Every finding on record at Kemg Home Health Care Inc

Purpose of Visit: Re-certification Survey. Entrance Date: 03/10/2021 An entrance conference was conducted in person with the office manager, Employee E and via telephone with the alternate administrator (Employee B) at 3:20 p.m. Employee B and E was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 0 Exit Date: 03/18/2021 An exit conference was conducted at 1:00 p.m. in person with the office manager and via telephone with the administrator, Employee A, and the alternate administrator, Employee B. The preliminary findings were discussed. The agency was given an opportunity to ask question and provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified EP- Emergency Preparedness HHA's- Home Health Agencies

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable Federal, State and local EP requirements to develop, establish and maintain a comprehensive emergency preparedness program that met the requirements to maintain an emergency preparedness plan that was reviewed, and updated at least every 2 years (per regulation) nor at least annually (per agency policy) for the years 2017, 2018 and 2019. The failure could place the agency's patients at risk of harm, in the event of an actual emergency or disaster, if the agency's emergency plan was not comprehensive and updated to meet applicable federal, state and local EP regulatory requirements and to meet the needs of the agency's patient population. FINDINGS INCLUDED: During the entrance conference at 3:20 p.m. on 03/10/2021, the alternate administrator, Employee B identified the office manager, Employee E, as the disaster coordinator. Employee B self-identified as the alternate disaster coordinator. On 03/11/2021 record review of the agency's EP plan showed that the alternate administrator, Employee B was the disaster coordinator and the office manager, Employee E was the "secondary contact." The emergency preparedness plan binder was reviewed on 03/11/2021. The binder contained a record titled "EMERGENCY PREPAREDNESS ASSESSMENT." The EP assessment was dated 12/23/2020. The EP record review did not identify any other records to establish that the agency had conducted annual internal reviews of the agency's emergency preparedness and response plan, for the years 2017, 2018 and 2019. During an interview on 03/18/2021 at approximately 10:00 a.m. with the administrator, Employee A and the alternate administrator, Employee B the surveyor discussed the above findings and asked why the agency had not evaluated the EP and response plan at least annually and after each actual emergency response. Employee A stated that it should have been completed by the previous owner, Identifier Q. On 03/18/2021 at 12:20 p.m. the office manager, Employee E provided an EP binder from the previous owner. The binder did not contain annual internal reviews for 2017, 2018 or 2019. There were no internal reviews after any actual emergency responses for 2017, 2018 or 2019. Record review of agency undated policy titled "Disaster/Emergency Preparedness" read in part: "Procedure ...The agency will review the emergency plan annually and conduct and evaluate an emergency response ..."

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 agency failed to provide Initial and Annual EP training to employees consistent with their expected roles and failed to maintain documentation of the training for four (Employees A, B, C and E) of four personnel records reviewed. The agency failed to enforce its policy to provide initial and annual EP training to agency employees. The agency failed to maintain documentation of staff training in the EP plan. This failure could cause employee's to not be aware of their role in the event of a disaster or emergency and cause the employees to have a lack of knowledge of policy and procedure changes in the EP plan. FINDINGS INCLUDED: During the entrance conference at 3:20 p.m. on 03/10/2021, the alternate administrator, Employee B identified the office manager, Employee E, as the disaster coordinator. Employee B self-identified as the alternate disaster coordinator. On 03/11/2021, record review of the agency's EP plan showed that the alternate administrator, Employee B was the disaster coordinator and the office manager, Employee E was the "secondary contact." The EP binder contained the correct designation for disaster coordinator and alternate. The emergency preparedness plan binder was reviewed on 03/11/2021. The review of the binder did not identify any records to establish that each staff member received annual training on their responsibilities in the agency's emergency preparedness and response plan, for the years 2018, 2019 and 2020. Personnel records were reviewed on 03/12/2021. Hire dates were obtained from employee rosters provided by the office manager. During an interview on 03/12/2021 at approximately 2:30 p.m. the surveyor asked where the agency in-service records for employees were located. The office manager, Employee E stated