximately 10:12 AM, review of the clinical record revealed the start of care date was 11/15/2003 and that SN services were ordered as documented on the "Home Health Certification and Plan of Care" for the following certification periods: 11/20/2025 through 01/18/2026. There was no documentation in the clinical record which provided evidence a comprehensive SN reassessment had been completed during the following recertification periods: 11/20/2025 through 01/18/2026. During interview conducted on February 27, 2026 at approximately 2:56 PM, the Admin and RN/CM's (Employees #8 and #9) confirmed there was no documentation in the clinical record which provided evidence the comprehensive SN reassessment had been completed in accordance with agency policy/procedures for the above identified patients.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based upon review of agency policy/procedure and clinical records and based on interview with the registered nurses/Clinical Managers (RN/CM-Employees #8 and #9) and the Administrator (Admin-Employee #10), the agency failed to ensure the initial/start of care (SOC) comprehensive nursing assessment was completed in accordance with agency policy/procedure for two (2) of two (2) active patients admitted to services after February 10, 2023. (Patients #1 and #3) Findings include: On February 27, 2026 at approximately 2:45 PM, review of the agency policy titled "Care Planning Process & Comprehensive Assessment" revealed the following under "Procedure": 1. Initial assessment visit initiates the care planning process...The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home from an inpatient unit, or on the physician/allowed practitioner ordered start of care date. Patient #1: Between February 25, 2026 at approximately 10:35 AM and February 26, 2026 at approximately 12:07 PM, review of the clinical record revealed the start of care date was 06/19/2024 and that skilled nursing (SN) services were ordered as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 06/19 through 08/17/2024. Review of "Home Health Certification and Plan of Care" documentation revealed the RN/CM (Employee #8) completed a SOC nursing assessment on 06/19/2024. There was no documentation in the clinical record which provided evidence the date of referral nor inpatient discharge date had been documented in the clinical record nor was documentation present which provided evidence the agency had obtained a physician-ordered start of care date. Patient #3: Between February 25, 2026 at approximately 1:55 PM and February 27, 2026 at approximately 2:40 PM, review of the clinical record revealed the start of care date was 07/26/2024 and that home health aide services were ordered as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 07/26 through 09/23/2024. Review of SN documentation revealed the initial RN comprehensive assessment was completed on by the RN/CM (Employee #9) on 07/26/2024. There was no documentation in the clinical record which provided evidence the date of referral nor inpatient discharge date had been documented in the clinical record nor was documentation present which provided evidence the agency had obtained a physician-ordered start of care date. There was no documentation in the clinical record which provided evidence the clinical record which provides evidence initial comprehensive nursing assessment had been completed by the RN/CM within 48 hours of referral, within 48 hours of the patient's return home from an inpatient unit or on the physician/allowed practitioner ordered start of care date. During interview conducted on February 27, 2026 at approximately 2:56 PM, the Admin and RN/CM's (Employees #8 and #9) confirmed there was no documentation in the clinical record which provided evidence the initial/SOC SN assessment had been had been completed by the RN/CM within 48 hours of referral, within 48 hours of the patient's return home from an inpatient unit or on the physician/allowed practitioner ordered start of care date for patients #1 and #3.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based upon review of agency policy/procedure and clinical records and based on interview with the registered nurse/Clinical Manager (RN/CM-Employee #9) and the Administrator (Admin-Employee #10), the agency failed to ensure a comprehensive skilled nursing (SN) reassessment had been completed in accordance with agency policy/procedure for one (1) of one (1) patients who was discharged from the agency due to staffing issues. (Patient #6) Findings include: On February 27, 2026 at approximately 2:45 PM, review of the agency policy titled "Care Planning Process & Comprehensive Assessment" revealed the following under "Procedure": IV. Update of the comprehensive assessment: The comprehensive assessment must be updated and revised...C. At discharge. Patient #6: On February 27, 2026 between the approximate