Every finding on record at Livingwell Home Health Agency Inc

Purpose of Visit: Re-certification Survey. Entrance Date: 04/08/2021 An entrance conference was conducted with the administrator, Employee A at 11:50 a.m. Employee A was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 15 Exit Date: 04/14/2021 An exit conference was conducted at 3:50 p.m. with the administrator, Employee A, and the office manager, Employee D. The preliminary findings were discussed. The agency was given an opportunity to ask question and 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. Met EP condition of participation. Abbreviation List: L & C- Licensed and Certified EP-Emergency Preparedness

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable Federal, State and local EP requirements to develop, establish and maintain a comprehensive emergency preparedness program that met the requirements to maintain an emergency preparedness plan that was reviewed, and updated at least every 2 years (per federal regulation) nor at least annually (per state regulation and agency policy) for the years 2019 and 2020. The failure could place the agency's patients at risk of harm, in the event of an actual emergency or disaster, if the agency's emergency plan was not comprehensive and updated to meet applicable federal, state and local EP regulatory requirements and to meet the needs of the agency's patient population. FINDINGS INCLUDED: During the entrance conference at 11:50 a.m. on 04/08/2021, the administrator, Employee A identified the alternate supervising nurse, Employee C as the Disaster Coordinator and the office manager, Employee D, as the alternate disaster coordinator. The emergency preparedness plan binder was reviewed on 04/08/2021. The binder contained a record titled "Emergency Preparedness Plan Review and Checklist." The EP plan review and checklist was dated 01/18/2018. The EP record review did not identify any other records to establish that the agency had conducted annual internal reviews of the agency's emergency preparedness and response plan, for the years 2019 and 2020. During an interview on 04/14/2021 at approximately 2:07 p.m. with the administrator, Employee A, the alternate supervising nurse, Employee B and the office manager, Employee D, the surveyor discussed the above findings and asked why the agency had not evaluated the EP and response plan at least annually. Employee A replied, "I think it was just not documented." Record review of agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8" revised 070120 read in part: "PURPOSE I. To ensure the Agency complies with all applicable Federal, State, and local emergency preparedness requirements ...POLICY...The plan and related policies and procedures must be reviewed and updated at least annually ..."

Purpose of Visit: Re-certification Survey with follow-up for survey dated 04/30/2018. Entrance Date: 04/08/2021 An entrance conference was conducted with the administrator, Employee A at 11:50 a.m. Employee A was informed that the purpose of the survey was for a 36-month recertification inspection and follow-up for survey dated 04/30/2021. L&C Census: 15 Exit Date: 04/14/2021 An exit conference was conducted at 3:50 p.m. with the administrator, Employee A, and the office manager, Employee D. The preliminary findings were discussed. The agency was given an opportunity to ask question and 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. Met conditions of participation. Abbreviation List: L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement SN- Skilled Nursing Registered Nurse (RN) Physical Therapist (PT) CMS- Center for Medicare and Medicaid Services OASIS -outcome and assessment information set