that the records were located the employees' personnel records. Employee A: Administrator. Hire date: 09/28/2018 Review of Employee A's personnel record showed that Employee A had not received training upon hire. Employee A's record did not contain any documentation of orientation to the agency's EP plan. Employee A's record did not contain any record of educational attendance for the agency's emergency preparedness and response plan for the years 2018, 2019 and 2020. Employee B: Alternate Administrator. Hire date: 12/03/2018 Review of Employee B's personnel record showed that the record did not contain any record of educational attendance for the agency's emergency preparedness and response plan for the years 2019 and 2020. Employee C: Supervising Nurse. Hire date: 10/10/2019 Review of Employee C's personnel record showed that the record did not contain any record of educational attendance for the agency's emergency preparedness and response plan for the year 2020. Employee E: Office Manager. Hire date: 11/14/2018 Review of Employee E's personnel record showed that the record did not contain any record of educational attendance for the agency's emergency preparedness and response plan for the years 2019 and 2020. During an interview on 03/12/2021 at approximately 2:00 p.m., the surveyor asked the alternate administrator, Employee A and the office manager, Employee E if the agency had provided all EP plan documents and reports that the agency wanted to provide. Employees B and E replied, "Yes." During an interview on 03/18/2021 at 10:00 a.m. with the administrator, Employee A and the alternate administrator, Employee B, the surveyor asked why the agency had not conducted annual training for the agency staff in their roles and responsibilities in the EP response and plan. Employee B replied, "We did it like over the phone. After COVID started I stopped going over there because I couldn't travel." The surveyor discussed that the agency EP records and personnel did not contain any documentation of the training. Employee B did not address the lack of training and lack of documentation in 2018 and 2019 prior to COVID. Agency undated policy titled "Disaster/Emergency preparedness Number 7.031.1" read in part: " ...Procedure ...5. Employees will be oriented on the emergency plan at during the new hire process and annually ..."

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 review of the agency's EP material and interview, the agency failed to conduct exercises to test the emergency plan annually, for the years 2017, 2018 and 2019. This failure could place the agency's patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster. FINDINGS INCLUDED: During the entrance conference at 3:20 p.m. on 03/10/2021, the alternate administrator, Employee B identified the office manager, Employee E, as the disaster coordinator. Employee B self-identified as the alternate disaster coordinator. On 03/11/2021, record review of the agency's EP plan showed that the alternate administrator, Employee B was the disaster coordinator and the office manager, Employee E was the "secondary contact." The EP binder contained the correct designation for disaster coordinator and alternate. The emergency preparedness plan binder was reviewed on 03/11/2021. The review of the binder did not identify any records to establish that the agency had conducted exercises to test the EP plan annually (per agency policy) nor (per regulations), for the years 2018 and 2019. During an interview on 03/12/2021 at approximately 2:00 p.m., the surveyor asked the alternate administrator, Employee A and the office manager, Employee E if the agency had provided all EP plan documents and reports that the agency wanted to provide. Employees B and E replied, "Yes." During an interview on 03/18/2021 at approximately 10:00 a.m. with the administrator, Employee A and the alternate administrator, Employee B the surveyor asked what type of exercises/drills the agency conducted to test the EP plan. Employee B, the alternate administrator stated that the agency had been, "doing COVID for the past year, where we have them call in if they have a fever." The office manager, Employee E replied, "So the drills would be like, we would text or call the providers and clients." The surveyor asked why the agency had not conducted full-scale exercises for disasters that were most likely to occur the agency's service area- to test the EP plan. Employee B replied, "I guess because of COVID. I guess we have not been having much traffic in the office." Employee B did not address the agency's failure to conduct exercises in 2018 and 2019 prior to COVID. The surveyor also discussed the federal requirements for conducting exercises to test the emergency plan annually. Record review of agency undated policy titled "Disaster/Emergency Preparedness" was not updated to include federal regulatory requirements to conduct exercises to test the emergency plan annually, in full-scale exercises, mock drills and/or tabletop exercises.

