Every finding on record at Loving Care Home Health LLC

A Recertification survey entrance conference was conducted on 04/15/25 with the Administrator. Census: Licensed and Certified (L&C)-0 Licensed Home Health (LHH)-12 Personal Assistance Services (PAS)-54 Acronyms: EP – Emergency Plan EPRP – Emergency Preparedness Response Plan

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct an exercise that may have included, but was not limited to a full-scale exercise (that was community-based or individual, facility-based) or a tabletop exercise (that included a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problems statements, directed messages, or prepared questions) designed to challenge the agency’s Emergency Preparedness Plan for two of three years reviewed (2023 and 2024). This failure could place the agency's patients at risk for harm by the possible failure of the agency's response in the event of an actual emergency. The findings included: During the entrance conference on 04/15/25 at 11:35 a.m., the surveyor requested the agency’s EPRP activities for 2023, 2024 and 2025. Review of the agency's Emergency Preparedness Response Plan failed to reveal evidence that the agency conducted an actual or mock annual drill for both 2023 and 2024. During concurrent review of the agency’s EPRP and interview on 04/24/25 at 12:46 p.m., the Administrator stated that there were not any drills conducted in either 2023 or 2024 for which she would have been responsible as the Administrator/Disaster Coordinator. Review of the agency’s policy and procedure manual revealed a policy titled, “Administrative Policy and Procedures Section: Emergency Preparedness, Emergency Preparedness Plan” with a date of 2017, revealed in part: “The agency will test its EP program at least annually and in accordance with its policy …”

A Recertification survey entrance conference was conducted on 04/15/25 with the Administrator. Census: Licensed and Certified (L&C)-0 Licensed Home Health (LHH)-12 Personal Assistance Services (PAS)-54 Acronyms: EP – Emergency Plan EPRP – Emergency Preparedness Response Plan

Purpose of Visit: Two Complaint Investigations An entrance conference was conducted on 10/05/2023 at 2:01 p.m., with the Administrator/Supervising Nurse. Census: Licensed and Certified Home Health (L&CHH): 22 Licensed Home Health (LHHS): 9 Personal Assistance Services (PAS): 65 An exit conference was conducted on 10/06/2023 at 7:15 p.m., with the Administrator/Supervising Nurse. The preliminary findings were discussed. The Administrator/Supervising Nurse was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies/Violations. Complaint Intakes: 399271 - Unsubstantiated #410600 - Substantiated

