Every finding on record at Life Care at Home

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: Based on record review and staff interviews it has been determined that the agency failed to meet the Condition of Participation relative to the development and maintenance of an Emergency Preparedness Plan. Findings are as follows: The agency failed to provide the following: -Evidence of an updated client disaster code triage list. -Evidence of testing their emergency operations plan by participating in a full-scale community-based exercise, or in a natural or man-made emergency requiring activation of the plan, or a mock disaster drill or tabletop exercise. -Evidence of an Emergency Preparedness Addendum based on the pandemic which was on the Community Based Risk Assessment. -Evidence of a patient triage list which identifies evacuation needs. (Refer to E006)

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 staff interview the agency failed to maintain an updated client disaster code triage list, to test their emergency operations plan by participating in a full-scale community-based exercise, or in a natural or man-made emergency requiring activation of the plan, or a mock disaster drill or tabletop exercise, Additionally, the agency failed to complete an Emergency Preparedness Addendum based on the pandemic which was identified on the Community Based Risk Assessment. Findings are as follows: Review of the agencies "Disaster Call Tree", in the the documents provided by the agency, which was updated on 12/10/2020, failed to contain any of the current administration or staff in charge of the agency. During a Surveyor interview on 12/2/2021, with the Case Coordinator, Staff F, she revealed that the call tree was inaccurate. Additional review of the documents, revealed a Community Based Risk Assessment, dated 8/4/2020, that identified the emerging infectious disease pandemic (EID), however the Emergency Preparedness Addendum attached to the Risk Assessment was never completed. During a Surveyor interview on 12/2/2021 at approximately 11:00 AM with Staff F, the Surveyor asked for the patient triage list. Staff F stated that she did not have a patient triage list. She later provided a list of 8 clients, 2 of which are not active clients. The list lacked the name of one of the current active clients. Staff F was unable to explain the above discrepancies. During an Surveyor interview on 12/6/2021, at approximately 1:45 PM, with the Administrator/Director of Nurses, Staff I, she was unable to produce evidence that the agency had conducted an annual review of the Emergency Preparedness Plan, had an accurate client triage list, had participated in a required exercise to test their plan, or complete the required addendum since the pandemic was added to the community risk assessment on 8/4/2020.

During this recertification survey a finding which constituted Immediate Jeopardy (IJ) was identified under Appendix B - Guidance to Surveyors: Home Health Agencies (Rev. 200, 02-21-20) §484.60 Condition of participation: Care planning, coordination of services, and quality of care. The Home Health Agency Vice President was informed of the Immediate Jeopardy identified on 12/8/2021 at approximately 10:00 AM. On 12/10/2021, the Home Health Agency submitted an abatement plan indicating the immediate actions the agency will take to prevent serious harm from occurring or recurring. This abatement plan indicates the following: -All patients will be transferred and accepted to another home care agency for ongoing care. -No admissions will be accepted until the organization has restructured their administration, hired qualified staff, and can provide appropriate/safe care to all its patients. This plan was verified as completed, all patients were informed, and transferred to other agencies by the administration on 12/10/2021. This was verified with the Executive Director of LHC Group Inc. through interview and correspondence emails.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview it has been determined that the agency failed to assure that the patient’s clinical record identifies all medication the patient is currently taking for 5 of 7 sample clients, Client ID #’s 1,2,3,4 and 5. Findings are as follows: 1) Client ID #1 has a start of care date of 11/17/2021, for skilled nursing services. Record review for client ID # 1 failed to reveal documentation of medications that the client is taking, or physicians orders. Review of the nurse’s note for the admission visit, dated 11/17/2021, completed by staff G, lacks any documentation that the client’s medication was reviewed or that the agencies Medication Profile was completed. 2) Client ID #2 had a start of care date of 6/18/2021 for services. Record review of the form entitled “Non-Oasis Comprehensive Assessment” dated 6/18/2021, completed by Staff Nurse L, failed to reveal evidence of the client’s medication orders. Record review of the form entitled “MEDICATION PROFILE” failed to reveal any medications listed. During an observation and interview on 12/3/2021 with the client during a home visit with Homemaker Staff A, she revealed that she was taking the following medications: trazadone, labetalol HCL, pregabalin, Jardiance, atorvastatin, Vitamin D, lamotrigine, lisinopril, amlodipine, Flonase and Trulicity. 3) Client ID #3 had a start of care date of 9/3/2021 for services. Record review of the form entitled “Non-Skilled Personal Care Assessment” dated 9/3/2021, completed by Staff K the interim executive director, failed to reveal evidence of the client’s medication orders. Record review of the form entitled “MEDICATION PROFILE” failed to reveal any medications listed. 4) Client ID #4 had a start of care date of 6/27/2021 for services. Record review of the form entitled “Non-Oasis Comprehensive Assessment” dated 6/27/2021, completed by Staff L, failed to reveal evidence of the client’s medication orders. Record review of the form entitled “MEDICATION PROFILE” failed to reveal any medications listed. 5) Client ID #5 had a start of care date of 6/27/2021 for services. Record review of the form entitled “Non- Oasis Comprehensive Assessment” dated 6/27/2021 and completed by Staff Nurse L, revealed the client is “currently taking 5 or more medications”, but failed to reveal any evidence of the client’s medication orders. Record review of the form entitled “MEDICATION PROFILE” failed to reveal any medications listed. During a Surveyor interview on 12/6/2021 at 11:33 AM, with Staff J she could not provide evidence of the documentation, in the clinical record, of the above client’s medication orders.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on surveyor observation, record review, staff and client interview it has been determined that the agency failed to provide each client an individualized written plan of care which included the following: revisions or additions, which must specify the care and services necessary to meet the patient specific needs identified in the comprehensive assessment, identification of the responsible disciplines, and measurable outcomes. Services failed to be furnished in accordance with accepted standards of practice for 6 of 7 sample clients, Client ID #s 1,2,3,4,5 and 7. Findings are as follows: 1. The agency failed to ensure that each client receives the home health services that are written in the individualized plan of care which identifies patient specific measurable outcomes and goals, that is periodically reviewed and signed by a doctor. (Refer to G 572) 2. The agency failed to ensure that the individualized plan of care included the following: -All pertinent diagnoses -the patient’s mental, psychosocial, and cognitive status -the types of services, supplies and equipment required -the frequency and duration of visits to be made -the prognosis, rehabilitation potential, functional limitations, activities permitted, and nutritional requirements -all medications and treatments. (Refer to G 574) 3. The agency failed to ensure that all patient care orders, including verbal orders are recorded in the plan of care. (Refer to G 576) 4. The agency failed to ensure that the visit schedule, including frequency of visits by HHA personnel, and personnel acting on behalf of the HHA. (Refer to G 614)

