Every finding on record at Monroe Co Hosp Progressive Hom

A recertification survey was conducted at Monroe County Hospital's Progressive Home Care on 8/19/25 to 8/21/25. The agency failed to meet the requirements of the Conditions of Participation for 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), §485.542(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 a review of the agency's Emergency Preparedness (EP) plan and staff interview it was determined the agency failed to review and update the EP plan every two years. This had the potential to affect all patients served, and all staff members employed by this agency. Findings include: 1. A review of the agency's EP plan revealed the plan had not been reviewed or updated since April 2022, which is three years and four months since last update. An interview was conducted on 8/21/25 at 10:45 AM with Employee Identifier # 1, Associate Executive Director, who confirmed the agency's EP plan had not been updated or reviewed since April 2022.

A recertification survey was conducted at Monroe County Hospital's Progressive Home Care on 8/19/25 to 8/21/25. Standard Level deficiencies were cited and will require an acceptable Plan of Correction.

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 observations, medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure medications were reconciled each Skilled Nurse (SN) visit per agency policy. This deficient practice affected two of three home visit (HV) patients including HV # 1, HV # 2, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: 8.15.1 Reviewed: 1/28/25 Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis... Procedure: ...2. ...The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated... 2. HV # 2 was admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. Review of the Home Health Care Certification and Plan of Care dated 7/11/25 revealed physician's orders for SN one visit per week for nine weeks, SN to perform medication reconciliation with each visit. A HV was conducted on 8/20/25 at 8:45 AM to observe care provided by EI # 5, Home Health Aide. During the home visit the medications were reviewed with HV # 2 and compared with the MP dated 8/19/25. The following is a list of the discrepancies: Eliquis 2.5 mg take one tablet twice daily was on the MP but not in the home. HV # 2 stated he/she had not taken the medication in three years. Colace sodium 100 mg oral capsule, take one cap orally twice daily. HV # 2 stated he/she has only taken the medication as needed for greater than three months. Hydrocodone 7.5/325 mg, take one tablet orally every four hours as needed for moderate pain was on the MP but not in the home. HV # 2 stated he/she had not taken the medication for greater than six months. Atorvastatin 40 mg oral table, take one tablet orally once daily was on the MP and in the home. HV # 2 stated he/she had the medication in the home but does currently take the medication. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1 who confirmed the medications were not reconciled per agency policy and physician's orders. 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage IV, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician's orders for SN one visit per week for eight weeks, SN to perform medication reconciliation with each visit. A HV was conducted on 8/20/25 at 10:15 AM to observe care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). During the home visit, EI # 4 reviewed the medications with HV # 1 and compared the medications with the Medication Profile (MP) dated 8/19/25. The following is a list of the discrepancies: Nitrofurantoin 50 milligrams (mg) take one every day, prescription dated 11/12/24, was in the home but not on the MP. HV # 1 stated he/she was currently taking the medication daily. Terbinafine 250 mg take one daily was on the medication list but not in the home. HV # 1 stated he/she had not been taking the medications for "a while." Omega 500 mg was in the home and not on the MP. HV # 1 stated he/she had been taking the medication for "a long while." An interview was conducted on 8/21/25 at 9:50 AM with EI # 1, Associate Executive Director, who confirmed the medications were not reconciled per agency policy and physician's orders.