time of 10:30 AM and 1:48 PM, review of the clinical record revealed the start of care date was 02/26/2023 and that skilled nursing services were ordered as documented on the "Home Health Certification and Plan of Care" for the following certification period: 08/31/2025 through 10/29/2025. Review of discharge summary documentation dated 10/29/2025 revealed the RN/CM (Employee #9) documented that the patient was discharged from services due to the inability to provide qualified staff. There was no documentation in the clinical record which provided evidence a comprehensive SN reassessment had been completed prior to the patient's discharge from the agency. During interview conducted on February 27, 2026 at approximately 2:56 PM, the Admin and RN/CM (Employee #9) confirmed there was no documentation in the clinical record which provided evidence the comprehensive SN reassessment had been completed prior to discharge for patient #6.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 8 through February 10, 2023, Interim Healthcare Services, Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure two (2) of two (2) hazard vulnerability assessments (HVA) included an event type/category for care-related emergencies. (2020 and 2022 HVA) Findings include: On February 10, 2023 at approximately 11:08 AM, review of the agency policy titled "Emergency Preparedness", revealed the following: -Definitions...All Hazards Approach...The approach is specific to the location of the provider and considers the particular type of hazards most likely to occur in their areas. These may include, but are not limited to, care-related emergencies... -Policies and Procedures…1. The Administrator/Manager or designee develops and implements office specific emergency preparedness plan policies/procedures, based on the office’s…b) Identified hazards in the office’s agency and community-based all-hazards approach risk assessment… On February 9, 2023 at approximately 4:15 PM, review of the agency "Client Discharge Report" revealed Client #5 expired (died) at home and that the discharge date was 01/26/2022. Client #1: On February 10, 2023 at approximately 12:28 PM, review of the clinical record revealed the start of care date was 04/02/2007, the primary diagnosis was quadriplegia (paralysis below the neck), that the client formulated an advance directive (living will), that skilled nursing (SN) and home health aide (HHA) services were to be provided, that SN problems included risk for ineffective breathing patterns and that HHA problems included potential alternation in safety related to immobility, neuromuscular involvement as documented on the "Home Health Certification and Plan of Care" for the recertification period of 01/13/2022 through 03/13/2022. Review of the "Home Care Aide Visit/Shift Charting Sheet" revealed the HHA shift began at 10:40 PM on 01/25/2022. Review of the "Narrative" note dated 01/26/2022 revealed the home care supervisor (Employee #6) documented that on 01/26/2022 that when the HHA went to reposition the client, the client was not breathing. The HHA contacted 911 but ambulance personnel reported that the client had expired. On February 10, 2023 at approximately 10:42 AM, review of Governing Body (GG) meeting minutes documentation revealed the GB reviewed/approved the Emergency Preparedness Plan/Program on 05/13/2022. On February 10, 2023 at approximately 11:08 AM, review of the "Threat/Hazard Risk Assessment" form, which was reviewed on 02/21/2020, failed to reveal that care-related emergencies had been included under the "Threat/Hazard" column/category. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed that care-related emergencies had not be included under the "Threat/Hazard" column/category on the "Threat/Hazard Risk Assessment" form which was reviewed in February 2020 and May 2022.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 8 through February 10, 2023, Interim Healthcare Services, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures and clinical records, observation and based on interview with a licensed practical nurse (LPN-Employee #2) and the administrator, the agency failed to ensure the "Home Health Certification and Plan of Care" included equipment and/or skilled nursing (SN) treatment/intervention orders for two (2) of six (6) clients who received SN services. (Clients #1 and #7) Findings include: On February 10, 2023 at approximately 3:20 PM, review of the agency policy titled "Developing a Plan to Meet Patient/Client Needs" revealed the following: Scope...All care/services is provided under a physician's or allowed practitioner's order. Procedure...7. A qualified designated employee obtains orders for care/services prior to the delivery of such...(b) Ensures a patient's individualized home health plan of care includes the following...(iii) The types of services, supplies and equipment required...