Every finding on record at Libbys Healthcare Management Inc

Purpose of visit: Recertification survey Entrance conference date: 06/09/2025 The census was: 42 Licensed and Certified patients: 42 The agency met Medicare Conditions of Participation for Emergency Preparedness.

Purpose of visit: Recertification survey Entrance conference date: 06/09/2025 The census was: 42 Licensed and Certified patients: 0 Abbreviations: Adm –Administrator DON - Director of Nurses ADON – Alternate Director of Nurses Alt Adm - Alternate Administrator HHA – Home Health Agency SOC - Start of Care POC – Plan of Care EMR – Electronic Medical Record

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review, interview, and observation the HHA failed to provide written information in three (Patients # 1, 2 and 3) of three patients who received a home visit. The HHA failed to provide the patient and caregiver with a copy of written instructions which outlined the patients' visit schedule and medication schedule/instructions. The failure to provide visit schedule detailing service visits caused the patients at risk of being uninformed and/or unable to identify the staff scheduled to provide care and services on behalf of the agency in the patient's homes. The failure of not providing medication instructions caused the patients and patient representative at risk to be uninformed of the patient's medication name, dosage and frequency, potential adverse effects, including significant side effects, and duplicate drug therapy. Findings Include: Review of the EMR for Patient #1: The EMR contained a POC, and a medication list electronically signed by the DON for the treatment period of 04/16/2025 to 06/14/2025 with a SOC date of 06/20/2024. A home visit was conducted with Patient #1 on 06/10/2025 at approximately 9:30 AM. The surveyor observed and reviewed home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. Review of the EMR for Patient #2: The EMR contained a POC, and a medication list electronically signed by the ADON for the treatment period of 05/16/2025 to 07/14/2025 with a SOC date of 03/22/2024. A home visit was conducted with Patient #2 on 06/10/2025 at approximately 10:40 AM. The surveyor observed and reviewed home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. Review of the EMR for Patient #3: The EMR contained a POC, and a medication list electronically signed by the ADON for the treatment period of 05/16/2025 to 07/14/2025 with a SOC date of 03/22/2024. A home visit was conducted with Patient #3 on 06/10/2025 at approximately 11:10 AM. The surveyor observed and reviewed home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. During an interview on 06/12/2025 at approximately 12:15 PM with the Adm/DON and Alt Adm, the surveyor discussed the findings from the review of home admission packets. The surveyor asked why the agency had not provided a visit schedule or updated medication list to the Patients # 1, 2 and 3. The DON replied that she did not provide a medication list and a visit schedule, she was not aware that the visit schedule and medication list was required. The surveyor asked what the agency policy was, the DON did not reply. The Adm and the Alt Adm did not dispute the findings.

An entrance conference was conducted on 06/21/2022 at 2:00 p.m. with the Adm/DON and Alt Adm # 2. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 9 An exit conference was conducted on 06/27/2022 at 1:10 p.m. with the Adm/DON and Alt Adm # 2. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviation List: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing/Supervising Nurse ALT DON-Assistant Director of Nursing/Alternate Supervising Nurse L & C- Licensed and Certified EP-Emergency Preparedness

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop and maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach in three (2019, 2020 and 2021) of three years. The failure could place the agency’s patients’ health and safety at risk because the agency would potentially be unable to help them in emergency or disaster situations. FINDINGS INCLUDED: During the entrance conference on 06/21/2022 at 2:00 p.m., the surveyor requested all agency EP records. The Alt Adm # 2 stated that on 03/25/2021 the agency was purchased from Former Owner and that the Former owner did not transfer any agency records. Review of the agency’s EP binder labeled “Emergency Preparedness Manual” did not reveal that the agency had developed and maintained an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for the survey review period of 07/03/2019 to 06/21/2022. The EP binder included the agency’s EP policy titled, “Emergency Preparedness and Response Plan EC.6.” The EP binder and the EP policy did not include a documented facility-based and community-based risk assessment that utilized an all-hazards approach. During an interview on 06/21/2022 at approximately 3:00 p.m. the surveyor asked the Alt Adm # 2 if the agency had any other records to submit for review from the records request list, which included EP records, provided during the entrance conference. The Alt Adm # 2 replied, “I will look.” At approximately 3:05 p.m. the Alt Adm # 2 stated, “That’s it.” During an interview with the Former Owner on 06/22/2022 at Approximately 10:30 a.m., the surveyor discussed the location of the agency’s records prior to the sale of the agency, on 03/25/2021, to the Current Owner. The Former Owner stated that the records were placed in storage and “he accidently shredded them.” During an interview with the Adm and Alt Adm # 2 on 06/27/2022 at approximately 12:15 p.m. the surveyor discussed the above findings of why the agency did not develop and maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for the survey review period of 07/03/2019 to 06/21/2022. The Alt Adm # 2 replied, “I was not aware of that.” The surveyor also discussed how not developing, implementing, and maintaining an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach could adversely affect the agency’s patients. The Alt Adm # 2 replied, “We wouldn’t be able to help them if we were in some emergency situation, potentially.” Review of agency policy titled, ““Emergency Preparedness and Response Plan EC.6” read in part: “PURPOSE I. To ensure the agency develops, maintains, and implements a written Emergency Preparedness and Response Plan, based on Agency risk assessment…POLICY 1. The Agency will have a written preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area…”