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 record review and staff interview it has been determined that the facility failed to ensure that the client receives 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 for 6 of 7 clients, Client ID # 1, 2, 3, 4, 5 and 7. Findings are as follows: 1) Client ID #1 had a start of care date of 11/17/2021 for skilled nursing services. Review of the record for this client fails to reveal any physicians’ orders for this agency to administer a monthly vitamin B-12 injection. Review of the record reveals a Home Health Certification and Plan of Care for period 10/18/2021 – 12/17/2021, with the providers name and contact information for another home care agency. The record lacks a physician’s order for this agency to administer the monthly Vitamin B-12 injection, that was administered to the client on 11/17/2021 by Staff G. The surveyor interviewed the Vice President, Staff J, on 12/6/2021, who stated that the nurse should have contacted the physician and obtained an order prior to the administration of the vitamin B-12 injection. 2) Client ID #2 had a start of care date of 6/18/2021 for non-skilled services. Client ID # 2’s record, reveal a “Client Order” form, dated 6/18/2021 under, “Type of Service Requested”, the document reveals "Aide", and in the section” hours per day/ # visits requested” the number 3 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the “HOME HEALTH CERTIFICATION AND PLAN OF CARE” document for the certification period of 6/18/2021- 8/16/2021, under the section, “Orders for Discipline and Treatments…” revealed “HHA [Home Health Aide] Hourly 15.00 Hour Weekly 15 times weekly for 52 week(s) starting 6/16/2021- 15 hours personal care…” Record review of the “Non- Oasis Comprehensive Assessment” completed on 6/18/2021 by Staff Nurse L, under the section entitled “Problems/ Interventions/Goals” revealed that HHA services were to be provided 15 hours a week for personal care and Homemaking services. It further reveals that “…HHA [is] to Provide Hands on Assistance with All ADLS [activities of daily living]/IADLS. [instrumental activities of daily living] …” Though the client continued to receive services from the agency during the survey period. There was no updated “Home Health Certification and Plan of Care” or assessment completed. The last on file was for the certification period of 6/18/2021- 8/16/2021. During a surveyor interview on 12/3/2021 at approximately 9:00AM with the client during a home visit provided by Homemaker Staff A, she revealed that sometimes Staff A washes, dries, and applies lotion to her feet. Staff A at the time of the home visit acknowledged that at times she has done this for the client. During a surveyor interview on 12/3/2021 at approximately 9:30 AM, Homemaker Staff A acknowledged that she does not have a License to be a Certified Nursing Assistant. She further revealed that she did not complete a training course to become a homemaker. Record review of the client’s visit documentation provided by the agency revealed the following: - There failed to be any documentation of visits for 8/29/2021 through 10/16/2021. - The client had 2 to 3 visits a week between 10/17/2021 through 12/3/2021 which were provide by Staff A, a staff member who is not a nursing assistant and who has been working as a homemaker but has no evidence of taking the homemaker course. During a surveyor interview on 12/6/2021 at 10:45 AM with Staff F, she revealed that the gap in visits was because the HHA who was doing the visits quit and the agency did not have the staff to do the visits. The record failed to contain any evidence of an updated order for services, or an updated assessment. During a surveyor interview on 12/6/2021 at 11:33 AM with Staff J, she acknowledged that Staff A was working outside her scope of practice, She further was unable to provide an updated client assessment or updated orders for service. Additionally, she acknowledged there was a gap in the client services due to staffing. 3) Client ID # 3’s record, reveal a “Client Order” form, dated 7/20/2021 under, “Type of Service Requested”, the document reveals "CNA", and in the section” hours per day/ # visits requested” the number 25 is documented. In a report provided to the surveyor on 12/22/2021 it was revealed the client had a discharge date of 7/24/2021. A second client order form dated 8/31/2021 failed to reveal clear instructions on the type of services required, number of hours per day, the number of visits per week and the number of weeks that visits were required. Review of a document titled “Paraprofessional Assignment Sheet” dated 9/13/2021, identifies the following: "Bath/complete shower, minimum assist every visit..." Review of the documentation provided by the agency failed to reveal visits prior to 10/4/2021. Review of the visit notes for the period between 10/4/2021 through 12/3/2021 revealed that a total of 28 visits were completed. Documentation was as follows: -18 out of 28 visits have documentation that showering/bathing was completed for the client. -8 out of 28 visits have no documentation regarding what tasks occurred during the visit. Review of the client visit notes, reveal that the client was seen by various staff who according to the Case Coordinator, Staff F, are all homemakers who should not have performed bathing. During an interview with Staff F, on 12/3/2021 at approximately 2:45 PM, she was unable to explain why the client did not have services on a regular basis or explain why the visits only began in October and were not consistent with the plan. During an Interview with staff F, on 12/3/2021 at approximately 2:45 PM, when asked why the staff were listed as Home Health Aides on the visit sheets and not homemakers, she stated that was the only option she had to put them in the documentation system. The surveyor interviewed the Vice President, Staff J, on 12/6/2021 at approximately 12:20 PM, she acknowledged that the homemakers’ scope of practice does not include personal care, and that she was unaware that the agency was listing homemakers as home health aids in the computer. 4) Client ID #4’s record, reveal a “Client Order” form, dated 6/27/2021 under “Type of Service Requested” the document reveals "Aide" the form lacks the number of hours per day/ or visits required. A non-oasis comprehensive assessment dated 6/29/2021, under section “Problems/Interventions/Goals; states Skilled Nursing” interventions and assess”, Home Health Aid six hours per week, Homemaker 6 hours per week. Nonskilled services to be provided are listed as, prepare meals, perform linen change, maintain a clean /safe environment. The form also states, admit onto services for non-skilled services, personal care/homemaking for 6 hours per week. Review of the visit notes for the period between 6/29/2021 through 12/3/2021 revealed that a total of 47 visits were completed. Documentation was as follows: -2 out of 47 visits have no documentation regarding what tasks occurred during the visit. Record review reveals that the agency failed to provide any visits from 8/15/2021 through 10/2/2021. During a surveyor visit to Client ID # 4 on 12/3/2021, s/he informed the surveyor that the homemaker cuts her/his fingernails for her/him sometimes and that s/he has a social worker and psychiatrist that s/he sees