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 Medical Record (MR) review, agency policy and procedure, and staff interview it was determined the agency failed to ensure all physician orders were complete and accurate. This affected two of seven MR's reviewed, including Home Visit (HV) # 1 and MR # 4 and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Plan of Care - CMS # 485 and Physician Orders Policy Number: Not Listed Reviewed Date: 1/28/25 Policy: Skilled nursing ... will be in accordance with a Plan of Care... Procedure: ... 4. The individualized plan of care must include the following: ...Patient-specific interventions and education, measurable outcomes and goals identified by the agency... 21. Drugs, services, and treatments are administered by staff only as ordered by physician... 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. A review of the Home Health Certification and Plan of Care (POC) dated 7/2/25 revealed an order for Skilled Nurse (SN) to change Foley catheter as ordered using sterile technique, SN to change size18 French Foley catheter every month at visit week of 5/12/25, 6/16/25, 7/7/25, or PRN due to leaking. An interview was conducted on 8/21/25 at 9:45 AM with Employee Identifier (EI) # 1, Associate Executive Director, who confirmed the staff failed to write an order for the Foley to be changed in August 2025 on the POC. 2. MR # 4 was admitted to the agency on 4/16/24 and recertified from 2/10/25 to 4/10/25 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Disorder of the Kidney and Ureter unspecified. A review of the POC dated 2/10/25 revealed an order for the SN to change Foley catheter every three weeks as ordered: week of 2/24/25, week of 3/17/25 and week of 4/7/25. No order was found with the size of the Foley catheter or the balloon size. An interview was conducted on 8/21/25 at 9:54 AM with EI # 1, who confirmed the order for the Foley was not complete on the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observations, agency policy and procedure, medical record (MR) review, and interviews with staff, it was determined the agency failed to ensure: 1. Wound care was provided as ordered. 2. Patient's weight was obtained as ordered. 3. Patient's Blood Sugar (BS) was monitored as ordered. This deficient practice affected four of 7 MR reviewed including Home Visit (HV) # 1, MR # 2, HV # 2, and MR # 1, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care - CMS # 485 and Physician Orders Policy Number: Not Listed Reviewed Date: 1/28/25 Policy: Skilled nursing ... will be in accordance with a Plan of Care... Procedure: ... 4. The individualized plan of care must include the following: ...All medications and treatments. ...All patient care orders, including verbal orders, must be recorded in the plan of care... 21. Drugs, services, and treatments are administered by staff only as ordered by physician... 4. MR # 1 was admitted on 7/6/25 with diagnoses including Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Chronic Kidney Disease with Stage 1-4 unspecified Chronic Kidney Disease. A review of the POC dated 7/6/25 revealed physician's orders for SN two visits per week for four weeks, then one visit per week for five weeks. Further review of the POC revealed SN to assess blood sugar at each visit and to perform wound care/dressing change to sacral wound every SN visit. Clean with Normal Saline, allowing time to dry, pack wound lightly with Dakin's soaked gauze and cover with Mepilex. A review of SN Visit Notes dated 7/24/25, 7/28/25, 8/1/25, and 8/5/25 revealed the SN documented covering the sacral wound with Allevyn instead of the ordered Mepilex. A review of SN Visit Notes dated 7/6/25, 7/7/25, 7/10/25, 7/22/25, 7/24/25, and 8/5/25 revealed the SN failed to document blood sugar. An interview was conducted on 8/21/25 at 9:59 AM with EI # 2, Clinical Manager, who confirmed the staff failed to follow the physician's order for blood sugar assessments and wound care. 3. HV # 2 was admitted to the agency on 11/13/24 and recertified for continued care on 7/11/25 to 9/8/25 with a primary diagnosis of Type Two Diabetes Mellitus with Foot Ulcer. A review of the POC dated 7/11/25 revealed an order for SN for one time a week for nine weeks. SN to clean left heel with normal saline, pat dry, apply Santyl ointment (debridement) followed by a wet to dry dressing, wrap with Kerlix (rolled gauze) and secure with Coban (self adherent wrap) daily and as needed. A further review of the POC revealed an order for SN to assess blood sugar monitoring and results; notifying the MD of blood sugar readings greater than 300 or less than 65. The review revealed no physician orders to obtain a fingerstick blood sugar. A review of the Skilled Nursing Visit note dated 7/21/25 revealed the nurse documented the left heel was cleaned with saline and covered with a Band-Aid. The staff failed to provide wound care to the left heel as ordered. A review of the Skilled Nursing Visit note dated 8/18/25 revealed the nurse documented: SN assessed the blood sugar via fingerstick to right middle finger. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1, who confirmed the nurse did not follow the physicians orders for wound care and had no orders to obtain patient's blood sugar. 1. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for eight weeks to perform wound care/dressing change to Stage 4 pressure ulcer to right buttock, clean with dial soap and water, pat dry, moisten coarse gauze with 0.125 % Dakin's Solution and apply directly to wound. Cover with Island dressing or Allevyn dressing. There were no other orders provided for the wound care. A HV was conducted on 8/20/25 at 10:15 AM to observe wound care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). EI # 4 removed the border dressing from the buttock and approximately 12 inches of gauze packing from inside the wound. EI # 4 then cleaned the wound with Normal Saline and gauze. EI # 4 failed to clean the wound with soap and water as per physician's orders. EI # 4 then unfolded a 4 x 4 gauze, soaked the gauze with Vashe, packed the wound with the Vashe soaked gauze, then covered the wound with Allevyn dressing. EI # 4 failed to clean the wound with Dakin's Solution and packed the wound with Vashe soaked gauze without a physician order. An interview was conducted on 8/20/25 at 11:15 AM with EI # 4 who was asked if the wound care was provided as ordered. EI # 4 responded "We switch back and forth from the Dakin's and Vashe to clean the wound, it depends on the drainage and the smell of the wound. The Dakin's is better if the wound has an odor to it." A review of the Skilled Nursing Visit notes dated 7/8/25, 7/15/25, 7/23/25, 7/30/25, 8/6/25 and 8/13/25 revealed the nurse documented cleaning the wound with normal saline instead of the ordered dial soap, and water. An interview was conducted on 8/21/25 at 9:50 AM with EI # 1, Associate Executive Director, who confirmed the wound care was not provided as ordered and there was no physician order for wound packing. 2. MR # 2 was admitted on 7/2/25 with diagnoses including Hypertensive Heart Disease, Heart Failure, and Atherosclerotic Heart Disease. Review of the Home Health Care Certification and Plan of Care dated 7/2/25 revealed physician's orders for SN one visit per week to assess weight change with each visit. Review of the SN Visit Notes dated 7/18/25, 7/25/25, 8/14/25, and 8/18/25 revealed no documentation the patient weight was obtained. An interview was conducted on 8/21/25 at 9:50 AM with EI # 1 who confirmed the agency failed to ensure the patient's weight was obtained on each SN visit as ordered.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, agency procedure and staff interview it was determined the agency failed to ensure all aide staff followed infection control precautions and bed bath procedure. This affected one of three home visit (HV) patients, including Home Visit (HV) # 1, and had the potential to affect all patients served by this agency. Findings include: Agency Procedure : Briggs Healthcare Infection Control Procedure number: N-140 Agency Review date 1/28/25 ...Required Infection Procedures: ...2. Remove gloves and wash hands after each contact... Agency Procedure: Briggs Healthcare Bed Bath Procedure Number P-140 Agency Review date 1/28/25 Purpose: To cleanse the skin, stimulate circulation, provide mild exercise, and promote comfort... Applies to: Home Health Aides... 16. Cover the patient and change bath water. 17. Remove gloves, wash hands put on new gloves... 21. Remove gloves , wash hands, change bath water, put on clean gloves... 1. HV # 2 was admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. A HV was conducted on 8/20/25 at 8:45 AM with Employee Identifier (EI) # 5, Home Health Aide to observe care provided to HV # 2. EI # 1, Associate Executive Director was present during the HV. Review of the Home Health Care Certification and Plan of Care dated 7/11/25 revealed physician's orders for an Aide to visit one time a week for one week effective week of 7/11/25, and one time a week for nine weeks effective week of 7/14/25 for Hygiene: Bath: Chair with each visit, Safety: standard precautions with each visit. During the HV, EI # 5 washed the perineal area of the patient, then washed and rinsed the lower body with the same basins of water and without changing gloves and performing hand hygiene. When the bath was complete EI # 5 did not change his/her gloves to obtain the patient's clothing and briefs, and dress the patient. An interview was conducted on 8/21/25 at 10:02 AM with EI # 1, who confirmed staff failed to follow the procedure for a bed bath and the agency infection control procedure.