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: This is a continuing deficiency from the survey conducted on 04/30/2018 cited under Tag G442 and this is a continuing deficiency from the survey conducted on 05/15/2015 cited under Tag G101. Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide patients # 6 and 7 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 6: Record review of the electronic and hard copy clinical records for Patient # 6 revealed a POC with a SOC date of 12/09/2019. The POC had a certification period 08/05/2020 to 10/03/2020 and a principal diagnosis of chronic obstructive pulmonary disease with acute exacerbation. The POC was signed by alternate supervising nurse, RN C and dated 08/03/2020. The POC contained an order for SN visits one time per week for four weeks and two to three as needed visits for the first 30 days and proposed SN visits one time per week for four weeks and two to three as needed visits for the second 30 days. Patient # 6's record included an undated discharge OASIS electronically signed by RN C that showed a date of discharge as 09/28/2020. The record also included a discharge summary that was signed by RN C and dated 09/28/2020. Patient # 6's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/28/2020. The records did not include a written NOMNC. Clinical Record # 7: Record review of the electronic and hard copy clinical records for Patient # 7 revealed a POC with a SOC date of 04/15/2020. The POC had a certification period 08/13/2020 to 10/11/2020 and a principal diagnosis of unspecified heart failure. The POC was signed by alternate supervising nurse, RN C and dated 08/11/2020. The POC contained an order for SN visits one time per week for four weeks and two to three as needed visits for the first 30 days and proposed SN visits one time per week for five weeks for the second 30 days. Patient # 7's record included a discharge OASIS electronically signed by the supervising nurse, RN A that showed a date of discharge as 09/28/2020. The record also included a discharge summary that was signed by RN A and dated 09/28/2020. Patient # 7's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/28/2020. The records did not include a written NOMNC. In an interview on 04/14/2021 at approximately 2:30 p.m. with the administrator/supervising nurse, RN A, the surveyor discussed the above findings and asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7. RN A replied, "I was not aware that it was not given." Agency policy titled "PATIENT/CLIENT TRANSFER DISCHARGE NOTICES PE.6" revised 080120 read in part: " ...POLICY ...III. The Agency will deliver the Notice of Medicare Non-Coverage( ...form) to the patient/client (or authorized representative), at least ...(2) calendar days before Medicare covered services end or the second day to the last day of service if care is not provided daily ..."

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review, observation and interview, the agency failed to enforce its written policy to ensure coordination of patient care when other facilities were involved in the patient's care; such as a group home/assisted living facility ensuring information, reporting and coordination of services concerning the health care services provided by the agency for two (Patients # 2 and 3) of two active patient's record reviewed who resided in a group setting. The failure could cause the patients' health and safety to be placed at risk and could cause a duplication of services. FINDINGS INCLUDED: Clinical Record #2: The electronic and hard copy clinical records for Patient # 2 contained a POC for the certification period of 02/01/2021 to 04/01/2021. The POC included a start of care date of 12/03/2020 and included primary diagnosis of stage two pressure ulcer of sacral region. The POC was dated 01/28/2021 and electronically signed by alternate supervising nurse, RN C. The POC contained an order for SN visits two times per week for three weeks, one time per week for one week and two to three as needed visits for the first thirty days, and proposed SN visits one time per week for five weeks with two to three as needed visits for the second 30 days. There was also an order for PT services for two times per week for three weeks. Patient # 2's clinical records did not contain documentation of the agency's communication and coordination of care with the group home nor of communication of coordination of care between the agency's staff about the patient's relocation. Clinical Record #3: The electronic and hard copy clinical records for Patient # 3 contained a POC for the certification period of 02/02/2021 to 04/02/2021. The POC included a start of care date of 12/05/2020 and included primary diagnosis of hypertensive chronic disease with stage one to four kidney failure. The POC was dated 01/28/2021 and electronically signed by alternate supervising nurse, RN C. The POC contained an order for SN visits two times per week for three weeks, one time per week for one week and two to three as needed visits for the first thirty days, and proposed SN visits one time per week for five weeks with two to three as needed visits for the second 30 days. Patient # 3's clinical records did not contain documentation of the agency's communication and coordination of care with the group home nor of communication of coordination of care between the agency's staff about the patient's relocation. On 04/09/2021 the agency's office manager, Employee D scheduled a visit with Patients # 2 and 3's caregiver, Identifier 2a, for 04/12/2021. The surveyor attempted to conduct a home visit on 04/12/2021 at approximately 9:00 a.m. with Patients # 2 and 3. The surveyor arrived at the residential address that was listed in Patients # 2 and 3's electronic record. The surveyor observed that the front door had a padlock on it and there was no answer after three knocks. The surveyor called the agency and spoke with the office manager, Employee D about the padlocked door. Employee D stated that Employee D would call the caregiver, Identifier 2a to find where the patients were relocated. Employee D provided a new address for the patients. Patients # 2 and 3 resided in an apartment complex where the surveyor observed other residents living in the apartment. The surveyor asked the caregiver, Identifier 2a how long the patients had resided in the current residence. Identifier 2a stated the patients had resided there since the "Ice Storm." The Ice Storm was on or around 02/15/2021. An interview was conducted with the supervising nurse, RN A and the office manager, Employee D, on 04/14/2020 at approximately 3:15 p.m. The surveyor discussed the above findings and asked what the living arrangements were where Patients 2 and 3 resided. RN A and Employee B replied, "I think it is a group home." The surveyor also asked why the agency had not coordinated care with the group home, the contracted PT services and SN service about the patients' relocation, on or around 02/15/2021. Employee D stated that the caregiver, Identifier 2a had stated the relocation was temporary. Agency policy titled "MONITORING PATIENT CARE/COORDINATION OF CARE PC.10" revised 08/01/20 read in part"...POLICY...II...The agency will collaborate with a...group home...in which the patient/client resides...PROCEDURE I. The Agency will integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care by all disciplines...III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This communication will be documented on a communication note..."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct and document PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. This failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 04/08/2021. A binder labeled "QAPI Manual" was provided by the office manager, Employee D, on 04/08/2021. Record review of the binder showed that it contained the agency's written QAPI plan. The last quarterly QAPI report in the binder was for the "3rd" quarter of 2017. The binder did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 04/09/2021 at approximately 4:30 p.m., with the administrator, Employee A and the office manager, Employee D, the surveyor asked if the agency had provided all QAPI information for review that was requested by the surveyor on 04/08/2021. Employees A and E stated yes, the agency had provided all requested information. During an interview with the administrator, Employee A on 04/14/2021 at approximately 2:25 p.m., the surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2018, 2019 and 2020. The administrator, Employee A stated that Employee A was not aware of the regulatory requirement to conduct PIP(s). Review of agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" revised 011318 read in part: PROCEDURE ...III ...D. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency's services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects ..."