for care and medications. S/he also informed the surveyor that s/he has an insulin pump and a physician at “the clinic”. During interview with Staff F, on 12/3/2021 at approximately 12:45 PM, she was unaware of the above and could not provide any documentation or communication with the above providers for coordination of care for the above services. During a teleconference with the Vice President and Administrator on 12/3/2021 at approximately 2:00 PM, they failed to produce evidence that the agency had orders for the services that were being provided, or how the number of visits and or hours were determined. They further failed to produce evidence that there was a coordination with the physician and or the other agencies involved in the clients care or that the agency was aware that the client had an insulin pump. Additionally, they acknowledged that a homemaker is working outside the scope of practice if providing personal care. 5) Client ID # 5’s record, reveal a “Client Order” form, dated 6/27/2021 under, “Type of Service Requested”, the document reveals Companion/Homemaker, and in the section” hours per day/ # visits requested” the number 3 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review for Client ID #5 revealed 8 out of 43 visits which failed to have any documentation of what tasks were completed on the visit. Further review of the Client’s visits revealed 11 out of 43 visits where it is documented “No” under the section “completed” for all the tasks listed. During these visits the time spent in the home ranged from 3 to 4 hours. Record review revealed that though the client was receiving visits up until the week of 12/5/2021, the last Non- Oasis Comprehensive Assessment was completed on 6/27/2021. During a surveyor interview on 12/7/2021 at 9:05 AM with Staff F, she was unable to explain why the staff member was in the home for between 3-4 hours yet failed to complete any of the tasks listed, or why no additional assessments were completed. 6) Client ID #7 had a start of care date of 5/25/2021. The client’s last visit date was 8/15/2021. Record review of the agency provided document entitled “CLIENT ORDER” form dated 5/25/2021 under the section “Type of Service Requested” the document reveals "Aide", there failed to be any instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the “Home Health Certification and Plan of Care” for the certification period of 5/25/2021 through 7/23/2021 revealed under the section entitled “Orders for Discipline and treatments…” it states “HHA Hourly 8 Hours Weekly for 12 Month(s) starting 5/25/2021…” Review of the record revealed a Non-skilled Personal Care Assessment dated 5/25/2021. There was no assessment of the client for the next certification period. Review of the visit notes completed by Staff N, for the period between 5/29/2021 through 8/15/2021 revealed that a total of 16 visits were completed. Documentation was as follows: -5 out of 16 visits have no documentation regarding what tasks occurred during the visit. During a surveyor interview on 12/7/2021 at approximately 11:30 AM with Staff J, she acknowledged that the agency did not have the proper order in place for services, or the comprehensive assessment that should have been completed for the client’s next certification period.

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 record review and staff interview it has been determined that the facility failed to ensure that the individualized plan includes all pertinent diagnoses, the patient’s mental, psychosocial and cognitive status, the types of services , supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, and all medications and treatments for 6 of 7 clients reviewed, Client ID #s 1, 2, 3, 4, 5 and 7. Findings are as follows: 1) Client ID #1 has a start of care date of 11/17/2021 for skilled nursing services. Review of the record for this client fails to reveal any physicians’ orders for this agency to administer a monthly vitamin B-12 injection. Record review failed to reveal documentation of any of the medications that the client is taking, or physician's medication orders. Review of the nurse’s note for the admission visit, dated 11/17/2021, completed by Staff G, lacked documentation that the client’s medication was reviewed or that the agencies Medication Profile had been completed. 2) Client ID #2 had a start of care date of 6/18/2021 for services. Record review revealed a “Client Order” form dated 6/18/2021 under “Type of Service Requested” reveals Aide, and in the section “hours per day/# visits required” the number 3 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. The date and time services were to begin was written as 6/18/2021 at 12:00 AM. Additionally this form was not signed by a physician. Record review of the “HOME HEALTH CERTIFICATION AND PLAN OF CARE” document for the certification period of 6/18/2021- 8/16/2021, under the section, “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” revealed “HHA [Home Health Aide] Hourly 15.00 Hour Weekly 15 times weekly for 52 week(s) starting 6/16/2021- 15 hours personal care…” Further review of the section entitled “Medications/ Dose/ Route/ Frequency...” revealed “No Medications Added” Record review of the form entitled “Non-Oasis Comprehensive Assessment” dated 6/18/2021, completed by Staff Nurse L, lacked documentation of the client’s medication or that the agencies Medication Profile had been completed. During an observation and interview on 12/3/2021 with the client during a home visit with Homemaker Staff A, the Client revealed that s/he was taking the following medications: trazadone, labetalol HCL, pregabalin, Jardiance, atorvastatin, Vitamin D, lamotrigine, lisinopril, amlodipine, Flonase and Trulicity. 3) Client ID #3 had a start of care date of 9/3/2021 and a discharge date of 7/24/2021. The client was receiving services. Record review revealed a “Client Order” form, dated 7/20/2021 which states, “Type of Service Requested”, and in the section , “hours per day/ # visits required” the number 25 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the form entitled “Non-Skilled Personal Care Assessment” dated 9/3/2021, completed by Staff K, the interim executive director, lacks documentation of the client’s medication or that the agencies Medication Profile had been completed. 4) Client ID #4 had a start of care date of 6/29/2021 for services. Record review revealed a “Client Order” form dated 6/27/2021 under the section “Type of Service Requested” this document reveals "Aide", and the section “hours per day/# visits required” was blank. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the agency provided document entitled “CLIENT ORDER” dated 6/27/2021 under the section “Type of Service Requested” revealed the following: There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the agency form entitled “Non-Oasis Comprehensive Assessment” dated 6/29/2021 lacked documentation of the client’s medication or that the agencies Medication Profile had been completed. 5) Client ID #5 had a start of care date of 6/27/2021. The client was receiving services. Record review revealed a “Client order” form dated 6/27/2021 under the section “Type of Service Requested” reveals Companion/Home maker, and the section “hours per day/ # visits required” the number 3 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the client’s record failed to reveal evidence of a Medication reconciliation. The document titled; “Medication Profile” provided by the agency failed to have any medications listed. Record review of the “Non- Oasis Comprehensive Assessment” dated 6/27/2021 for the certification period of 6/27/2021 through 8/25/2021 revealed that the client is “currently taking 5 or more medications” but lacked documentation of the client’s medication or that the agencies Medication Profile had been completed. During surveyor interview on 12/6/2021 at 11:33 AM, with Staff J, she could not provide evidence of the documentation, in the clinical record, of the above client’s medication orders. 