Purpose of Visit: Re-certification Survey. Entrance Date: 03/10/2021 An entrance conference was conducted in person with the office manager/Employee E and via telephone with the alternate administrator, Employee B at 3:20 p.m. Employee B and E were informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 0 Exit Date: 03/18/2021 An exit conference was conducted at 1:00 p.m. in person with the office manager and via telephone with the administrator, Employee A, and the alternate administrator, Employee B. The preliminary findings were discussed. The agency was given an opportunity to ask question and provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified HHA's- Home Health Agencies PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement Novel Coronavirus Disease of 2019-COVID-19 CDC-Centers for Disease Control

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. This failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 03/11/2021. A binder labeled "QAPI Plan of Correction" was provided by the office manager, Employee E, on 03/11/2021. Record review of the binder showed that it contained the agency's written QAPI plan. The last QAPI reports in the binder were dated 01/01/2017 to 03/31/2017. The binder did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. On 03/12/2021 the alternate administrator, Employee B provided a binder that included meeting minutes for the agency, as well as meeting minutes for three other agencies operated by the agency administration. Review of the binder did not show any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 03/12/2021 at approximately 2:00 p.m., with the alternate administrator, Employee B and the office manager, Employee E, the surveyor asked if the agency had provided all QAPI information for review that the agency wanted to provide. Employees A and E replied, "Yes." During an interview with the administrator, Employee A, and the alternate administrator, Employee B, on 03/18/2021 at approximately 11:00 a.m., the surveyor asked what the agency did for its QAPI program. Employee B replied, "We have meetings." Employee B stated that the agency conducted meetings approximately every three months. The surveyor also asked why the agency had not conducted PIP(s) per federal regulatory requirements. Employee A stated that "we thought" the former owner, Identifier Q "was doing it." Review of agency undated policy "Quality Assessment & Performance Improvement Plan" showed that the policy was not updated to include the June 13, 2018 federal regulatory requirements for HHAs to conduct performance improvement projects.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. The agency failed to address: priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The agency failed to maintain a QAPI Program implemented by the QAPI committee. The QAPI program was not ongoing and focused on Patient outcomes that were measurable. The QAPI committee did not review and update or revise the plan of implementation at least once within a calendar year for the years 2018, 2019 and 2020. The failure could place the agency's Patients at risk of negative Patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 03/11/2021. A binder labeled "QAPI Plan of Correction" was provided by the office manager, Employee E, on 03/11/2021. Record review of the binder showed that it contained the agency's written QAPI plan. The last QAPI report in the binder was dated 01/01/2017 to 03/31/2017. The binder did not contain any reports, reviews or documentation that indicated the agency had maintained a QAPI program that included the federal regulatory requirements, as listed above, for the years 2018, 2019 and 2020. On 03/12/2021 the alternate administrator, Employee B provided a binder that included meeting minutes for the agency, as well as for three other agencies operated by the agency administration. Review of the binder did not show that the meeting minutes contained any reports, reviews or documentation that indicated the agency had maintained a QAPI program that included the federal regulatory requirements, as listed above, for the years 2018, 2019 and 2020. During an interview on 03/12/2021 at approximately 2:00 p.m., with the alternate administrator, Employee B and the office manager, Employee E, the surveyor asked if the agency had provided all QAPI information for review that the agency wanted to provide. Employees A and E replied, "Yes." During an interview with the administrator, Employee A, and the alternate administrator, Employee B, on 03/18/2021 at approximately 11:00 a.m., the surveyor asked what the agency did for its QAPI program. Employee B replied, "We have meetings." Employee B stated that the agency conducted meetings approximately every three months. The surveyor also asked why the agency had not ensured that an ongoing program for quality improvement and patient safety was implemented and maintained for the years 2018, 2019 and 2020. Employee A stated that "we thought" the former owner, Identifier Q "was doing it." Agency undated policy titled "Quality Assessment Performance Improvement Plan" read in part: "...Policy...The agency will establish and maintain an ongoing Quality Assessment Performance Improvement Program comprised of a system of measures that captures significant outcomes that are essential to optimal care and are used in service planning and coordination of services and events..."