(x) All medications and treatments... Client #1: During home visit conducted on February 9, 2023 at approximately 10:10 AM, observation of the client's medical equipment revealed a primary and back-up ventilator (mechanical device which assists with breathing) and a suction machine were maintained in the home. During interview conducted during the home visit, the LPN (Employee #2) reported the back-up ventilator was utilized when the client required evacuation from the building. The LPN also reported that tracheal (lower airway) suctioning is performed using a 14 Fr. (catheter size) in-line tracheostomy (suctioning through the tube which is inserted into a surgically created airway located in the front of the neck) suction catheter. The LPN reported that nasal suctioning has been performed using small suction catheters which were are stored with the client's supplies. Between February 8, 2023 at approximately 11:03 AM and February 9, 2023 at approximately 12:22 PM, review of the clinical record revealed primary ventilator orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 01/29/2023 through 03/29/2023 but there was no documentation which provided evidence that physician orders for a back-up ventilator, back-up ventilator settings nor suctioning orders had been included on the "Home Health Certification and Plan of Care" for the current recertification period. Client #7: On February 10, 2023 at approximately 2:40 PM, review of the clinical record gastric (feeding) tube (GT) and GT feeding orders were included on the "Home Health Certification and Plan of Care" for the recertification period of 01/29/2023 through 03/29/2023. Review of "Continuous Care Nursing Treatment/Flow Sheet" documentation revealed the SN performed a GT residual (stomach contents check on 01/30 01/31, 02/01, 02/02 and 02/03/2023. There was no documentation which provided evidence that physician orders for GT residual checks had been included on the "Home Health Certification and Plan of Care" for the current recertification period. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed that physician orders for the above referenced equipment and SN treatments/interventions had not been included on the recertification "Home Health Certification and Plan of Care" for the aforementioned clients.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, documentation, and the Pennsylvania (PA) Department of Health (DOH) website reports, and based on interview with the administrator, the agency failed to submit two (2) of two (2) COVID-19 related reports to the PA DOH Event Reporting System (ERS) website prior to February 8, 2023. Findings include: On February 10, 2023 at approximately 11:02 AM, review of the agency infection control policy/procedure manual revealed COVID-19 is a Health Department reportable disease as documented on the agency form titled "List of Reportable Diseases". On February 8, 2023 at approximately 8:30 AM, review of the PA DOH website (https://www.health.pa.gov/topics/Reporting-Registries/Pages/Reportable-Diseases.aspx) revealed Health Department Reportable Diseases, subcategory COVID-19, is a PA DOH reportable event. On February 10, 2023 at approximately 10:38, review of the employee COVID-19 tracking log revealed the home care supervisor/Director of Health Care Services (Employee #7) tested positive for COVID-19 on August 8, 2020 and October 18, 2022. On February 8, 2023 at approximately 8:30 AM, review of the PA DOH ERS website failed to reveal that the agency had submitted reports of the above referenced COVID-19 positive results for Employee #7 to the PA DOH ERS website prior to 02/08/2023. During interview on February 23, 2023 at approximately 3:45 PM, the administrator confirmed the agency failed to submit reports of the above referenced COVID-19 results to the PA DOH ERS website prior to 02/08/2023.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on review of agency policies/procedures, clinical records and documentation, and based on interview with the administrator, the agency failed to ensure one (1) of one (1) adverse client/patient events was reviewed during the Professional Advisory Committee (PAC-Group of Professional Personnel) meeting conducted in May 2022. (Client/Patient #5) Findings include: On February 10, 2023 at approximately 3:12 PM, review of the agency policy titled "Quality Assessment and Performance Improvement" revealed the following: Policy...The designated areas for quality assessment and performance improvement address the following...c) Findings related to occurrences/adverse events and any related sentinel event... On February 10, 2023 at approximately 3:13 PM, review of the agency policy titled "Occurrence and Sentinel Events" revealed the following: Definitions...Sentinel Event: An unexpected occurrence involving death... On February 9, 2023 at approximately 4:15 PM, review of