7) Client ID #7 had a start of care date of 5/25/2021. The client’s last visit date was 8/15/2021. The client was receiving services. Record review revealed a “Client order” form dated 5/25/2021 under the section “Type of Services Requested” this document reveals "Aide", and the section “hours per day/ # visits required” was blank. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the “Home Health Certification and Plan of Care” for the certification period of 5/25/2021 through 7/23/2021 revealed under the section entitled “Orders for Discipline and treatments…” it states “HHA Hourly 8.00 Hour Weekly for 12 Month(s) starting 5/25/2021…” During a surveyor interview on 12/7/2021 at approximately 11:30 AM with Staff J, she acknowledged that the agency did not have the proper orders in place for services for the above clients. She further could not provide evidence of documentation, in the clinical record, of the above listed client’s medication orders.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure that all patient care orders, including verbal orders, must be recorded in the plan of care for 1 of 7 clients reviewed, Client ID # 1. Findings are as follows: Client ID #1 has a start of care date of 11/17/2021 for skilled nursing services. Review of the client’s record failed to reveal any physicians’ orders for this agency to administer a monthly vitamin B 12 injection. Record review reveals a Home Health Certification and Plan of Care for period 10/18/2021 – 12/17/2021, with the providers name and contact information for another home care agency. During an interview with the Vice President, Staff J, on 12/6/2021, at approximately 11:00 AM, she stated that the nurse should have contacted the physician and obtained a physician's order prior to the administration of the vitamin B 12 injection.

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 record review and staff interview it has been determined that the agency failed to ensure that the client's visit schedule, which includes frequency of visits to be completed by the Home Health Agency is consistent with the client's plan of care for 5 of 7 clients reviewed, Client ID # 2, 3, 4, 5 and 7. Findings are as follows: 1) Client ID #2 had a start of care date of 6/18/2021 for services. Record review revealed a “Client Order” form dated 6/18/2021 under “Type of Service Requested” the document reveals "Aide", and in the section “hours per day/#visits required” the number 3 is documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. The date and time services were to begin was written as 6/18/2021 at 12:00 AM. Additionally this form was not signed by a physician. Review of the “HOME HEALTH CERTIFICATION AND PLAN OF CARE” document, for the certification period of 6/18/2021- 8/16/2021, under the section, “Orders for Discipline and Treatments” revealed “...Hourly 15.00 Hour, Weekly 15 times weekly, for 52 week(s), starting 6/16/2021- 15 hours personal care…” Record review of the “Non-Oasis Comprehensive Assessment” completed on 6/18/2021 by Staff Nurse L, under the section entitled “Problems/ Interventions/Goals” revealed that HHA services were to be provided 15 hours a week for personal care and Homemaking services. It further reveals that “…HHA to Provide Hands on Assistance with All ADLS [activities of daily living]/IADLS. [instrumental activities of daily living] …” Record review of the client’s visit documentation provided by the agency revealed of 24 weeks of service reviewed 17 weeks did not meet the hours specified on the clients Plan of care document and 7 weeks had no visits at all. 2) Client ID #3 had a start of care date of 9/3/2021 for services. Record review revealed a “Client Order” form dated 7/20/2021 under “Type of Service Requested” the document reveals "CNA", and in the section “hours per day/ # visits required” the number 25 was documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review revealed a “Client Order” form dated 8/31/2021 which failed to indicate the type of services, instructions on the number of hours per day, visits per week and the number of weeks that the visits were required. Record review of the client’s visit documentation provided by the agency revealed of 12 weeks of service reviewed 5 had no visits at all and 7 weeks did not have specific orders for visits to be performed. 3) Client ID #4 had a start of care date of 6/29/2021 for services. Record review revealed a “Client Order” form dated 6/27/2021 under “Type of Service Requested” the document reveals "Aide", and the section “Hours Per Day/ # Visits required” was blank. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the client’s visit documentation provided by the agency revealed of 23 weeks of service reviewed 15 weeks did not have specific orders for visits to be performed, and 8 weeks had no visits at all. 4) Client ID #5 had a start of care date of 6/27/2021 for services. Record review revealed a “Client Order” form dated 6/27/2021 under “Type of Service Requested” the document reveals Companion/Homemaker, and under the section “Hours Per Day/ # Visits required” the number 3 was documented. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. The date and time services were to begin was blank. Record review of the client’s visit documentation provided by the agency revealed of 20 weeks of service reviewed 19 weeks did not have specific orders for visits to be performed, and 1 week had no visits at all. 5) Client ID #7 had a start of care date of 5/25/2021. The client’s last visit date was 8/15/2021. Record review revealed a “Client Order” form dated 5/25/2021 under “Type of Service Requested” the document reveals "Aide", and the section “Hours Per Day/ #Visits Required” was blank. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review of the “Home Health Certification and Plan of Care” for the certification period of 5/25/2021 through 7/23/2021 revealed under the section entitled “Orders for Discipline and treatments…” it states “HHA Hourly 8 Hour Weekly for 12 Month(s) starting 5/25/2021…” Record review of the client’s visit documentation provided by the agency revealed of 13 weeks of service reviewed, 13 weeks did not meet the hours specified on the client's Plan of Care document. During a surveyor interview on 12/6/2021 at 10:45 AM with Staff F, she revealed that the gaps in visits were because the agency didn’t have the staff to do the visits. During a surveyor interview on 12/7/2021 at approximately 11:30 AM with Staff J, she acknowledged that the agency did not have the appropriate orders in place for the services provided to the above clients.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and staff interview, it has been determined that the Condition of Participation: Quality assessment and performance improvement has not been met relative to; the agency failed to develop, implement, and maintain an effective, ongoing HHA wide, data driven Quality Assessment and Performance Improvement (QAPI) program. Findings are as follows: Review of the agencies QAPI documentation provided by the agency failed to contain a QAPI plan, which includes program objectives, organizations involved, oversight responsibilities, with a written plan of an active program that includes ongoing monitoring of quality. The agency also lacked evidence of a physician and or medical director’s oversight. During surveyor interview on 12/6/2021 at 10:05 AM, with the Administrator/Director of Nurses, she was unable to provide evidence of a current QAPI program, or evidence that the QAPI committee had reviewed a written QAPI plan. The documentation also lacked evidence of a Professional Advisory Committee (PAC) that met twice a year. The Administrator/Director of Nurses acknowledged that the agency had not established a PAC, that is required to meet at least twice a year, comprised of a physician, a nurse, a representative of each therapeutic service offered, and one member who is neither an owner nor an employee. During an additional interview with the Administrator on 12/7/2021 at approximately 1:30 PM, she acknowledged that the agency did not have an active QAPI program, or established a PAC committee with a physician/medical director who had been participating in the agency’s quality assessment.