An entrance conference was conducted on 06/21/2022 at 2:00 p.m. with the Adm/DON and Alt Adm # 2. The Adm/DON was informed that the purpose of the survey was for a 36-month recertification inspection with a follow-up for survey dated 07/02/2019. L&C Census: 9 An exit conference was conducted on 06/27/2022 at 1:10 p.m. with the Adm/DON and Alt Adm # 2. The preliminary findings were discussed. The agency was given an opportunity to provide additional information. Additional information was provided. Written instructions were provided to the agency for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. Abbreviation List: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nursing/Supervising Nurse ALT DON-Assistant Director of Nursing/Alternate Supervising Nurse L & C- Licensed and Certified POC-Plan of Care SN-Skilled Nurse HHA-Home Health Agency QAPI-Quality Assessment Performance Improvement COVID-19- Novel Coronavirus Disease 2019

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide 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 to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: This is a continuing deficiency cited at G 0422 at survey dated 07/02/2019. Based on observation, interview and record review, the agency failed to provide written notice of the HHA's transfer and discharge policies to a patient or selected representative within four business days of the initial evaluation visit, in three (Patients # 4, 5 and 8) of three patients who received a home visit. The failure did not conform to the patient's right to be provided written notice related to the criteria used to determine if the patient could be discharged or transferred from agency services. The failure could place the agency’s patients at risk to have their patient rights not honored related to their possible discharge or transfer. FINDINGS INCLUDED: The surveyor reviewed the agency's sample "Medicare" admission packet on 06/21/2022. The sample packet did not include written notice of the agency's patient transfer and discharge policies. Patient # 4 Review of the clinical record for Patient # 4 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 06/23/2022 at approximately 12:00 noon, observation and review of Patient #4's home folder revealed that the folder did not include written notice of the agency's transfer and discharge policies. The home folder included all documents that were in the sample Medicare admission packet. Patient # 5 Review of the clinical record for Patient # 5 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Essential (primary) Hypertension. The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 06/23/2022 at approximately 11:00 a.m., observation and review of Patient #5's home folder revealed that the folder did not include written notice of the agency's transfer and discharge policies. The home folder included all documents that were in the sample Medicare admission packet. Patient # 8 Review of the clinical record for Patient # 8 revealed POC for the certification period of 04/10/2022 to 06/08/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for eight weeks. During a home visit conducted on 06/23/2022 at approximately 12:30 p.m., observation and review of Patient #8's home folder revealed that the folder did not include written notice of the agency's transfer and discharge policies. The home folder included all documents that were in the sample Medicare admission packet. During an interview with the Adm/DON and Alt Adm # 2 on 06/27/2022 at 11:45 a.m., the surveyor discussed the above findings of why the agency had not provided written notice of the agency's transfer and discharge policies within four business days of the initial evaluation visit to Patients # 4, 5 and 8. The Alt Adm # 2. replied, “I think we just did not, forgot to put them in there.” The Adm/DON replied, “I just discuss with them.” The surveyor also discussed how not providing the written notice of the HHA's transfer and discharge policies to a patient or selected representative within four business days of the initial evaluation visit could adversely affect the agency’s patients. The Alt Adm # 2 replied, “If it is their right then, they definitely need it since it is their right.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review, observation and interviews, the agency failed to advise patients of the names, addresses, and telephone numbers of federally funded and state-funded entities that service the area where the patient resided, in three (Patients # 4, 5 and 8) of three patients who received home visits. This failure did not conform to the patients’ right to be provided information regarding the entities in the event such information was needed by the patient. The failure could cause the agency’s patients to be uninformed of resources that were available for them in their service area. FINDINGS INCLUDED: On 06/21/2022 the surveyor reviewed the agency's sample "Medicare" admission packet. The sample packet did not include the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that serve the area where the patients resided: Agency on Aging Center for Independent Living Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. The packet did include a document titled “Notice of Medicare Non-Coverage.” The notice had an area to insert the name and number of the Quality Improvement Organization. The area was not completed with the name and contact number. Patient # 4 Review of the clinical record for Patient # 4 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for nine weeks. The record also included a Notice of Medicare Non-Coverage that was signed by Patient # 4. The Notice included the name of the Quality Improvement Organization, but the numbers listed were not updated to the current contact numbers. During a home visit conducted on 06/23/2022 at approximately 12:00 noon, the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the federally funded and state-funded entities that served the area where the patient resided. The home folder included all documents that were in the sample Medicare admission packet. Patient # 5 Review of the clinical record for Patient # 5 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Essential (primary) Hypertension. The POC contained an order for skilled nursing visits for one time per week for nine weeks. The record also included a Notice of Medicare Non-Coverage that was signed by Patient # 5. The Notice included the name of the Quality Improvement Organization, but the numbers listed were not updated to the current contact numbers. During a home visit conducted on 06/23/2022 at approximately 11:00 a.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the federally funded and state-funded entities that served the area where the patient resided. The home folder included all documents that were in the sample Medicare admission packet. Patient # 8 Review of the clinical record for Patient # 8 revealed POC for the certification period of 04/10/2022 to 06/08/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for eight weeks. The record also included a Notice of Medicare Non-Coverage that was signed by Patient # 8. The Notice included the name of the Quality Improvement Organization, but the numbers listed were not updated to the current contact numbers. During a home visit conducted on 06/23/2022 at approximately 12:30 p.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the federally funded and state-funded entities that served the area where the patients resided. The home folder included all documents that were in the sample Medicare admission packet. On 06/27/2022 at 11:39 a.m., the surveyor discussed the above findings with the Adm/DON and Alt Adm # 2 of why the sample admission packet and home folders for Patients # 4, 5 and 8 did not include the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that served the area where the patients resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Organization. The Alt Adm # 2 stated that the agency was not aware of the regulatory requirement. The surveyor also discussed how not providing the agency’s patients with the required names and contact information for the federally funde3d and state-funded entities could adversely affect the agency’s patients. The Alt Adm # 2 replied, “Us not being as well informed as we should be, just in general is not going to be very beneficial for them.”