the agency "Client Discharge Report" revealed Client #5 expired (died) at home and that the discharge date was 01/26/2022. Client #5: On February 10, 2023 at approximately 12:28 PM, review of the clinical record revealed the start of care date was 04/02/2007, the client was 59 years old, the primary diagnosis was quadriplegia (paralysis below the neck), that the client formulated an advance directive (living will), that skilled nursing (SN) and home health aide (HHA) services were to be provided, that SN problems included risk for ineffective breathing patterns and that HHA problems included potential alternation in safety related to immobility, neuromuscular involvement as documented on the "Home Health Certification and Plan of Care" for the recertification period of 01/13/2022 through 03/13/2022. Review of the SN "Continuous Care Nursing Treatment/Flow Sheet" dated 01/25/2022 revealed that at 8:00 AM, the client's vital signs were as follows: Temperature: 97.4, Pulse 62, Respirations (breathing rate) 16, Blood Pressure 112/64 and Pulse Oximetry reading (oxygen level in the blood) of 95%. On 01/25/2022 at 4:00 PM, the SN documented that the client was in the wheelchair watching television, that there was no complaint of increased pain/discomfort and that care was tolerated well. Review of the "Home Care Aide Visit/Shift Charting Sheet" revealed the HHA shift began at 10:40 PM on 01/25/2022. Review of the "Narrative" note dated 01/26/2022 revealed the home care supervisor (Employee #6) documented that on 01/26/2022, when the HHA went to reposition the client, the client was not breathing. The HHA contacted 911 but ambulance personnel reported that the client had expired. On February 10, 2023 at approximately 10:41 AM, review of agency meeting minutes failed to reveal that the above referenced adverse client/patient event (death), which occurred at home during the HHA shift, had been reviewed during the QAPI nor Professional Advisory Committee (PAC) meetings conducted on 05/18/2022. During interview conducted on February 10, 2023 at approximately 12:20 PM, the administrator reported that adverse client/patient events have not been reviewed during the QAPI/PAC meetings. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed that the above referenced adverse client/patient event had not been reviewed during the QAPI/PAC meetings conducted on 05/18/2022.

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 review of agency policies/procedures, personnel files and documentation, and based on interview with the administrator, the agency failed to ensure employee COVID-19 vaccination exemption requests were completed as per agency policy/procedure for 9 of 14 staff members. (Employees #9, #11, #12, #13, #!4, #15, #16, #17 and #18) Findings include: On February 10, 2023 at approximately 10:28 AM, review of the agency policy/procedure titled "COVID-19 Vaccination, Exemptions, and Contingency Plan" revealed the following: Procedure...6. The Administrator/Manager or designee who receives an exemption request from an employee/staff member for a medical...or religious exemption from COVID-19 vaccination must provide at minimum the following documentation supporting their exemption request...6(b) Medical Exemption-Documentation for a medical exemption must include at a minimum...Sample Request for Medical Exemption from COVID-19 Vaccination Requirement... 6(c) Religious Exemptions--Documentation for a religious exemption must include at a minimum...Sample Request for Religious Exemption from COVID-19 Vaccination Requirement... On February 10, 2023 at approximately 10:25 AM, review of COVID-19 employee exemption request calculations revealed a total of 14 staff members were granted religious exemptions to the COVID-19 vaccine. Review of COVID-19 employee exemption request forms on February 10, 2023 at approximately 9:15 AM revealed the following: -The "Employee COVD-19 Vaccination Attestation" form (Form #1) included a check box for which the employee could request an exemption due to "Other" due to religious beliefs or due a history of severe allergic reactions (medical). -The "Request for Religious Exemption/Accommodation Related to COVID-19 Vaccination" from included an area to document the reason for which the employee was requesting a religious exemption. Between February 9, 2023 at approximately 2:09 PM and February 10, 2023 at approximately 9:15 AM, review of personnel file and COVID-19 employee exemption request documentation revealed the following: -Employee #9: The licensed practical nurse (LPN) completed the COVID-19 vaccine attestation Form #1 was 01/12/2022. The LPN documented that the exemption request category was "Other" but there was no documentation which provided evidence that the LPN completed a religious exemption request form (Form #2) nor a medical exemption request form. -Employee #11: The certified