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on record review and staff interview it has been determined that the facility failed to ensure compliance with Federal, State, and local laws and regulations related to the health and safety of patients relative to employee background checks for 7 of 8 employees reviewed, health screenings for 7 of 8 employees reviewed, and Covid-19 vaccination for 2 of 8 employees reviewed. Findings are as follows: 1) R.I. Gen. Laws § 23-17-34 states in part, "Any person seeking employment in a nursing facility, a home nursing-care provider, hospice provider, or a home-care provider who is, or is required to be, licensed, registered, or certified with the department of health if that employment involves routine contact with a patient or resident without the presence of other employees, shall undergo a national criminal records check that shall include fingerprints submitted to the Federal Bureau of Investigation (FBI) by the bureau of criminal identification of the department of attorney general..." Record review revealed Staff A was hired 6/9/2021. This employee was hired as a homemaker/companion. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff B was hired 8/26/2021. This employee was hired as a homemaker/companion. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff C was hired 11/1/2014. This employee was hired as a Registered Nurse. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff D was hired 10/27/2021. This employee was hired as a homemaker/companion. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff E was hired 11/9/2021. This employee was hired as a homemaker/companion. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff F was hired 8/28/2021. This employee was hired as a case coordinator, she has her Nursing Assistant certification. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. Record review revealed Staff H was hired 11/24/2021. This employee was hired as a homemaker/companion. The employee personnel file lacked evidence of a national criminal records check that included fingerprints. During a surveyor interview on 12/2/2021 at approximately 12:45 PM with Staff F, she acknowledged that they hadn’t performed a national criminal record check that included fingerprints pursuant to Rhode Island Law for the above staff members. 2) The Rules and Regulations Pertaining to Immunization, Testing, and Health Screening for Health Care Workers (R23-17-HCW) states, in part: "...3.5 In accordance with the guidelines set forth by the Advisory Committee on Immunization Practices (ACIP), evidence of immunity is required for all health care workers (with the exception of health care workers who receive a medical exemption) against: 3.51 Measles, Mumps, Rubella (a) Pre-Employment: Two (2) doses of MMR (measles-mumps-rubella) vaccine. Alternately, two (2) doses of live mumps-containing vaccine and one (1) dose of rubella vaccine. (b) Laboratory evidence of immunity or laboratory confirmation of disease (i.e. laboratory report of positive IgG titers for measles, mumps and/or rubella are considered negative and vaccination is required. 3.5.2 Varicella (Chickenpox) (a) Two (2) doses of varicella vaccine. The second dose of varicella vaccine must be administered at least four (4) weeks after the first dose; OR (b) Laboratory evidence of immunity or laboratory confirmation of disease; OR (c) A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease; OR (d) History of herpes zoster based on healthcare provider diagnosis. 3.5.3 Tetanus, Diphtheria and Pertussis (Whooping Cough): (a) Pre-employment: One (1) single dose of Tdap (tetanus-diphtheria-pertussis) vaccine is required for all health care workers who have not previously received a dose of Tdap vaccine. 3.5.5 Tuberculosis (TB): (a) Pre-employment. Evidence that the health care worker is free of active tuberculosis based upon the results of a negative two-step tuberculin skin test shall be required. (1) If documented evidence is provided by the health care worker that a two-step tuberculin skin test, performed within the most recent twelve (12) months prior to hire, was negative, the requirements of this section shall be met. (i) For health care workers who can present documentation of serial tuberculin testing with negative results in the prior two (2) years (or more), a single baseline negative tuberculin test is sufficient evidence of absence of TB infection. (2) A negative FDA-approved blood assay for Mycobacterium tuberculosis (BAMT) may be used instead of a two-step tuberculin skin test. If the baseline BAMT is positive, screening should proceed as indicated below for positive PPD. (3) Documentation shall include date and result of the tuberculin skin test (PPD), and reaction size in millimeters or an actual copy of the laboratory test result from a BAMT. (4) If the PPD test or BAMT is positive, consistent with the most current Centers for Disease Control and Prevention {CDC} guidance, or a previous one is known to have been positive, a physician's or other licensed practitioner's (acting within his/her scope of practice) certification that the health care worker is free of active disease shall be required. (5) A physician, certified registered nurse practitioner, or a physician assistant may certify that the health care worker is currently free of TB based on his/her clinical judgment for complex cases or unusual circumstances that do not fit the above criteria. 3.5.6 Hepatitis B Vaccination and Testing. (c) Employees at risk of exposure to blood-borne pathogens shall be offered hepatitis B vaccine within ten (10) days of employment. (4) Employees have the option of signing a standard OSHA declination form if they choose not to be vaccinated and should be counseled regarding risk..." While performing a review of the facility's personnel files, relative to immunizations, the following was identified: Staff A, hired on 6/9/2021, lacked evidence of varicella vaccine or immunity, Tdap vaccine and evidence that a second tuberculin skin test was obtained. Staff B, hired on 8/26/2021, lacked evidence that a second tuberculin skin test was obtained. Staff D, hired on 10/27/2021, lacked evidence of all of the above pre-employment health screenings. Staff E, hired on 11/9/2021, lacked evidence of her 2nd and 3rd Hepatitis B vaccine, MMR vaccine or varicella vaccine or immunity. Staff F, hired on 8/28/2021, lacked evidence of all of the above pre-employment health screenings. Staff G, hired on 11/17/2021, lacked evidence of all of the above pre-employment health screenings. Staff H, hired on 11/24/2021, lacked evidence of Hepatitis B vaccination, MMR, Varicella vaccination or immunity, Tdap, and that the second tuberculin skin test was obtained. During an interview on 12/8/2021 at approx. 9:30 AM with Staff I, she could not provide evidence that the above pre-employment screenings had been conducted. 