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have/implement and enforce written policies to provide Bloodborne Pathogen (BBP) training as required by the Occupational Safety and Health Administration (OSHA), 29 CFR 1910.1030 and Appendix A relating to BBP for 10 of 11 agency staff (A, C, D, J, K, L, M, N, O, P and Q) and 5 of 5 contracted staff (E, F, G, H and I) whose personnel records were reviewed. This deficient practice caused the agency to be out of compliance and placed the agency’s staff, contracted staff, and the patients they served at risk for exposure to infectious and communicable diseases. The findings included: Review of the OSHA 29 CFR 1910.1030 read in part, “…The employer provides information and training to workers. Employers must ensure that their workers receive regular training that covers all elements of the standard including, but not limited to information on bloodborne pathogens and diseases, methods used to control occupational exposure, hepatitis B vaccine, and medical evaluation and post-exposure follow-up procedures. Employers must offer this training on initial assignment, at least annually thereafter…” During an interview with the Administrator/Supervising Nurse on 10/06/23 at p.m., the Nurse Surveyor requested the Bloodborne Pathogen training for Staff A, C, D, E, F, G, H, I, J, K, L, M, N, O, P and Q. The Administrator/Supervising Nurse stated, “honestly, I don’t think they were done, but I will check.” The Administrator/Supervising Nurse stated, “that she is still waiting on the BBP training from the contracted therapy company and added, “that she is aware of the requirement…and moving forward will ensure that it is done and that they are in compliance.” During the same interview, the Nurse Surveyor requested the agency’s policies/procedures regarding BBP training. During the exit conference, on 10/06/23 at 7:00 p.m., the Administrator/Supervising Nurse was informed that the agency had two business days to provide the proof of training for the BBP training for Staff A, C, D, E, F, G, H, I, J, K, L, M, N, O, P and Q. On 10/10/23 at 9:47 a.m., the Administrator/Supervising Nurse provided additional information regarding the Hepatitis B and Bloodborne Pathogen Training and stated that the therapy company for the contracted staff did not have any BBP training, and that their therapists are not required to take any BBP training. The Administrator/Supervising Nurse stated that she was not able to find any BBP training for agency staff and not able to find the policies/procedures regarding the training. She stated that she did find the training manual for BBP training that is supposed to be used during BBP training by the staff member. Review of the agency’s policy titled, “Infection & Exposure Control Program” dated 1-2018, that read in part, “…2. The Organization shall develop and implement policies and procedures in compliance with current applicable local public health, state, federal, accrediting bodies, and OSHA regulations…7. F. Educating staff, patient, and caregivers on infection control.”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the supervising nurse or the alternate supervising nurse did not make sure that care was provided according to a client's needs as written in the plan of care or care plan for two of four Clients (#2 and #4) whose clinical records were reviewed in that: Client #2 did not receive physical therapy services as ordered by the physician. Client #4 did not receive home health aide services as ordered by the physician. This deficient practice placed Client #2 and #4 at risk of receiving inadequate care and services, not coordinating care with their physicians, and having unmet needs which could result in negative outcomes. The findings included: Review of Client #2’s electronic clinical record (ECR) revealed a start of care (SOC) date of 08/29/23 and a plan of care (POC) for the certification period of 08/29/23 – 10/27/23, with a diagnosis of trochanteric bursitis (inflammation of the outer hip near the groin) of the left hip and included orders for physical therapy (PT)to evaluate and treat. Review of the ECR revealed that a PT evaluation was done on 09/02/23 and included orders for PT visit frequencies of once a week for one week, twice a week for five weeks and once a week for one week. Further review of the ECR revealed PT visits as follows: Week of 09/17/23 only one PT visit done on 09/22/23 Week of 09/24/23: no PT visits were done. Week of 10/01/23: no PT visits were done. Further review of the ECR did not include any documentation of missed visits or any communication notes indicating that visits were attempted, and that the agency and the client’s primary care physician was notified. During concurrent record review and interview on 10/06/23 at 2:15 p.m., the Administrator/Supervising Nurse stated, “that Client #2 lived in an assisted living facility (ALF)… that, yes, she could see PT visits were not done according to the POC and that she was not made aware and that there were no missed visit notes or communication notes that visits were attempted and that the agency and PCP were notified. Review of Client #4’s ECR revealed a SOC date of 01/03/23 and a POC for the certification period of 01/03/23 – 03/13/23 and included a primary diagnosis of unspecified asthma (chronic lung disease caused by inflammation and tightening of the muscles around the airway making it difficult to breathe). Further review of the POC included orders for home health aide (HHA) visit frequency of three times a week for eight weeks effective the week of 01/16/23. Review of Client #4’s ECR revealed the following: Week of 01/15/23 - only one HHA visit was done on 01/20/23. During concurrent record review and interview on 10/06/23 at 2:30 p.m., the Administrator/Supervising Nurse stated, “that’s correct, there was only one HHA visit made that week, that there was no missed visit note or communication notes regarding why visit was missed, that she was not made aware, that there was a breakdown in the communication/system with the previous Administrator.” During this complaint investigation, HHA Q was not available for an interview, no longer employed by the agency. Review of the agency’s policy (LD.7) titled, “Responsibilities of the Director of Home Health Services” revised 09/21/2004 read in part, “Agency defines the responsibilities of the Director of Home Health Services to include but not be limited to 1.2. Coordinating and integrating care provided by the agency staff, including contractual providers…1.9. Assures that a client’s plan of care is executed as written.”