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: This is a continuing deficiency cited at G 0574 at survey dated 07/02/2019. Based on record review and interview in seven (Patients #1, 3, 4, 5, 6, 7 and 8) of seven active records with the current POC reviewed, the agency failed to develop POC’s that covered all the pertinent elements. The POC's of the identified patients failed to contain 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. The failure could place the agency’s patients at risk of a decline in their health status and subsequent unnecessary emergency room visits and hospital re-admissions. FINDINGS INCLUDED: Patient record #1- Record Review: The clinical record contained a POC for the certification period 06/09/2022 to 08/07/2022, signed by the Adm/DON on 06/06/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record #3- Record Review The clinical record contained a POC for the certification period 06/10/2022 to 08/08/2022, signed by the Adm/DON on 06/06/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record # 4-Record Review: The clinical record contained a POC for the certification period of 06/09/2022 to 08/07/202, signed by the Adm/DON on 06/06/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record # 5-Record Review: The clinical record contained a POC for the certification period of 06/09/2022 to 08/07/202, signed by the Adm/DON on 06/06/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record # 6-Record Review: The clinical record for contained a POC for the certification period of 06/13/2022 to 08/11/202, signed by the Adm/DON on 06/09/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record #7-Record Review: The clinical record contained a POC for the certification period 05/14/2022 to 07/12/2022, signed by the Adm/DON on 05/09/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. Patient record # 8-Record Review: The clinical record for contained a POC for the certification period of 06/09/2022 to 08/07/202, signed by the Adm/DON on 06/06/2022. The POC contained an area for “Patient Risk Profile” that read “Risk factors: Currently taking 5 or more meds. Currently reports exhaustion.” The POC did not contain 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. During an interview with the Adm/DON and the Alt Adm # 2 on 06/27/2022 at approximately 11:45 a.m., the surveyor discussed the above findings of why the POC’s for Patient's #1, 3, 4, 5, 6, 7 and 8 did not include the patient's risks for emergency department visits or hospital re-admissions. The Adm/DON replied, “I just explain to patient about emergency preparedness.” The surveyor also discussed how not including the patient's risks for emergency department visits or hospital re-admissions in the patients’ POC’s could adversely affect them. The Adm/DON replied, “If I don’t explain to them, they will possibly go to emergency room.” The Alt Adm # 2 replied, “It would affect their health negatively if we don’t address how to prevent re-hospitalization.”

