Every finding on record at Kingsway Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/17/25. No deficiencies cited.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 04/17/25. Standard level deficiencies cited. Abbreviations: % = percent AM = morning lbs. = pound LPN = Licensed Practical Nurse MD = Medical Doctor O2 = oxygen OASIS = Outcome and Assessment Information Set PM = afternoon Pt./Pts. = Patients POC = Plan of Care PsOC = Plans of Care PT = Physical Therapist Q = every rtnop = retinopathy RN = Registered Nurse sat = saturation SN = Skilled Nurse SOC = Start of Care unsp = unspecified w = with w/o = without

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 on the review of the Error Summary report and staff interview, it was determined in 33 of 74 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 03/01/24 to 03/26/25, was reviewed on 04/14/25 at 10:30 AM. The report included error # -3330 (Record Submitted late: The Submission date is more than 30 days after the date assessment was completed on this record), for 34 of 74 late submissions, 44.59 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing on 04/15/25 at 4:00 PM, it was confirmed that the error occurred.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, home visit observation and staff interview, it was determined that for 3 of 7 (Pts. #1, #2 and #3) clinical records reviewed, the Agency failed to ensure, at time of admission, a copy of the Agency's transfer and discharge policy was provided to Pts. and their families. Findings include: 1. The Agency Pt. admission folder provided by the Agency was reviewed on 04/14/25 and 04/16/25. The folder lacked a copy of the Agency's transfer and discharge policy. 2. The following home visits were conducted from 04/14/25 at 3:30 PM to 04/15/25 at 12:30 PM: Pt. #1. SOC 03/17/25. Pt. #2. SOC 11/20/24. Pt. #3. SOC 03/28/25. During the home visits, the Pt. admission folders were observed and lacked a copy of the Agency's transfer and discharge policy. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, the Director of Nursing indicated the same admission folder is given to all Patients and, confirmed the admission folder did not contain a copy of the Agency's transfer and discharge policy.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, home visit observation, and staff interview, it was determined that for 3 of 7 (Pts. #1, #2 and #3) clinical records reviewed, the Agency failed to provide information regarding the Administrator and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 04/16/25. The folder lacked documentation identifying the Agency Administrator's name, their address and phone number to file a complaint and/or grievance. 2. The following home visits were conducted from 04/14/25 at 3:30 PM to 04/15/25 at 12:30 PM: Pt. #1. SOC 03/17/25. Pt. #2. SOC 11/20/24. Pt. #3. SOC 03/28/25. During the home visits, the Pt. admission folders were observed and lacked the Agency's Administrator, their address and phone number to file a complaint and/or grievance. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, it was confirmed this was the admission folder used for all admissions and that the folder lacked contact information for the Administrator.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, home visit interview and staff interviews, it was determined for 3 of 7 (Pts. #5, #6 and #3) clinical records reviewed, the Agency failed to ensure care was provided as ordered by the Physician as indicated in the POC. 3. Pt. #3 was admitted to the home health services on 04/04/25 with the diagnoses of Muscle Weakness and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 04/15/25. The clinical record contained a POC dated 04/04/25, that required the “sharps safety”. On 04/15/25 at 11:30 AM, a home visit was conducted with the PT. During the home visit interview, the patient’s daughter stated they were not provided with the sharp container and was disposing sharps into their garbage container. 4. The above findings were confirmed, during the interview with the Director of Nursing, on 04/15/25 between 2:30 PM and 3:30 PM. Findings include: 1. Pt. #5 was admitted to home health services on 08/31/24 with the diagnosis of Other Polyosteoarthritis. The clinical record was reviewed on 04/15/25, and included the POC effective 02/27/25 which required, “Orders for Discipline and Treatment, Nursing…SN to assess Pt.’s O2 sat level every SN visit and report saturation less than 90% to MD.” The SN notes for the following dates 03/17/25, 03/31/25 and 04/07/25, lacked documentation of reading for O2 saturation. 2. Pt. #7 was admitted to home health services on 08/31/24 with the diagnosis of but not limited to Pain in the Right Knee and Unspecified Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 04/15/25, and included the POC for the certification period of 12/14/24 to 02/01/25 which required, “Orders for Discipline and Treatment, Nursing…SN to weigh patient Q visit and to keep a log of daily weights and report and increase of 2 lbs./day or 5 lbs./week to MD.” The SN for the following dates 12/11/24 and 12/18/24, lacked documentation of the Pt.'s weight.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews, policy review and staff interviews, it was determined for 2 of 7 (Pts. #5 and #4) clinical records reviewed, the Agency failed to ensure PsOC included all the requirements. 2. Pt. #4 was admitted to the home health services on 08/09/24 with the diagnosis of Type 2 Diabetes “w unsp diabetic rtnop w/o macular edema”. The clinical record was reviewed on 04/15/25. The clinical record contained a POC dated 04/06/25 that required the SN to assess the patient. The POC lacked the frequency for the SN services, provided by the Agency. 3. The above findings were confirmed, during the interview with the Director of Nursing, on 04/15/25 between 2:30 PM and 3:30 PM. Findings include: 1. Pt. #5 was admitted for home health services on 08/31/24 with the diagnoses of Other Polyosteoarthritis. The clinical record was reviewed on 04/15/25. The Plan of Care effective 02/27/25 lacked documentation of vital signs parameters.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined that for 2 of 2 (Pts. #6 and #7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary within 5 days after discharge. Findings include: 1. Pt. #6 was admitted to Home Health Services on 07/19/24 with the diagnosis of Mild Cognitive Impairment. The record contained a Discharge comprehensive assessment dated 09/10/24, indicating that Pt. #6 was discharged from the Agency. The record lacked documentation that a copy of the Pt.'s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 12/04/24 with the diagnosis of Pain in Right Knee. The record contained a Discharge comprehensive assessment dated 01/15/25, indicating that Pt. #7 was discharged from the Agency. The record lacked documentation that a copy of the Pt.’s discharge summary was sent to the Physician. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, the above findings were confirmed.

A Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.102 Emergency Preparedness. 42 CFR 484.105 Organization and Administration Services. 42 CFR 484.110 Clinical Records

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: A. Based on observation and staff interview, it was determined the Agency failed to establish and maintain an Emergency Plan; failed to ensure its Emergency Plan was based on a facility-based and community-based risk assessment that utilizes an all hazards approach; failed to develop and implement Emergency Plan policies; failed to develop a communication plan that contains how the Agency collaborates with state and local officials, and includes the required names and contact information; and failed to develop and implement an Emergency Plan training and testing program based on its Emergency Plan. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency failed to establish and maintain a comprehensive Emergency Plan. (E0004). 2. The Agency failed to ensure it established an Emergency Plan that was based on a facility-based and community-based risk assessment, utilizing an all hazards approach. (E-0006). 3. The Agency failed to develop and implement Emergency Plan policies and procedures (E0013). 4. The Agency failed to develop and maintain an Emergency Plan that contains how the Agency collaborates with state and local officials. (E0029). 5. The Agency failed to have an Emergency Communication Plan that included the required names and contact information (E0030). 6. The Agency failed to provide an Emergency Preparedness staff training and testing program, based on its Emergency Plan. (E-0036). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate direction or supervision in the event of an emergency or disaster.

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: A. Based on staff interview and observation, it was determined the Agency failed to establish and maintain a comprehensive Emergency Plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. On 2/8/22 at 3:40 PM, it was observed the Agency’s Emergency Plan was not provided for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide an Emergency Plan.