nurses aide (CNA) completed the COVID-19 vaccinate attestation Form #1 on 01/06/2022. The CNA documented that the exemption request category was "Other" but there was no documentation which provided evidence that the CNA completed a religious exemption request form (Form #2) nor a medical exemption request form. -Employee #12: The home health aide (HHA) completed the COVID-19 vaccine attestation Form #1 on 01/04/2022. The HHA documented that the exemption request category was "Other". A handwritten exemption request dated 01/29/2022 revealed the HHA documented that the HHA requested an exemption after consultation with an immunologist who did not recommend the vaccine. There was no documentation which provided evidence that the HHA completed a religious exemption request form (Form #2) nor a medical exemption request form. -Employee #13: The HHA completed the COVID-19 vaccine attestation Form #1 on 01/09/2022. The HHA documented that the exemption request category was "Other" but there was no documentation which provided evidence that the CNA completed a religious exemption request form (Form #2) nor a medical exemption request form. -Employee #14: The date of hire of the personal care aide (PCA) was 10/27/2020. The PCA completed the COVID-19 vaccine attestation Form #1 on 02/08/2023. The religious exemption request form (Form #2) was dated 01/05/2022 which was more than one (1) year prior to the completion of the COVID-19 vaccine attestation form (Form #1). -Employee #15: The HHA completed the COVID-19 vaccine attestation Form #1 on 01/05/2022. The HHA documented that the exemption request category was "Other" but there was no documentation which provided evidence that the CNA completed a religious exemption request form (Form #2) nor a medical exemption request form. -Employee #16: The date of hire of the HHA was 02/01/2014. The HHA completed the COVID-19 vaccine attestation Form #1 on 02/01/2023. The religious exemption request form (Form #2) was dated 01/05/2022 which was more than one (1) year prior to the completion of the COVID-19 vaccine attestation form (Form #1). -Employee #17: The date of hire of the HHA was 10/31/2022. The HHA did not complete the COVID-19 vaccine attestation Form #1 until 02/01/2023 which was 3 months after the date of hire. The religious exemption request form (Form #2) was dated 01/05/2022 which was more than one (1) year prior to the date of hire. -Employee #18: The HHA completed the COVID-19 vaccine attestation Form #1 on 01/06/2022. The HHA documented that the exemption request category was "Other". Review of religious exemption request Form #2 revealed the HHA was requesting an exemption from the vaccine due to a past history of allergic reactions. There was no documentation which provided evidence that the HHA completed a medical exemption request form. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed that the above referenced COVID-19 vaccine exemption requests were not completed as per agency policy/procedures for the above identified employees.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, clinical record and personnel files, and based on interview with a licensed practical nurse (LPN-Employee #2), a home care supervisor (Employee #6) and the administrator, the agency failed to ensure documentation was maintained in the personnel file which provided evidence that an annual tracheostomy (surgically created artificial airway located in the front of the neck) and ventilator competency demonstration was completed for three (3) of five (5) nursing staff who provided tracheostomy/ventilator maintenance/care or oversight of tracheostomy/ventilator maintenance/care. (Employees #2, #6 and #10) Findings include: On February 10, 2023 at approximately 3:25 PM, review of the agency policy titled "File Maintenance of Employees that Provide or Manage Patient Care/Client Services" revealed the following: Procedure...Employee File...(c) Completed skills check list(s) as applicable... Client #1: Between February 8, 2023 at approximately 11:03 AM and February 9, 2023 at approximately 12:22 PM, review of the clinical record revealed skilled nursing is to provide tracheostomy and ventilator maintenance and care as documented on the "Home Health Certification and Plan of Care" for the recertification period of 01/29/2023 through 03/29/2023. Review of "Continuous Care Nursing Treatment/Flow Sheet" and ventilator flow sheet documentation revealed the following nursing staff provided tracheostomy and ventilator maintenance/care in January or February 2023: Employees #2, #6 and #10. During telephone interview conducted on February 10, 2023 at approximately 11:35 AM, the licensed practical nurse (LPN-Employee #2) reported that the home care supervisor (Employee #6) conducts tracheostomy/ventilator competency evaluation/skills demonstration during onsite visits at the home of Client #1. Between