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure a patient received education on a new medication prior to discharge. This deficient practice affected one of one patients with therapy only ordered including MR # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Patient Education Policy Number: 9.22.1 Reviewed: 1/28/25 Policy: Agency staff will provide initial and ongoing education to meet each individual patient's needs. ... Procedure: ... 2. Based on patient's condition, physician ordered care and assessed needs, patient/family will receive education, as appropriate, about: ...Medications, including safe and effective use... 1. MR # 4 was admitted on 2/24/25 with diagnoses including Multiple Sclerosis and Hemiplegia. Review of the Home Health Care Certification and Plan of Care dated 2/24/25 revealed physician's orders for Physical Therapy (PT) one visit per week for seven weeks and to reconcile medications with each visit. Review of the Patient Care Order dated 3/25/25 revealed orders for Bactrim 400 milligrams, take 0.5 tablets daily for 14 days. Review of the Physical Therapy Visit Notes revealed no documentation the patient was provided education on the new medication. There was no documentation a Skilled Nurse visit was completed. Review of the Patient Care Order dated 4/15/25 revealed physician's orders to discharge from physical therapy and all home health services secondary to goals met. An interview was conducted on 8/21/25 at 10:00 AM with Employee Identifier # 1, Associate Executive Director who confirmed there was no patient education provided for the new medication.

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 the Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice, agency procedure, Medical Record (MR) review, and staff interview, it was determined the agency failed to ensure the staff documented accurately and completely in the MR. This affected three of three wound care MR's reviewed including Home Visit (HV) # 2, HV # 1, and MR # 1 and had the potential to affect all patients served by this agency. Findings include: Alabama Board of Nursing Chapter 610-x-6: Standards of Nursing Practice 610-X-6-.06 Documentation Standards: (1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be: (a) Legible (b) Accurate (c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... " Agency Procedure: Wound Measurement Briggs Healthcare Procedure Number: G-270 Review Date:1/28/25 Procedure: ...f. Wound Measurements are done with routine would care procedures... g. Documentation of wound measurements is part of the required documentation for all wound care procedures. 3. MR # 1 was admitted on 7/6/25 with diagnoses including Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Chronic Kidney Disease with Stage 1-4 unspecified Chronic Kidney Disease. A review of the POC dated 7/6/25 revealed physician's orders for SN two visits per week for four weeks, then one visit per week for five weeks. A further review of the POC revealed an order for SN to perform wound care to clean sacral wound with Normal Saline, allowing time to dry, pack wound lightly with Dakins soaked gauze and cover with Mepilex. A review of the SN Visit Note dated 7/14/25 and 7/21/25 revealed the SN failed to document the depth measurement. An interview was conducted on 8/21/25 at 9:59 AM with EI # 2, Clinical Manager, who confirmed the nurse failed to document the depth measurement. 1. HV # 2 was and admitted to the agency on 7/13/24 and recertified from 7/11/25 to 9/8/25 with a primary diagnosis of Diabetes with Foot ulcer. A review of the POC dated 7/11/25 revealed an order for Skilled Nurse (SN) for one time a week for nine weeks with orders for the SN to assess blood sugar monitoring and results: notifying the Doctor of Medicine (MD) of blood sugar readings greater than 300 or less than 65. A review of the Skilled Nursing Visit notes dated 7/16/25, 7/21/25 and 8/4/25 revealed the nurse failed to document the blood sugar monitoring results. A further review of the POC revealed an order for SN to clean left heel with normal saline, pat dry, apply Santyl ointment (debridement) followed by a wet to dry dressing, wrap with Kerlix (rolled gauze) and secure with Coban (self adherent wrap) daily and as needed. A review of the Skilled Nursing Visit notes dated 7/16/25, 8/4/25, 8/13/25, and 8/18/25 revealed the nurse failed to document the wound care performed during the visit. A review of the Skilled Nursing Visit note dated 7/16/25, 7/21/25, 8/4/25, and 8/18/25 revealed the nurse failed to document the wound measurements. An interview was conducted on 8/21/25 at 10:02 AM with Employee Identifier (EI) # 1 Associate Executive Director, who confirmed the nurse failed to document the blood sugar monitoring results, wound care performed and the measurements. 