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), §485.625(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: A. Based on staff interview and observation, it was determined the Agency failed to ensure it developed an Emergency Preparedness Plan that was based on facility-based and community-based risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. On 2/8/22 at 3:40 PM, it was observed the Agency’s Emergency Plan, including a facility-based and community-based risk assessment which utilizes an all-hazards approach, still was not provided for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide an Emergency Plan that included a facility-based and community-based risk assessment.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to establish and maintain Emergency Plan policies and procedures. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. On 2/8/22 at 3:40 PM, it was observed the Agency’s Emergency Plan, including policies and procedures, was not provided for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide an Emergency Plan, which included emergency policies and procedures

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to develop and maintain an Emergency Communication Plan that includes how the Agency collaborates with state and local officials. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. On 2/8/22 at 3:40 PM, it was observed the Agency’s Emergency Plan, including a communication plan that indicates how the Agency will collaborate with state and local officials, was not provided for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide an Emergency Plan, which included a communication plan indicating how the Agency would collaborate with state and local officials.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to develop and maintain an Emergency Communication Plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. On 2/8/22 at 3:40 PM, it was observed the Agency’s Emergency Plan, including an Emergency Communication plan that contains the names and contact information for staff members, entities providing service under arrangement, patient physicians, and volunteers, was not provided for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide an Emergency Plan, which included an Emergency Communication Plan containing the required names and contact information.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to provide emergency preparedness staff training, as well as testing of its Emergency Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Agency’s Emergency Plan was requested for review. 2. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed the Agency’s Emergency Plan, including documentation of staff training and testing of its plan, including a full-scale or table top testing exercise, was not provided for review. The Director of Nursing confirmed the Agency did not have a Emergency Plan, which included documentation of emergency preparedness staff training, as well as testing of the plan.

42 CFR484.80 (f)(3): Eligible training and competency evaluation organizations. A Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.102 Emergency Preparedness. 42 CFR 484.105 Organization and Administration Services. 42 CFR 484.110 Clinical Records Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 2/9/22. This applies even if the agency is not currently conducting aide training and/or competency evaluation. Abbreviations: Pt./Pts.= Patient/Patients SN= Skilled Nurse POC/PsOC= Plan of Care/Plans of Care SOC= Start of Care AM= Morning PM= Afternoon/Evening

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to provide documentation the Administrator was appointed by the governing body, the Agency Supervisor and Personnel were qualified for their positions, ensure a pre-designated, qualified person was appointed as Alternate Administrator, the Agency Supervisor provides oversight of all Pt. care services and personnel, and develops, implements, and updates Pt. individualized PsOC. Findings include: 1. The Agency failed to provide documentation the Administrator was appointed by the Governing Body. (G946). 2. The Agency failed to provide documentation the Agency Supervisor is available during all operating hours. (G950). 3. The Agency failed to provide documentation it employs qualified personnel. (G952). 4. The Agency failed to provide documentation a qualified, pre-designated person assumes the responsibilities of the Administrator when the Administrator is unavailable. (G954). 5. The Agency failed to provide documentation it assumes the development, implementation, and updates Pt. individualized PsOC. (G968). The cumulative effect of these systemic practices resulted in the Agency’s inability to effectively govern Agency operations and Pt. care services.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: A. Based on observation and staff interview, it was determined the Agency failed to provide documentation the Administrator was appointed by the Governing Body. This has the potential to affect all the patients served by the Agency. Findings include: 1.On 2/8/22 at 11:40 AM, the Director of Nursing stated the Administrator was not available and that the appointment as Administrator was done by the Governing Body. Documentation of this was requested at that time. 2. As of 3:40 PM on 2/8/22, it was observed no documentation regarding the appointment of the Administrator by the Governing Body was not presented. 3. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed the Administrator was not available until next week, and documentation was not presented confirming Administrator was appointed by the Governing Body.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to ensure the Director of Nursing or the pre-designated Alternate Director of Nursing is available during operational hours of business. This has the potential to affect all Pts. receiving services from the Agency. 1. During the entrance interview with the Director of Nursing on 2/8/21 at 11:40 am, the Director of Nursing stated she was the pre-designated Alternate Administrator and was currently performing duties as Alternate Administrator. The Director of Nursing stated the Administrator was unavailable until the next week. The Director of Nursing stated E #3 was the pre-designated Alternate Director of Nursing. The Director of Nursing failed to produce documentation E #3 was the Alternate Director of Nursing. 2. As of 2/8/22 at 3:40 PM, documentation that E #3 is the Alternate Director of Nursing was not provided. E#3 was not present in person at the Agency’s and or available for contact.

