Every finding on record at Life Plus Hoealth Care, Inc

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: A. Based on review of clinical records and Staff interview, it was determined that the Agency failed to ensure the Staff followed the Plan of Care. This was found in 4 of 7 (Pts. # 1, 5, 6 and 3) clinical records reviewed. Findings include: 1. Pt. #1 SOC 09/01/22 Primary Diagnosis: Pressure Ulcer of Sacral. The clinical record was reviewed on 09/27/22 at 1:30 PM. The Plan of Care dated 09/01/21 required the PT services 1 time a week for 1 week, 2 times a week for 3 weeks and 1time a week for 3 weeks. The PT failed to visit/ assess the patient during the week of 09/01/22 (week #1). The PT documented the evaluation as 09/10/22 and the POC was not modified. 2. Pt. #5 SOC 08/16/22 Primary Diagnosis: Essential Hypertension. The clinical record was reviewed on 09/28/22 at 11:00 AM. The Plan of Care dated 08/16/21 required the PT to visit 1 time a week for 2 weeks, 2 times a week for 2 weeks and 1 time a week for 4 weeks. The PT failed to visit/ assess the patient during the week of 08/16/22 (week #1). The PT documented the evaluation as 08/24/22 and the POC was not modified.The same Plan of Care dated 08/16/21 required the OT to evaluate and treat. The OT failed to visit/ assess the patient during the week of 08/16/22 (week #1). The OT documented the evaluation as 08/25/22 (week #2) and the POC was not modified. 3. Pt. #6 SOC 06/18/22 Primary Diagnosis: Hemiplegia following Cerebral Infract affecting Left Non-dominant Side. The clinical record was reviewed on 09/28/22 at 1:00 PM. The Plan of Care dated 06/18/22 required the PT to evaluate and treat. The PT failed to visit/ evaluate the patient during the week of 06/18/22 (week #1). The PT documented the evaluation as 06/25/22 (week #2) and the POC was not modified. The same Plan of Care dated 06/18/22 required the ST to evaluate. The ST failed to visit/ assess the patient during the week of 06/18/22 (week #1). The ST documented the evaluation as 07/19/22 (week #6) and the POC was not modified. 4. Pt. #3 SOC 09/17/22 Primary Diagnosis: Hemiplegia. The clinical record was reviewed on 09/28/22 at 10:00 AM. The signed Plan of Care dated 09/17/22 required “…PT to evaluate and appropriately treat….” The record lacked any PT evaluation. During interview with the Administrator, Assistant Administrator and Clinical Director on 09/29/2022 at 10:15 AM, the Director of Clinical Services stated that the patient refused physical therapy services. The POC was not modified. 5. During interviews with the Administrator, Assistant Administrator and Clinical Director on 09/29/2022 from 10:15 AM through 11:30 AM, the Clinical Director confirmed that the Plans of care were not followed.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on the review/observation of vaccination records, Staff interviews and policy review, it was determined the Agency failed to ensure the 100% vaccination rate requirements and failed to ensure a complete vaccination policy that required documentation of the verbal medical exemption. This was found in 1 of 11 (Staff #11) providing Patient Care. Findings include: 1. On 09/28/22 at 10:00 AM, the Agency’s vaccination records were reviewed. It was observed that the personnel file of Staff #11 lacked documentation of the vaccination, lacked an exemption status and Staff #11 continued to visit patients (non-vaccinated Patient #1 and vaccinated Patient #2). 2. On 09/28/22 at 10:20 AM, during the interview with the Assistant Administrator and Clinical Director, it was stated that Staff #11 hired 12/04/19 was a part- time Aide and was not vaccinated because of her allergy. The clinical record of Patient #1 included a visit by Staff #11 on 09/09/22. The clinical record of Patient #2 also included visits by Staff #11 on: 08/03, 08/10, 08/19, 08/24, and 08/31/22.' 3. On 09/28/22 at 3:00 PM, a phone interview was conducted with Staff #11. She stated that she verbally reported her medical exemption and verbally reported weekly testing to the Clinical Director. The Agency lacked the required documentation to verify the medical exemption and proof of the weekly test results. 4. On 09/28/22 at 1:30 PM, the Agency’s policy titled “Mandatory Vaccination Policy” was reviewed and was incomplete. The policy lacked the process for the medical exemption requests. The policy failed to include the required process:“the recognized clinical reason for the contraindication; a statement recommending the staff be exempted from vaccination requirement; and a signature and date by a licensed practitioner, who is not the individual requesting the exemption.” 4. On 09/28/22 at 2:45 PM, and 09/29/22 at 10:30 AM, during the interview with the Clinical Director , Administrator and Assistant Administrator the above findings were confirmed.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on review of clinical records, Agency’s policy and Staff interview, it was determined that the Agency failed to ensure the Staff documented all interventions/ services and responses to those intervention/ services. This was found in 4 of 7 (Pts. #1, 6, 2 and 7) clinical records reviewed. Findings include: 1. Pt. #1 SOC 09/01/22 Primary Diagnosis: Pressure Ulcer of Sacral. The clinical record was reviewed on 09/27/22 at 1:30 PM. The Plan of Care dated 09/01/21 required Aide services 1 time a week for 9 weeks. The Aide documented a visit on 09/09/22, with no further visit notes as of 9/27/2022. There was no documentation for any communication to physician or patient/family response to the missed visit. 2. Pt. #6 SOC 06/18/22 Primary Diagnosis: Hemiplegia following Cerebral Infract affecting Left Non-dominant Side. The clinical record was reviewed on 09/28/22 at 1:00 PM. The PT failed to document the evaluation and the patient/family responses. 3. Pt. #2 SOC 06/20/22 Primary Diagnosis: Hypertensive Chronic Kidney Disease. The clinical record was reviewed on 09/28/22 at 9:45 AM. The POC effective 08/19/22 required Home Health aide frequency of 1 time a week for 9 weeks. The record lacked current Home health aide visit notes for week 6 (09/14 to 09/10), week 7 (09/11 to 09/17) and week 8 (09/18 to 09/24). There was no documentation for any communication to physician or patient/response to the missed visit. 4. Pt. #7 SOC 10/15/21 Primary Diagnosis: Chronic Pain syndrome. The closed clinical record was reviewed on 09/29/22 at 9:00 AM. The POC effective 04/13/22 required Home Health aide frequency of 2 times a week for 9 weeks. The record documented a visit from the HHA (week 4) dated 5/5/22 and lacked another note for that week. There was no documentation for any communication to physician or patient/family response to the missed visit. 5. During interviews with the Administrator, Assistant Administrator, Clinical Director on 09/29/2022 from 10:15 AM to 11:30 AM, the Clinical Director, confirmed the above findings.