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: This is a continuing deficiency cited at G 0614 at survey dated 07/02/2019. Based on records review, observation, and interview, the HHA failed to ensure that a written visit schedule was provided to the patient that was consistent with the patient's most current plan of care, in three (Patients # 4, 5 and 8) of three patients who received a home visit. This failure did not allow the patients and/or caregivers the ability to anticipate care and service visits on a regular and consistent basis. The failure could also cause visit schedule conflicts with the patients’ medical or other appointments and could cause missed visits. FINDINGS INCLUDED: The surveyor reviewed the agency's sample "Medicare" admission packet on 06/21/2022. The sample packet included a written visit schedule form. Patient # 4 Review of the clinical record for Patient # 4 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 06/23/2022 at approximately 12:00 noon, observation and review of the agency folder provided to the patient revealed it did not include a written schedule for care and service visits by the agency staff or other care providers assigned by the agency. The home folder included all documents that were in the sample Medicare admission packet. The visit schedule form was not completed. Patient # 5 Review of the clinical record for Patient # 5 revealed POC for the certification period of 02/09/2022 to 04/09/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Essential (primary) Hypertension. The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 06/23/2022 at approximately 11:00 a.m., observation and review of the agency folder provided to the patient revealed it did not include a written schedule for care and service visits by the agency staff or other care providers assigned by the agency. The home folder included all documents that were in the sample Medicare admission packet. The visit schedule form was not completed. Patient # 8 Review of the clinical record for Patient # 8 revealed POC for the certification period of 04/10/2022 to 06/08/2022. The POC revealed a start of care date of 02/09/2022 and a primary diagnosis of Hypertensive heart disease with heart failure. The POC contained an order for skilled nursing visits for one time per week for eight weeks. During a home visit conducted on 06/23/2022 at approximately 12:30 p.m., observation and review of the agency folder provided to the patient revealed it did not include a written schedule for care and service visits by the agency staff or other care providers assigned by the agency. The home folder included all documents that were in the sample Medicare admission packet. The visit schedule form was not completed. During an interview with the Adm/DON and Alt Adm # 2 on 06/27/2022 at 11:45 a.m., the surveyor discussed the above findings of why the agency had not ensured that a written visit schedule was provided to the patient that was consistent with the patient's most current plan of care to Patients # 4, 5 and 8. The Adm/DON stated that she only discussed with them the frequency. The surveyor also discussed how not ensuring that a written visit schedule was provided to the patient that was consistent with the patient's most current plan of care could adversely affect the agency’s patients. The Alt Adm # 2 replied, “so that they would know when we are planning to visit, so that there are no conflicts.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview The HHA's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained; that the HHA‐wide QAPI efforts addressed priorities for improved quality of care and patient safety; that all improvement actions were evaluated for effectiveness, and that clear expectations for patient safety were established, implemented, and maintained in three (2019, 2020 and 2021) of three years. The failure could limit the agency's ability to review client outcomes, to identify and to immediately correct any problems and concerns in service delivery which might directly or potentially threaten the care and safety of clients. The failure could also place the agency’s clients’ health and safety at risk. FINDINGS INCLUDED: During the entrance conference on 06/21/2022 at 2:00 p.m. the surveyor requested all agency QAPI records. The Alt Adm # 2 stated that on 03/25/2021 the agency was purchased from Former Owner and that the Former owner did not transfer any agency records. Review of the agency’s QAPI binder labeled “QAPI Manual” did not reveal that the agency’s QAPI Committee had implemented and reviewed a QAPI program consistent with state and federal requirements for the survey review period of 07/03/2019 to 06/21/2022. The QAPI binder included the agency’s QAPI policy titled, “Quality Assessment Performance Improvement PLAN.” The binder also had blank QAPI forms that had not been completed. The QAPI binder and the QAPI policy did not include any records that revealed the agency had implemented and reviewed a QAPI program consistent with state and federal requirements for the survey review period of 07/03/2019 to 06/21/2022. During an interview on 06/21/2022 at approximately 3:00 p.m. the surveyor asked the Alt Adm # 2 if the agency had any other records to submit for review from the records request list, which included QAPI records, provided during the entrance conference. The Alt Adm # 2 replied, “I will look.” At approximately 3:05 p.m. the Alt Adm # 2 stated, “That’s it.” During an interview with the Former Owner on 06/22/2022 at Approximately 10:30 a.m., the surveyor discussed the location of the agency’s records prior to the sale of the agency on 03/25/2021, to Current Owner. The Former Owner stated that the records were placed in storage and “he accidently