3)The Rhode Island Department of Health regulation titled: "REQUIREMENT FOR IMMUNIZATION AGAINST COVID-19 FOR ALL WORKERS IN LICENSED HEALTH CARE FACILITIES AND OTHER PRACTICING HEALTH CARE PROVIDERS" (216-RICR-20-15-8), effective 8/17/2021, states, in part: Vaccinated" means a person has received all recommended dose(s) of a COVID-19 vaccine authorized by the U.S. Food and Drug Administration (FDA) or World Health Organization or all recommended dose(s) of another COVID-19 vaccine approved by the Department...” Record review of the employee Covid-19 vaccination records revealed the following: Staff E, hired on 1/9/2021 has received only one dose of the Moderna vaccine on 11/17/2021. Record review failed to reveal evidence of the second dose. Review of the visit documentation for Client ID # 3 revealed that Staff E had been out on 4 home maker visits for the following dates 11/29, 11/30, 12/1, and 12/2/2021. Staff H, hired on 11/24/2021, who was observed by the surveyor providing services to Client ID #3, has received only one dose of the Pfizer vaccine on 11/23/2021. Record review failed to reveal evidence of the second dose. During an interview on 12/3/2021 at approximately 2:00 PM via video conference, Staff K stated she was unaware of the Rhode Island requirement for immunization against Covid-19 for all health care workers who work in a licensed health care facility. Staff I and Staff J revealed that both employees from this point forward have been removed from the schedule while they wait for the second vaccination.

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: Based on record review and staff interviews the agency failed to meet the Condition of participation for Organization and administration of services. The HHA failed to organize, manage, administer, and maintain the highest practicable functional capacity, to provide optimal care for each patient's medical, nursing, and rehabilitative needs. Failures relative to the following standards were identified: The agency failed to ensure that the governing body assume responsibility for the agency's overall management and operation, and the provision of all home health services. (Refer to G 942) The agency failed to ensure that the administrator and clinical manager were responsible for the day-to-day operation of the HHA, and to employ qualified personnel. (Refer to G 948) The agency failed to ensure that the HHA employs qualified personnel (Refer to G 952) The agency failed to meet the to employ a clinical manger, who is qualified to provide oversight of all patient care services and personnel. (Refer to G 958)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the governing body failed to assume responsibility for the agency's overall management and operation, and the provision of all home health services. Findings are as follows: Review of the agencies policy titled " Organizational Responsibilities and Organizational Charts…” under the title “Purpose” states: -“To delineate the lines of communication and responsibilities within the organization -To comply with applicable laws, regulations, and standards -To ensure appropriate management of the agency by qualitied individuals and oversight of the care, treatment, and services provided. Policy: Administrative and supervisory functions are not delegated to other organizations or agencies. All services not furnished directly by the agency are monitored and coordinated by the agency. Procedure: -Senior Management develops and revises changes in the organizational structure as needed by the changes in the organization. -The organizational chart is maintained, up to date and defines appropriate lines of responsibility. -Supervising and reporting relationships and the relationship of administration and the governing body are clearly defined in these documents. -The Executive Director, appointed by the Board of Directors through Senior Management delegation serves as the delegated person so functioning as the governing body….” Review on 12/2/2021 at 1:45 PM of the agencies Disaster Call tree, which was updated on 12/10/2020, revealed a staff list which contained an Executive Director, Patient Care manager, and the 5 nurses listed, all who are no longer employed at the agency. During an interview with Staff F, she stated the agency does not have a nurse available at this time. She informed the surveyor that she was "in charge". She stated that she is on call 24 hours if staff or clients have questions, they call her. During a surveyor interview on 12/6/2021 at approximately 11:00 AM, with the Administrator, who resides and primarily works out of another state, she revealed that she oversees the agency and comes to Rhode Island about once a week. She further acknowledged that she was not aware, that staff who were not fully vaccinated for Covid 19 were working, that background checks were not completed for employees, that the homemakers had not completed the basic training course, that client assessments, physicians’ orders, and plans of care were not being followed. Additionally, she was not aware that homemakers were providing personal care to clients, that homemakers visits were being documented as home health aide visits, or that the proper assessments and certifications for the clients were not being completed and implemented. During a surveyor interview on 12/6/2021 at 1:20 PM, with the Vice President she revealed that after the current evaluation of the clients she was implementing an immediate plan and that all current services were being placed on hold, and she was notifying referral sources, physicians, clients and employees. Additionally, she stated that new orders and non-skilled plans of care will be established before services are resumed.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and staff interviews, the agency failed to ensure that a qualified individual was responsible for the day to day operation of the agency. Findings are as follows; During a surveyor interview on 12/2/2021 at approximately 10:30 AM, with Case Coordinator, Certified Nurse Assistant, Staff F, she revealed that she was "in charge" of the office and that they did not have a Clinical Manager. She stated that she is on call 24 hours a day, assigns the staff to the clients, and takes the calls from clients and staff. Additionally, she stated that she recently hired several homemakers, and assigns them to do home visits. She stated that she does not have a schedule for the per diem Nurse, instead contacts her to see what visits she has completed. Staff F also stated that she calls the Interim Administrator (who is in another state) when she has questions.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the facility failed to ensure homemakers employed were qualified relative completion of a basic homemaking training program for 5 of 5 homemakers. Staff ID's A, B, D, E & H. Findings are as follows: Record review of the agency’s personnel information revealed the following: Staff A, hire date 6/9/2021, is being utilized as a homemaker. There is no evidence of a basic training program in homemaker skills. Staff B, hire date 8/26/2021, is being utilized as a homemaker. There is no evidence of a basic training program in homemaker skills. Staff D, hire date 10/27/2021, is being utilized as a homemaker. There is no evince of a basic training program in homemaker skills. Staff E, hire date 11/9/2021, is being utilized as a homemaker. There is no evidence of a basic training program in homemaker skills. Staff H, hire date 11/24/2021, is being utilized as a homemaker. There is no evidence of a basic training program in homemaker skills. During a surveyor interview on 12/7/2021 at approximately 9:40 AM Staff F, the case coordinator, was unable to produce evidence that the homemakers had completed a basic training program of at least 20 hours of classroom instruction and 5 hours of practical experience. Additionally, she was unaware that the homemakers needed to complete a basic training course. During a surveyor interview on 12/8/2021 at approximately 9:00 AM with Staff I, she revealed that the agency does not have any evidence of homemaker training for any of the above staff.