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: A. Based on staff interview and observation, it was determined the Agency failed to ensure it employs qualified personnel. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the personnel files of all current employees (E #1, 2, 3, 4, 5, and 6) were requested for review. 2. As of 2/8/22 at 3:40 PM, it was observed no personnel files were presented for review. The Director of Nursing confirmed the personnel files of E #1, 2, 3, 4, 5, and 6 were unavailable for review.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: A. Based on staff interview, it was determined the Agency failed to provide documentation of a qualified, pre-designated person who assumes the responsibilities of the Administrator in the absence of the Administrator. Findings include: 1.During the entrance interview on 2/8/22 at 11:40 AM, The Director of Nursing stated the Administrator was not available this week, as she was the pre-designated Alternate Administrator. A copy of the designation letter documenting that the Director of Nursing is the designated person to cover in the absence of the Administrator was requested for review. 2. During an interview with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM a copy of the letter of designation documenting that the Director of Nursing is the pre-designated person to cover for the Administrator was requested for review. The letter of designation was not provided. 3. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed the Administrator was not available until next week and the letter of designation was not presented for review.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to develop, implement, and update individualized PsOC. This was found in 3 of 4 (Pt. #2, 3, and 4) pts. reviewed for clinical record content. Findings include: 1. On 2/8/22 at 1:45 PM, the Director of Nursing presented a list of Pts. admitted to the Agency within the past 12 months. Pts. #2, 3, and 4 were on this list. The clinical records of Pts. #2, 3, and 4 were requested. 2. On 2/8/22 at 3:40 PM, it was observed the clinical records, including PsOC of Pts. #2, 3, and 4 were unavailable for review. The Director of Nursing confirmed the clinical records including the PsOC of Pts. #2, 3, and 4 were not provided and unavailable for review

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to maintain complete clinical records, including comprehensive assessments, PsOC, Physician orders, clinical notes, interventions and Pt. response, goals for care, Pt. contact information for Pts. and their Physicians, discharge/transfer summaries, and retain clinical records as per requirements. This has the potential to affect 4 of 4 Pts. (Pt. #1, 2, 3, and 4). 1. The Agency failed ensure clinical records contained comprehensive assessments, PsOC, Physician orders, and clinical notes. (G1012). 2. The Agency failed to ensure clinical records included clinical interventions and Pt. response. (G1014). 3. The Agency failed to include goals in PsOC. (G1016). 4. The Agency failed to ensure clinical records contained contact information for the Pt., Patient’s Representative, and Primary Caregiver. (G1018). 5. The Agency failed to ensure clinical records contained contact information for the Patient’s Physician. (G1020). 6. The Agency failed to ensure clinical records contained discharge/transfer summaries for Pts. who were discharged/transferred from Agency services. (G1022). 7. The Agency failed to retain complete clinical records, as per requirements. (G1026). The cumulative effect of these systemic practices resulted in the Agency’s inability to complete and maintain Pt. clinical records.

