Every finding on record at Lakeview Village Home Health

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (5FE77-H1) at Lakeview Village Home Health from 06/28/23 to 06/30/23 resulted in the following standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness Plan (EPP) on 6/29/2023, the agency failed to ensure the EPP included documentation of efforts to contact the local, regional, State, or Federal emergency preparedness officials, and include a process for cooperation and collaboration with the local, regional, State, or Federal emergency preparedness officials. This failure could result in inadequate planning and preparedness for an emergency event. Findings Included: The agency's EPP dated 6/28/23, did not have documentation of efforts to contact the local, regional, State, or Federal emergency preparedness officials, and include a process for cooperation and collaboration with the local, regional, State, or Federal emergency preparedness officials.

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), §485.542(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, REHs at §485.542, 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 Emergency Preparedness Plan (EPP) and interview, the agency failed to provide evidence or documentation showing participation in a community-based emergency exercise. Findings Include: Review of the EPP on 6/29/23, the EPP training program was missing documentation showing participation in a community-based emergency exercise.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site (Recertification) survey (#6028C-H1) conducted at the above-named Home Health Agency (HHA) from 06/28/23 to 06/30/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 418, Subpart C through E with the following standard-level deficiencies cited.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review, and staff interview the home health agency skilled staff failed to ensure the patient's right to participate in , be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 11 of 13 sample patients (Patients 1-6,8,10-13). The home health agency's failure to ensure the patient's right to consent to frequency of services placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1's Admission Consent dated 05/01/23 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Therapy (ST) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 1's plan of care indicated SN visits to be "1w1; 2w1 (1 time a week for 1 week; 2 times a week for 1 week); PT visits 1w1; 2w1;, OT visits 1w1; 2w1;, and ST 1w1; 2w1". Review of Start of Care Assessment visit dated 05/01/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/03/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 05/02/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Review of ST Evaluation visit dated 05/02/23 lacked documentation of ST providing the patient or caregiver with a frequency of visits for services. Observation during Patient 1's home visit with Skilled Nurse on 06/28/23 at 1:30 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 2 Review of Patient 2's Admission Consent dated 06/02/23 showed Skilled Nurse (SN), and Physical Therapy (PT) were both marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 2's plan of care indicated SN visits to be "2w1; 3w2; 2w2; 1w1; PT visits 1w1; 2w2; OT 2w2; ST 2w2; 2w3". Review of Start of Care Assessment visit dated 06/02/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 06/06/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 06/07/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Review of ST Evaluation visit dated 06/08/23 lacked documentation of ST providing the patient or caregiver with a frequency of visit for services. Observation during Patient 2's home visit with Physical Therapy Assistance (PTA) on 06/28/23 at 2:00 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Surveyor questioned the patient as to how he knew when clinicians would be making home visits and he stated, "they usually call me the night before". Patient 3 Review of Patient 3's Admission Consent dated 05/19/23 showed Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy were all marked "eval and treat" however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 3's plan of care indicated SN visits to "2w1; 1w5; 2w1; 1w3; PT 1w1; 2w2; 1w1;, OT 1w1; 2w1". Review of Start of Care Assessment visit dated 05/19/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/23/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 05/22/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Observation during Patient 3's home visit with Skilled Nurse on 06/29/23 at 11:00 AM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 4 Review of Patient 4's Admission Consent dated 05/24/23 showed Physical Therapy (PT) was marked with an X however, there was no evidence of the frequency of visits on the signed consent form. Review of Patient 4's plan of care indicated PT visits to be "2w3". Review of Start of Care Assessment visit dated 05/24/23 lacked documentation of the PT providing the patient or caregiver with a frequency of visits for PT or discussing the overall plan of care with the patient and/or caregiver. Observation during Patient 4's home visit with Skilled Nurse on 06/29/23 at 12:05 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 5 Review of Patient 5's Admission Consent dated 04/07/23 showed Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy (OT) were all marked with an X however, there was no evidence of the frequency of visits on the signed consent form. Review of Patient 5's plan of care indicated SN visits to be "1w1; 2w2; 1w2; PT 1w1; 2w3; OT 2w2; 1w1. Review of Start of Care Assessment visit dated 04/07/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation dated 04/10/23 lacked evidence of PT providing patient or caregiver with a frequency of visits for service. Review of OT Evaluation dated 04/12/23 lacked evidence of OT providing patient or caregiver with a frequency of visits for service. Observation during Patient 5's home visit with Physical Therapy Assistant (PTA) on 06/29/23 at 12:50 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Surveyor questioned the patient's wife as to how they knew when clinicians would make visits and she stated, "on Sunday nights they call us but there's no routine to it". Patient 6 Review of Patient 6's Admission Consent dated 03/27/23 showed Skilled Nurse (SN) was circled however, there was no evidence of the frequency of visits on the signed consent form. Review of Patient 6's plan of care indicated SN visits to be "1mo2" and 3 "PRN". Review of Start of Care Assessment visit dated 03/27/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Patient 8 Review of Patient 8's Admission Consent dated 04/26/23 showed Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy (OT) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 8's plan of care indicated SN visits to be "1w1; 1w1; 1w1; 2w1; 1w3; PT visits 2w1; OT visits 2w1; 1w1;". Review of Start of Care Assessment visit dated 04/26/23, lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 04/27/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 04/26/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Patient 10 Review of Patient 10's Admission Consent dated 05/08/23 showed Physical Therapy (PT), and Occupational Therapy (OT) were both marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 10's plan of care indicated PT visits to be "1w1; 2w2; 1w1; and OT w21; 1w1". Review of Start of Care Assessment visit dated 05/08/23 lacked documentation of the PT providing the patient or caregiver with a frequency of visits for PT or discussing the overall plan of care with the patient and/or caregiver. Review of OT Evaluation visit dated 05/09/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for service. Patient 11 Review of Patient 11's Admission Consent dated 05/02/23 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Therapy (ST) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 11's plan of care indicated SN visits to be "1w1; 3w1; 2w2; 1w2; PT 1w1; 2w3; OT 2w2; 1w1; ST 2w3". Review of Start of Care Assessment visit dated 05/02/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/03/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for service. Review of OT Evaluation visit dated 05/05/23 lacked documentation of OT providing the patient or caregiver with the frequency of visits for service. Review of ST Evaluation visit dated 05/04/23 lacked documentation of ST providing the patient or caregiver with a frequency of visits for service. Patient 12 Review of Patient 12's Admission Consent dated 03/05/23 showed Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy (OT) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 12's plan of care indicated SN visits to be "2w2; 1w2; PT 1w1; 2w2; OT 1w2". Review of Start of Care Assessment visit dated 03/05/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 03/07/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 03/06/23 lacked documentation of OT providing the patient or caregiver with the frequency of visits for services. Patient 13 Review of Patient 13's Admission Consent dated 04/19/23 showed Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy (OT) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 13's plan of care indicated SN visits to be "1w1; 3w6; and 3 PRN", PT and OT to eval and treat. Review of Start of Care Assessment visit dated 04/19/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Record review revealed the PT and OT Evaluation visits were not made due to the patient being transferred to the hospital on 04/20/23. During an interview on 06/30/23 at 9:15 PM, the Administrator stated it is the expectation that the clinician performing the Start of Care Assessment would complete the visit frequency line of the Admission Consent form and not just mark the disciplines. She confirmed the above findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedule including frequency of visits by HHA personnel for 13 of 13 Patients (Patients 1 - 13). The home health agency's failure to ensure the patients received written instruction regarding planned visits placed all patients, currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1's plan of care indicated Skilled Nurse (SN) visits to be "1w1; 2w1 (1 time a week times 1; 2 times a week times 1) Physical Therapy (PT) visits 1w1; 2w1; Occupational Therapy (OT) visits 1w1; 2w1;, and Speech Therapy (ST) 1w1; 2w1". Review of Start of Care Assessment visit dated 05/01/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/03/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 05/02/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Review of ST Evaluation visit dated 05/02/23 lacked documentation of ST providing the patient or caregiver with a frequency of visits for services. Observation during Patient 1's home visit with Skilled Nurse on 06/28/23 at 1:30 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 2 Review of Patient 2's plan of care indicated SN visits to be "2w1; 3w2; 2w2; 1w1; PT visits 1w1; 2w2; OT 2w2; ST 2w2; 2w3". Review of Start of Care Assessment visit dated 06/02/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 06/06/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 06/07/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Review of ST Evaluation visit dated 06/08/23 lacked documentation of ST providing the patient or caregiver with a