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and staff interviews it was determined that the agency failed to employ a Clinical Manger, who is a qualified individual to provide oversight of all patient care services and personnel. Findings are as follows: During a surveyor interview on 12/2/2021 with the agency Case Coordinator, Staff F, she revealed that she is the employee that oversees the office. She stated that she calls the “regional mangers” when she has a question and they come in for a day, once every 2 to 3 weeks. She also informed the surveyors that she is on call 24 hours a day, and that if the staff or clients have questions/concerns they call her. During a Surveyor interview on 12/6/2021 at approximately 11:05 AM, with the Area Executive Director, Staff I, she acknowledged that the agency did not have a clinical manager, since the Executive Director, Staff L had left the agency on 8/20/2021.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review, staff and client interviews, the agency failed to coordinate client care with other agencies and providers for 2 of 3 clients, ID#'s 3 & 4, who were interviewed during home visits, Findings are as follows: 1. Record review for client ID # 3, who had a start of care date of 7/20/2021, lacked evidence of any other agencies or clinics involved in the clients care. During client interview during a home visit on 12/3/2021, the client informed the surveyor that s/he has services from another home care agency, which provides a nurse, PT and OT three times a week. Additionally, the client informed the surveyor that s/he has weekly appointments at the wound clinic relative to the wounds on his/her legs. During surveyor interview with staff F, on 12/3/2021, upon return from the home visit, the surveyor asked Staff F if she was aware of the client going to wound clinic and receiving services from another agency and she stated that was not aware. Additionally, she could not produce any documentation of coordination with the other agencies involved in the clients care, or evidence on the plan of care. 2. Record review for client ID # 4, who has a start of care date of 6/29/2021, lacked evidence of any other agency or clinics involved in the clients care. During a home visit to the client on 12/3/2021, the client informed the surveyor that s/he has a social worker and psychiatrist from another agency. This client also informed the surveyor that s/he is seen at another clinic for his/her insulin pump. During surveyor interview with staff F, on 12/3/2021, upon return from the home visit, the surveyor asked Staff F if she was aware of the client receiving services from other agencies relative to mental health and medical clinic relative to diabetes management and she stated that was not aware. Additionally, she could not produce any documentation of coordination with the other agencies involved in the clients care, or evidence on the plan of care.

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: Based on record review and staff and client interview it has been determined that the agency has failed to meet the Condition of Participation relative to maintaining clinical records containing past and current information for every patient accepted by the HHA and receiving home health services that were accurate, adhere to current clinical record documentation standards of practice and be available to physicians issuing orders and appropriate staff. Findings are as follows: The agency failed to ensure the contents of the clinical record include a current comprehensive assessment, including all the assessments from the most recent home health admission, clinical notes, plans of care, and physicians order. (Refer to G 1012) The agency failed to ensure the contents of the clinical record include all interventions, including medication administration, treatments, and services and responses to those interventions. (Refer to G 1014) The agency failed to meet the standard of practice related to Authentication. The facility failed to ensure all entries are legible, clear, complete, and appropriately authenticated, dated, and timed. (Refer to G 1024)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and staff interview it was determined the agency failed to ensure the clinical record included the client’s current comprehensive assessment, including all the assessments from the most recent home health admission, clinical notes, plans of care and physician orders for 6 of 7 clients reviewed, Client ID #s 1, 2, 3, 4, 5 and 7. Findings are as follows: 1) Client ID #1 has a start of care date of 11/17/2021 for skilled nursing services. Review of the record for this client fails to reveal any physicians’ orders for this agency to administer a monthly vitamin B-12 injection. Review of the record reveals a Home Health Certification and Plan of Care for period 10/18/2021 – 12/17/2021, with the providers name and contact information for another home care agency. 2) Record review for Client #2 revealed a client order dated 6/18/2021 for an "Aide". In the box entitled “Hours Per Day/ # Visits Required” the number 3 was written. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. The date and time services were to begin was written as 6/18/2021 at 12:00 AM. Record review further revealed that though the client continued to receive services into December of 2021, the agency failed to have evidence of a current Non-Oasis Comprehensive Assessment. The last comprehensive assessment on file was for the 6/18/2021 through 8/14/2021 certification period. 3) Record review for Client ID #3 revealed a client order dated 7/20/2021 for a CNA.In the box entitled “Hours Per Day/ # Visits Required” the number 25 was written. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review for Client ID #3 revealed a client order dated 8/31/2021. There failed to be clear instruction on the type of service, number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review further revealed that though the client continued to receive services into December of 2021, the agency failed to have evidence of a current Non-Oasis Comprehensive Assessment. 4) Record review of client #4 revealed a Client Order dated 6/27/2021 for an "Aide".There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. Record review further revealed that though the client continued to receive services into December of 2021, the agency failed to have evidence of a current Non-Oasis Comprehensive Assessment. The last being for the certification period of 6/27/2021 through 8/25/2021. 5) Record review of Client #5 revealed a Client Order for a Companion and Home maker. In the box entitled “Hours Per Day/ # Visits Required” the number 3 was written. There failed to be clear instruction on the number of hours per day, the number of visits per week and the number of weeks that visits were required. 6) Record review for Client # 7 revealed a client order dated 5/25/2021 for an Aide with no hours per day, or number of visits specified. Record review further revealed that the agency failed to have evidence of an updated Non-Oasis Comprehensive Assessment after the certification period of 5/25/2021 through 7/23/2021, even though the client continued to have visits until 8/15/2021. During a surveyor interview on 12/7/2021 at approximately 11:30 AM, with Staff J, she acknowledged that the agency failed to have complete and accurate orders for services. She further revealed that she would have expected a Non-Oasis Comprehensive Assessment to be completed at the end of 60 days, for the new certification period, but was unable to provide evidence that these assessments were completed.