February 9, 2023 at approximately 2:09 PM and February 10, 2023 at approximately 9:10 AM, review of personnel files revealed the following: Employee #2: The date of hire of LPN was 11/14/2023. Review of the "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" forms dated 11/23/2021 and 02/08/2022 revealed the date that tracheostomy/ventilator skills demonstration was performed was not documented by the home care supervisor (Employee #6) nor was the form signed by Employee #6. Employee #6: The date of hire of the home care supervisor/registered nurse was 12/09/2008. The "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" skills demonstration was performed on 03/04/2021. There was no documentation which provided evidence that a "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" form was completed in 2022. Employee #10: The date of hire of the LPN was 02/25/1995. The "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" skills demonstration was performed on 03/12/2021. There was no documentation which provided evidence that a "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" form was completed in 2022. During interview conducted on February 10, 2023 at approximately 12:06 PM, the home care supervisor (Employee #6) reported that tracheostomy/ventilator skills competency demonstrations are completed annually by nursing staff who provide tracheostomy/ventilator maintenance and care. Employee #6 confirmed that tracheostomy/ventilator skills demonstration dates were not documented on the "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" form for Employees #2, #6 and #10. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed that tracheostomy/ventilator skills demonstration dates were not documented on the "Home Care Tracheostomy/Ventilator Evaluation & Experience Checklist" form for Employees #2, #6 and #10.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the Home Care Supervisor/Director of Health Care Services (Employee #7) and the administrator, the agency failed to ensure details regarding one (1) of one (1) anticipated client/patient deaths were documented in the clinical record. (Client/Patient #6) Findings include: On February 10, 2023 at approximately 3:40 PM, review of the agency policy titled "Anticipated Death at Home" revealed the following: Procedure…The designated employee documents the following information in the patient/client record: a) The time of the reported death; b) Circumstances observed or reported leading up to the death; c) The time the office or supervisor was notified of the death: d) The notification of death was provided to the family/caregiver including family/caregiver names: f) Notification to the healthcare practitioner… On February 9, 2023 at approximately 4:15 PM, review of the agency "Client Discharge Report" revealed Client #6 expired (died) at home and that the discharge date was 12/09/2022. Client #6: On February 10, 2023 at approximately 1:42 PM, review of the clinical record revealed the start of care date was 07/29/2019, the client was 92 years old, the primary diagnosis was wedge compression fracture of T1-T12 (back) vertebrae and that home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 11/10/2022 through 01/08/2023. Review of the follow-up/recertification “Paraprofessional Services Evaluation” dated 10/18/2022 revealed the client was receiving hospice services, that the client experienced a decrease in ambulation (walking) and that vital signs were as follows: Temperature 97.5, Pulse 83, Respirations 20 and Blood Pressure 130/80. The client’s blood sugar reading was 79. Review of the "Home Care Aide Visit/Shift Charting Sheet" revealed that on 11/27/2022, the HHA shift began at 7:00 AM and ended at 10:00 AM. Review of the “Discharge/Transfer” summary and physician order dated 12/09/2022 revealed the client expired at home on 11/27/2022. There was no documentation in the clinical record which provided evidence that details regarding the client’s death had been documented in the clinical record as required in the above referenced agency policy. During interview conducted on February 10, 2023 at approximately 2:31 PM, the Home Care Supervisor/Director of Health Care Services (Employee #7) reported that the client expired during the HHA shift on 11/27/2022 but that the hospice nurse was present at the time of the client’s death. Employee #7 reported that the hospice nurse pronounced the client and notified the client’s physician of the client’s death. Employee #7 reported that details regarding the client’s death were not documented in the clinical record as per the above referenced agency policy/procedure. During interview conducted on February 10, 2023 at approximately 3:45 PM, the administrator confirmed details regarding the Client #6’s death were not documented in the clinical record as per the above referenced agency policy/procedure.