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 interviews, the agency's governing body failed to ensure that an ongoing program for quality improvement and patient safety was implemented and maintained. In one of one (QAPI Program) the agency failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained. The agency failed to maintain an agency wide QAPI Program. The QAPI program was not ongoing and focused on Patient outcomes that were measurable, for the years 2018, 2019 and 2020. The failure could place the agency's Patients at risk of negative Patient care outcomes if substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. FINDINGS INCLUDED: The surveyor requested all agency QAPI documents/reports/manuals on 04/08/2021. A binder labeled "QAPI Manual" was provided by the office manager, Employee D, on 04/08/2021. Record review of the binder showed that it contained the agency's written QAPI plan. The last quarterly QAPI report in the binder was for the "3rd" quarter of 2017. The last QAPI Action Plan was dated 03/03/2017. The binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an agency wide QAPI program that included the federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 04/09/2021 at approximately 4:30 p.m., with the administrator, Employee A and the office manager, Employee D, the surveyor asked if the agency had provided all QAPI information for review that was requested by the surveyor on 04/08/2021. Employees A and E stated yes, the agency had provided all requested information. During an interview with the administrator, Employee A on 04/14/2021 at approximately 2:25 p.m., the surveyor asked why the agency had not ensured that an agency-wide ongoing program for quality improvement and patient safety was implemented and maintained for the years 2018, 2019 and 2020. Employee A stated that the agency did not have "our contracted agency onboard, so it was not completed the way it was supposed to." Agency policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.1" revised 011318 read in part: "...POLICY...I the Governing Body will ensure that the QAPI program ...III. The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS ...IV. Executive responsibilities...A. That an ongoing program for quality improvement and patient/client safety is defined, implemented, and maintained: B. That the agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient/client safety, and that all improvement actions are evaluated for effectiveness ...