frequency of visit for services. Observation during Patient 2's home visit with Physical Therapy Assistance (PTA) on 06/28/23 at 2:00 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Surveyor questioned the patient as to how he knew when clinicians would be making home visits and he stated, "they usually call me the night before". Patient 3 Review of Patient 3's plan of care indicated SN visits to "2w1; 1w5; 2w1; 1w3; PT 1w1; 2w2; 1w1; OT 1w1; 2w1". Review of Start of Care Assessment visit dated 05/19/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/23/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 05/22/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Observation during Patient 3's home visit with Skilled Nurse on 06/29/23 at 11:00 AM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 4 Review of Start of Care Assessment visit dated 05/24/23 lacked documentation of the PT providing the patient or caregiver with a frequency of visits for PT or discussing the overall plan of care with the patient and/or caregiver. Observation during Patient 4's home visit with Skilled Nurse on 06/29/23 at 12:05 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 5 Review of Patient 5's plan of care indicated SN visits to be "1w1; 2w2; 1w2; PT 1w1; 2w3;, OT 2w2; 1w1. Review of Start of Care Assessment visit dated 04/07/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation dated 04/10/23 lacked evidence of PT providing patient or caregiver with a frequency of visits for service. Review of OT Evaluation dated 04/12/23 lacked evidence of OT providing patient or caregiver with a frequency of visits for service. Observation during Patient 5's home visit with Physical Therapy Assistant (PTA) on 06/29/23 at 12:50 PM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Surveyor questioned the patient's wife as to how they knew when clinicians would make visits and she stated, "on Sunday nights they call us but there's no routine to it". Patient 6 Review of Patient 6's plan of care indicated SN visits to be "1mo2" and 3 "PRN". Review of Start of Care Assessment visit dated 03/27/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Patient 8 Review of Patient 8's plan of care indicated SN visits to be "1w1; 1w1; 1w1; 2w1; 1w3; PT visits 2w1; OT visits 2w1; 1w1;". Review of Start of Care Assessment visit dated 04/26/23, lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 04/27/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 04/26/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for services. Patient 10 Review of Patient 10's plan of care indicated PT visits to be "1w1; 2w2; 1w1; and OT w21; 1w1". Review of Start of Care Assessment visit dated 05/08/23 lacked documentation of the PT providing the patient or caregiver with a frequency of visits for PT or discussing the overall plan of care with the patient and/or caregiver. Review of OT Evaluation visit dated 05/09/23 lacked documentation of OT providing the patient or caregiver with a frequency of visits for service. Patient 11 Review of Patient 11's plan of care indicated SN visits to be "1w1; 3w1; 2w2; 1w2; PT 1w1; 2w3; OT 2w2; 1w1; ST 2w3". Review of Start of Care Assessment visit dated 05/02/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 05/03/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for service. Review of OT Evaluation visit dated 05/05/23 lacked documentation of OT providing the patient or caregiver with the frequency of visits for service. Review of ST Evaluation visit dated 05/04/23 lacked documentation of ST providing the patient or caregiver with a frequency of visits for service. Patient 12 Review of Patient 12's plan of care indicated SN visits to be "2w2; 1w2; PT 1w1; 2w2; OT 1w2". Review of Start of Care Assessment visit dated 03/05/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Review of PT Evaluation visit dated 03/07/23 lacked documentation of PT providing the patient or caregiver with a frequency of visits for services. Review of OT Evaluation visit dated 03/06/23 lacked documentation of OT providing the patient or caregiver with the frequency of visits for services. Patient 13 Review of Patient 13's plan of care indicated SN visits to be "1w1; 3w6; and 3 PRN", PT and OT to eval and treat. Review of Start of Care Assessment visit dated 04/19/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Record review revealed the PT and OT Evaluation visits were not made due to the patient being transferred to the hospital on 04/20/23. During an interview on 06/30/23 at 10:55 AM, Staff A, Administrator, stated that, the agency had not been giving the patients written information regarding the frequency of visits.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule/instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 13 of 13 Patients (Patients 1 - 13). The home health agency's failure to ensure the patients received written instruction regarding medication administration placed all patients, currently on service, at risk for adverse medication outcomes, and unmet needs. Findings Include: Patient 1 Review of Patient 1's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/01/23 lacked documentation of the skill nurse (SN) providing the patient or caregiver with written instructions regarding current medications. Observation during Patient 1's home visit with SN on 06/28/23 at 1:30 PM, review of home folder documents provided by the home health agency lacked evidence of a current medication list being provided to the patient. Patient 2 Review of Patient 2's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 06/02/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Observation during Patient 2's home visit with Physical Therapy Assistance (PTA) on 06/28/23 at 2:00 PM, review of home folder documents provided by the home health agency lacked evidence of a current medication list being provided to the patient. Patient 3 Review of Patient 3's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/19/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Observation during Patient 3's home visit with SN on 6/29/23 at 11:00 AM, review of home folder documents provided by the home health agency lacked evidence of a current medication list being provided to the patient. Patient 4 Review of Patient 4's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/24/23 lacked documentation of the PT providing the patient or caregiver with written instructions regarding current medications. Observation during Patient 4's home visit with Skilled Nurse on 06/29/23 at 12:05 PM, review of home folder documents provided by the home health agency lacked evidence of a current medication list being provided to the patient. Patient 5 Review of Patient 5's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 04/07/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Observation during Patient 5's home visit with Physical Therapy Assistant (PTA) on 06/29/23 at 12:50 PM, review of home folder documents provided by the home health agency lacked evidence of a current medication list being provided to the patient. Patient 6 Review of Patient 6's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 03/27/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 7 Review of Patient 7's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/23/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 8 Review of Patient 8's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 04/26/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 9 Review of Patient 9's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 03/21/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 10 Review of Patient 10's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/8/23 lacked documentation of the PT providing the patient or caregiver with written instructions regarding current medications. Patient 11 Review of Patient 11's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 05/2/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 12 Review of Patient 12's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 03/05/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. Patient 13 Review of Patient 13's plan of care indicated the patient was taking multiple medications. Review of Start of Care Assessment visit dated 04/19/23 lacked documentation of the SN providing the patient or caregiver with written instructions regarding current medications. During an interview on 6/30/23 at 10:55 AM, Staff A, Administrator, stated that, the agency was supposed to be providing the patient either a handwritten list of medications or taking them a printed copy.

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 interview and record review, it was determined the home health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 5 of 5 patients (Patients 1, 3, 5, 8, and 13). The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Patient 1 Review of Patient 1's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 5/1/23 and a Certification Period from: 05/01/23 to 06/29/23. Review of visit notes for the current certification period showed a transfer to the hospital on 06/03/23. The home health agency completed a Transfer to In-Patient (TIF) Assessment on 06/03/23 however, failed to send a copy of the summary to the facility. There was email documentation from Staff B dated 06/02/23 regarding the patient being at the hospital but no documented evidence of sending a transfer summary within the two-day timeframe. Patient 3 Review of Patient 3's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 5/19/23 and a Certification Period from: 05/19/23 to 07/17/23. Review of visit notes for the current certification period showed a transfer to the hospital on 05/23/23. The home health agency completed a Transfer to In-Patient (TIF) Assessment on 05/23/23 however, there was no documented evidence of a transfer summary created or sent to the receiving facility. Patient 5 Review of Patient 5's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 04/07/23 and a Certification Period from: 04/07/23 to 06/05/23. Review of visit notes for episode 04/07/23 to 06/07/23 showed a transfer to the hospital on 05/26/23. The home health agency completed a Transfer to In-Patient (TIF) Assessment on 05/26/23 however, there was no documented evidence of a transfer summary created or sent to the receiving facility. Patient 8 Review of Patient 8's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 04/26/23 and a Certification Period from: 04/26/23 to 06/24/23. Review of visit notes for the current episode showed a transfer to the hospital on 05/24/23. The home health agency completed a Transfer to In-Patient (TIF) Assessment and a Transfer Summary on 05/24/23. here was no documented evidence of the summary being sent to the receiving facility within 2 days. Patient 13 Review of Patient 13's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 04/19/23 and a Certification Period from: 04/19/23 to 06/17/23. Review of visit notes for the current episode showed a transfer to the hospital on 04/20/23. The home health agency completed a Transfer to In-Patient (TIF) Assessment and a Transfer Summary on 04/20/23. There was no documented evidence of the summary being sent to the receiving facility within 2 days. During an interview on 06/30/23 at 10;30 AM, Staff A, Administrator, confirmed the agency was unable to provide any evidence of the Transfer Summaries being sent to the receiving facilities.