A recertification survey was attempted 8/2/22. The agency staff were unavailable and denied access to records to conduct a survey. A Determination has been made that this agency is not in compliance with the Conditions of Participation for: 42 CFR 484.105 Organization and Administration of Services The Agency is precluded from conducting Aide training and/or competency evaluations for 24 months effective 08/02/22. This applies even if the Agency is not currently conducting Aide training and/or competency.

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 the staff interview and on-site observations, it was determined the Agency failed to manage administrative and supervisory oversight for the Agency's Patients. This has the potential to affect all patients being served by the agency. Findings include: 1. The Agency failed to ensure administrative oversight for all patient care. (G958). The cumulative effect of these systemic practices resulted in the Agency's inability to provide care effectively.

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: A. Based on the on-site observations and a telephone interview, it was determined the Agency failed to ensure the oversight for all the patient care. Findings include: 1. On 08/02/22 at 9:00 AM, it was observed that the Agency was opened by the "Biller" (not a Nurse). The Acting Administrator/Clinical Director was called and stated that both she and the Administrator were unavailable. It was also stated that her designee was not available today and would not be able to assist with the survey. 2. On 08/02/22 at 9:30 AM and 10:30AM, during telephone interviews with the Acting Administrator, it was stated that the Agency has 5 patients and 3 Nurses ( Clinical Director and two part-time Registered Nurses). The Acting Administrator stated that no clinical staff was available to come into the agency and or assist with the survey. The Acting Administrator was informed that a recommendation for termination would be submitted due to lack of access to records, documents and an inability to conduct the survey. It was observed that the Agency failed to ensure the oversight for all the patient care. 3. The above findings were confirmed by Acting-Administrator/ Clinical Director, 08/02/22 at 9:30 AM and 10:30 AM.