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: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure clinical records contained comprehensive assessments, PsOC, Physician orders, and clinical notes. This was found in 4 of 4 (Pts. #1, 2, 3, and 4) pts. reviewed for clinical record content. . Findings include: 1. Pt. #1. SOC 10/24/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 2/8/22 at 2:15 PM. The record included the POC effective 12/18/21 to 2/15/22, which included the Physician’s order “SN Frequency: 1 Week 9.” The record lacked documentation of comprehensive assessments, as well as weekly SN visits. 2. On 2/8/22 at 1:45 PM, the Director of Nursing presented a list of Pts. admitted to the Agency within the past 12 months. Pts. #1, 2, 3, and 4 were on this list. Pt. #1’s clinical record was presented. The clinical records of Pts. #2, 3, and 4 were requested and not presented. 3. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed Pt. #1’s clinical record presented did not contain comprehensive assessments and clinical notes, and the clinical records of Pts. #2, 3, and 4 were unavailable for review.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure clinical records included clinical interventions and Pt. response to these interventions. This was found in 4 of 4 (Pts. #1, 2, 3, and 4) pts. reviewed for clinical record content. Findings include: 1. Pt. #1. SOC 10/24/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 2/8/22 at 2:15 PM. The record lacked documentation of clinical interventions and the Patient’s response to these interventions. 2. On 2/8/22 at 1:45 PM, the Director of Nursing presented a list of Pts. admitted to the Agency within the past 12 months. Pts. #1, 2, 3, and 4 were on this list. Pt. #1’s clinical record was presented. The clinical records of Pts. #2, 3, and 4 were were requested and not presented. 3. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed Pt. #1’s clinical record presented did not contain clinical interventions and pt. response to these interventions, and the clinical records of Pts. #2, 3, and 4 were unavailable for review.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: A. Based on observation and staff interview, it was determined the Agency failed to include Pt. PsOC containing goals for care. This was found in 3 of 4 (Pts. #2, 3, and 4) pts. reviewed for clinical record content. Findings include: 1. On 2/8/22 at 1:45 PM, the Director of Nursing presented a list of Pts. admitted to the Agency within the past 12 months. Pts. #2, 3, and 4 were on this list. The clinical records of Pts. #2, 3, and 4 were requested and not presented. 2. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed the clinical records of Pts. #2, 3, and 4 were unavailable for review, including PsOC and goals for care.

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure clinical records included contact information for pts., representatives, and caregivers. This was found in 4 of 4 (Pts. #1, 2, 3, and 4) pts. reviewed for clinical record content. Findings include: 1. Pt. #1. SOC 10/24/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 2/8/22 at 2:15 PM. The record lacked documentation of contact information for the Pt., representative, and caregiver. 2. On 2/8/22 at 1:45 PM, the Director of Nursing presented a list of Pts. admitted to the Agency within the past 12 months. Pts. #1, 2, 3, and 4 were on this list. Pt. #1’s clinical record was presented. The clinical records of Pts. #2, 3, and 4 were requested and not presented. 3. During an interview with the Director of Nursing on 2/8/22 at 3:40 PM, it was confirmed Pt. #1’s clinical record did not contain the contact information of the Pt., representative, and caregiver, and the clinical records of Pts. #2, 3, and 4 were unavailable for review.

Contact info for primary care practitioner CFR(s): 484.110(a)(5) Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA; and This ELEMENT is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to maintain the contact information for the Physician who will be providing services to the Pts. after being discharged from the Agency. This has the potential to affect the Pts. who have received services within the last 12 months (Pts. #2, 3, and 4) and have been discharged. Findings include: 1. During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, (Pts. #2, 3, and 4) closed medical records were requested for review. 2. On 2/8/22 at 3:40 PM, the closed medical records of (Pts. #2, 3, and 4) from the Pt. list provided by the Director of Nursing were still not presented for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide the requested closed medical records of (Pts. #2, 3, and 4) for review.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to maintain the discharge/transfer summaries in the Pts. records. This has the potential to affect all the Pts. who have received services within the last 12 months (Pts. #2, 3, and 4) and have been discharged. Findings include: 1.During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, the Pts. closed medical records of (Pts. #2, 3, and 4) were requested for review. 2. On 2/8/22 at 3:40 PM, the closed medical records of (Pts. #2, 3, and 4) from the Pt. list provided by the Director of Nursing were still not presented for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide requested closed medical records of (Pts. #2, 3, and 4) for review.

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: A. Based on staff interview and observation, it was determined the Agency failed to retain Pts. records after they were discharged. This has the potential to affect all Pts. who received services from the Agency within the last 12 months (Pts. #2, 3, and 4) who have been discharged. Findings include: 1.During interviews with the Director of Nursing on 2/8/22 at 11:40 AM and 1:42 PM, (Pts. #2, 3, and 4) closed medical records were requested for review. 2. On 2/8/22 at 3:40 PM, the requested closed medical records of (Pts. #2, 3, and 4) from the Pt. list provided by the Director of Nursing were still not presented for review. During an interview at that time with the Director of Nursing, it was confirmed the Agency did not provide the requested closed medical records of (Pts. #2, 3, and 4) for review.