shredded them.” During an interview with the Adm and Alt Adm # 2 on 03/27/2022 at approximately 12:00 noon, the surveyor discussed the above findings of why the agency had not implemented and reviewed a QAPI program consistent with state and federal requirements for the survey review period of 07/03/2019 to 06/21/2022. The Alt Adm # 2 replied, “I was not aware of that. I did not know that.” The surveyor also discussed how not implementing and reviewing a QAPI program consistent with state and federal requirements for the survey review period of 07/03/2019 to 06/21/2022 could adversely affect the agency’s patients. The Alt Adm # 2 replied, “I see it definitely negatively affecting their health and their wanting to continue with our agency and the [agency’s] professionalism.” Review of agency policy titled “Quality Assessment Performance Improvement PLAN” revised 100116 read in part “PURPOSE TO develop a Quality Assessment Performance Improvement PLAN, implemented by a QAPI Committee, that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. POLICY I. The Agency will develop a plan that is evaluated, reviewed, and updated or revised at least once within the calendar year…by the QAPI Committee…V. The performance improvement plan will be implemented…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program. The infection control program did not include a method for identifying infectious and communicable disease problems, in three (2019, 2020 and 2021) of three years. The failure could place the agency’s clients at risk for exposure to and spread of communicable and/or infectious diseases. FINDINGS INCLUDED: During the entrance conference on 06/21/2022 at 2:00 p.m. the surveyor requested all agency Infection control records. The Adm/DON stated that the agency had one patient who was currently positive for COVID-19. The Alt Adm # 2 stated that on 03/25/2021 the agency was purchased from Former Owner and that the Former owner did not transfer any agency records. Review of the agency’s Infection Control binder labeled “Infection Control” did not reveal that the agency had maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program for the survey review period of 07/03/2019 to 06/21/2022. The infection control binder contained an infection control report (for an infection other than COVID-19) for Client # 7 dated 06/09/2022 and signed by LVN # 2. The binder did not include any other infection control reports or logs. The binder did not include any other records to show that the agency had maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program for the survey review period of 07/03/2019 to 06/21/2022. During an interview on 06/21/2022 at approximately 3:00 p.m. the surveyor asked the Alt Adm # 2 if the agency had any other records to submit for review from the records request list, which included Infection control records, provided during the entrance conference. The Alt Adm # 2 replied, “I will look.” At approximately 3:05 p.m. the Alt Adm # 2 stated, “That’s it.” During an interview with the Former Owner on 06/22/2022 at Approximately 10:30 a.m., the surveyor discussed the location of the agency’s records prior to the sale of the agency on 03/25/2021, to the Current Owner. The Former Owner stated that the records were placed in storage and “he accidently shredded them.” Patient # 7 Review of Patient # 7’s clinical record revealed a POC for the certification period 05/14/2022 to 07/12/2022, signed by the Adm/DON on 05/09/2022. The POC listed a primary diagnosis of essential (primary) hypertension. The POC contained an order for skilled nurse visits for one time per week for nine weeks. Patient # 7’s record also revealed a “Missed Visit Form” dated 06/16/2022 and signed by LVN # 2. The missed visit form read in part: “…Comments: Pt Dx of COVID-19…” The missed visit form did not include: Date the infection was detected; Primary diagnosis; Signs/symptoms; Pathogen and Treatment. The clinical record did not include an infection control report, for the COVID-19 infection, in accordance with agency policy for documenting patient infections. Review of the agency’s QAPI records did not reveal that the agency had included its infection control program as an integral part of its QAPI program. There were no records of the infections (dated 06/09/2022 and 06/16/2022) for Client # 7, in the agency’s QAPI records. During an interview with the Adm/DON and Alt Adm # 2 on 06/27/2022 at 12:45 p.m., the surveyor discussed the above findings of why the agency had not maintained a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program for the survey review period of 07/03/2019 to 06/21/2022. The Adm/DON replied, “[LVN # 2] is [Client # 7’s] nurse. He missed the visit because the patient had COVID.” She also stated, “I need to do it [complete the report].” The surveyor also discussed how not maintaining a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program (in accordance with regulatory requirements and agency policy) could adversely affect the agency’s clients. The Alt Adm # 2 replied, “COVID might spread.” Review of agency policy titled “Infection Control Program IC.2” revised 070120 read in part: “PURPOSE…The program improves patient/client health outcomes through risk reduction, prevention, identification and control of infections and communicable diseases in patients/clients and staff. POLICY I. The Agency’s infection control program will be based on the following criteria…C. Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections…H. Current federal, state, and local laws…PROCEDURE…D. Documentation completed by all staff will include at a minimum: Date the infection was detected 2. Patient’s/client’s name 3. Primary diagnosis 4. Signs/symptoms 5. Type of Infection 6. Pathogen…7. Treatment…”