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control and investigation of infectious diseases that was an integral part of the Agency's QAPI program. 1. The agency failed to document in the agency QAPI program and infection control program Patients 15, 16, 17 and 18's COVID-19 infection (four of four patients with positive COVID-19 test results). 2. The agency failed to report the COVID-19 positive patients (Patients # 15, 16, 17 and 18) to DSHS or the local health department as required by CDC guidance (four of four patients). 3. The agency failed to document an influenza infection for an employee, PAS Field Supervisor, Employee P (one of one employee with an influenza infection). The failure could cause the agency to not identify, prevent, control, and investigate infections and to not develop actions that could improve or prevent the spread of infections to the agency's patients. FINDINGS INCLUDED: Record review of the agency's infection control binder labeled "Infection Control 2014-2017" provided by the office manager, Employee E, on 03/11/2021 revealed the last client infection report was dated 05/20/2017. The binder did not include any infection control logs for 2018, 2019, 2020 or currently for 2021. The agency infection control binder did not contain documentation of COVID-19 infections for Patients # 15, 16, 17 and 18. The agency's records did not show that the infections were reported to the DSHS or the local health department. The binder did not include any documentation for an influenza infection for Employee P. On 03/11/2021, record review of the agency's QAPI records did not show that the agency had reviewed the agency's infections for the years 2018, 2019 and 2020 or that they had implemented a plan to take appropriate actions that would result in improvement and disease prevention. On 03/12/2021 at 2:00 p.m., the surveyor asked if the agency had provided all infection control documents and reports that the agency wanted to provide. The alternate administrator, Employee B and the office manager, Employee E replied, "Yes." On 3/18/2021 at approximately 11:00 a.m., the surveyor asked where the agency documented client and staff infections. The supervising nurse, Employee C replied, "In the log that should be there somewhere, but I don't know where." The surveyor stated that during the entrance conference on 03/10/2021, Employee E stated that the agency had patients who had previously tested positive for COVID-19 and Employee B stated on 3/11/2021 that she had previously tested positive for COVID-19. The surveyor asked where the documentation was located, since it was not in the binder. Employee E replied, "I have it." Employee E printed a list that included Clients # 15, 16, 17, and 18's names and date of the infections and a list that included Employee B's name. The surveyor also asked why the agency had not maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, reporting and investigation of infectious diseases that was an integral part of the Agency's QAPI program. In relation to reporting, the administrator, Employee A stated that the agency was told they did not have to report because it would be double reporting. The surveyor discussed the federal, state and local requirements to report communicable/reportable infections. Record review of agency undated policy titled, "Infection/Exposure Control Plan"" read in part: " ...Policy: A. The Personal Assistance Agency will design, measure, assess and improve the function of surveillance, prevention, control of infections monthly through its performance Improvement Plan ...6. Require documentation of infections that are acquired while the client is receiving services from the Agency. Documentation must include the date that the infection was detected, the client/employee's name, primary diagnosis, signs/symptoms, type of infection, pathogens identified and treatment ...8. Comply with all state and federal regulations ...G. Upon learning of a client or employee infection, the PAS Supervisor must log the infection in the Client or Employee Infection Control Log ..." Record review of agency undated policy titled, "Evaluating and Maintaining Records of Infections Among Clients/Clients" read in part: "...Policy: All clients and employees with a suspected infection will be added to the Infection Control Log within twenty-four (24) hours of discovery ..."