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: Based on record review and staff interview it was determined the agency failed to ensure the clinical record included all interventions, including medication administration, treatments and services and responses to those interventions for 6 of 7 clients reviewed, Client #s 1, 2, 3, 4, 5 and 7. Findings are as follows: 1) Client ID #1 has a start of care date of 11/17/2021 for skilled nursing services. Review of the record for this client fails to reveal any physicians’ orders for this agency to administer a monthly vitamin B-12 injection. Review of the record reveals a Home Health Certification and Plan of Care for period 10/18/2021 – 12/17/2021, with the providers name and contact information for another home care agency. The record lacks a physician’s order for this agency to administer the monthly Vitamin B-12 injection, that was administered to the client on 11/17/2021 by staff G. The surveyor interviewed the Vice President, Staff J, on 12/6/2021, who stated that the nurse should have contacted the physician and obtained an order prior to the administration of the vitamin B-12 injection. 2) Record review for Client ID #2 revealed 6 out of 40 visits which failed to have any documentation of what tasks were completed on the visit. This equals 15% of visits which fail to contain any documentation about what interventions were completed on the visit and the client’s response to those interventions. Further record review failed to reveal evidence of medication reconciliation. The document titled; “Medication Profile” provided by the agency failed to have any medications listed. During a surveyor interview during a home visit on 12/3/2021, with Client #2, she revealed that she is currently taking Trazadone, Labetalol, Pregabalin, Jardiance, Atorvastatin, Vitamin D, Lamotrigine, Lisinopril, Amlodipine, Flonase and Trulicity. 3) Client ID #3 had a start of care date of 9/3/2021 for services. Record review of the form entitled “Non-Skilled Personal Care Assessment” dated 9/3/2021, completed by Staff K the Interim Executive Director, failed to reveal evidence of the client’s medication orders. 4) Client ID #4 had a start of care date of 6/27/2021 for services. Record review of the form entitled “Non-Oasis Comprehensive Assessment” dated 6/27/2021, completed by Staff L, Executive Director, failed to reveal evidence of the client’s medication orders. 5) Record review for Client ID #5 revealed 8 out of 43 visits which failed to have any documentation of what tasks were completed on the visit. Further review of the Client’s visits revealed 11 out of 43 visits where it is documented “No” under “completed” for all the tasks listed. During these visits the time spent in the home ranged from 3 to 4 hours. During a surveyor interview on 12/7/2021 at 9:05 AM with Staff F, she was unable to explain why the staff member was in the home for between 3-4 hours yet failed to complete any of the tasks listed. Record review of the client’s record failed to reveal a medication reconciliation. The document titled; “Medication Profile” provided by the agency failed to have any medications listed. Record review of the “Non- Oasis Comprehensive Assessment” dated 6/27/2021 for the certification period of 6/27/2021 through 8/25/2021 revealed that the client is “currently taking 5 or more medications” under the section of the assessment entitled “Frequency and Duration” it states “Has Change in orders” but no medication orders are documented. 6) Record review for Client ID #7 revealed, 6 out of 17 visits which failed to have any documentation of what tasks were completed on the visit. This equals 35 % of visits which fail to contain any documentation about what interventions were completed on the visit and the client’s response to those interventions. During a surveyor interview on 12/6/2021 at approximately 11:30 AM with Staff J, she revealed that a medication reconciliation should have been completed and documented by the nurse during the assessment. She was unable to provide evidence that this was completed. During a surveyor interview on 12/7/2021 at 12:22 PM with Staff I, she revealed that the staff member should be documenting what tasks are being completed at each visit. She was unable to provide evidence that this documentation was completed for the above visits.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and staff interview it was determined the agency failed to ensure that all entries are legible, clear, complete, and appropriately authenticated, dated, and timed for 2 of 7 clients, Client ID #s 3 and 5. Findings are as follows: 1) Record review of a document entitled "Paraprofessional Assignment Sheet" which was electronically signed on 9/13/2021 by Staff L had the documented goal of " The client's personal care needs and ADLs will be met safely with the assistance of the paraprofessional." Surveyor interview with Staff I, revealed that Staff L's last day of work was on 8/20/2021. She was unable to explain Staff L's signature on the document. 2) Record review of a supervisory visit for Staff M, which was conducted in the home of Client ID #5, was documented as occurring on 6/9/2021. This client had a Start of Care date of 6/27/2021, and therefore was not receiving services on the date of the documented supervisory visit. During a surveyor interview on 12/7/2021 at 9:15 AM with Staff I, she was unable to explain how a supervisory visit would have been completed in the client’s home prior to his/her start of care date.