2. HV # 1 was admitted on 7/13/23 and recertified from 7/2/25 to 8/30/25 with diagnoses including Pressure Ulcer of Right Buttock, Stage 4, Encounter for attention to colostomy, and Encounter for Fitting and Adjustment of Urinary Device. A review of the POC dated 7/2/25 revealed an order for SN one time a week for eight weeks. Further review of the POC revealed SN to perform wound care/dressing change to stage four right buttock gluteal fold. Clean with dial soap and water, pat dry, moisten coarse gauze with 0.125 % Dakin's Solution and apply directly to right buttock wound. Cover with island dressing or Allevyn ( foam dressing) twice daily and as needed for soilage. SN to instruct caregiver on how to perform wound care twice daily in the SN's absence. A review of the Skilled Nursing Visit note dated 7/15/25 revealed the nurse failed to document the depth measurement. An interview was conducted on 8/21/25 at 9:45 AM with EI # 1, who confirmed the staff failed to document the depth measurement.

During an onsite recertification survey on 3/23/22 at Monroe County Hospital Progressive Home Care agency, standard level deficicies were identified and an acceptable Plan of Correction is required.

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 review of the agency Emergency Management policies and procedures last approved 2/19/21, the agency Emergency Preparedness Plan manual documentation, and interviews with Employee Identifier (EI) # 1, Administrator, it was determined the agency failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach was conducted and documented at least every 2 years. This had the potential to negatively affect all patients and staff. Findings include: Agency Policy Title: Agency Facility-Based and Community-Based Risk Assessment Policy 2.2.1 Date Approved: 2/1/21 The Agency Administrator, Director of Clinical Services and staff implement emergency operations plan. The Agency primarily serves elderly, homebound patients. Vulnerabilities for patients may include no caregivers…and no way to evacuate home safely. Purpose To describe the Agency’s approach to responding to internal and external emergencies… Procedure 3. The emergency preparedness program includes but is not limited to the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed an updated at least every 2 years. The plan: Is based on and includes a documented, facility-based (Agency) and community-based risk assessment, utilizing an all-hazards approach…. Review of the agency Emergency Preparedness Plan (EPP) manual documentation on 3/21/22 at 10:50 AM revealed documents titled, Monroe County Hospital Hazard and Vulnerability Assessment Tool- Technological Events, Human Related Events and Events Involving Hazardous Materials. There was no date documented on the 3 assessments tools. Further review of the agency EPP manual revealed no documentation agency staff completed an agency-based risk assessment using an all hazards approach and there was no documentation a community-based risk assessment using an all hazards approach was completed. In an interview conducted on 3/22/22 at 2:45 AM, EI # 1 reported the agency participated with the Monroe County Hospital system Emergency Preparedness Program. EI # 1 confirmed there was no documentation staff completed an agency-based risk assessment and there was no documentation provided that a community-based risk assessment using an all hazards approach had been completed at least every 2 years per agency policy and procedure.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the agency Emergency Management policies and procedure last approved 2/19/21, the agency policy and procedure titled, Communication Plan and Policy for Emergency Operations Plan, the agency Active Employee List, the Progressive Home Care (PCH) Disaster Call/Text Back List and interview with Employee Identifier (EI) # 1, Administrator, it was determined the agency failed to follow its own policy and procedure and review/update and document all staff’s contact information in the agency’s Communication Plan. Findings include: Agency Policy Title: Communication Plan and Policy for Emergency Operations Plan (EOP) 2.3.1 Date Approved: 2/19/21 Policy The Agency has developed and maintained an emergency preparedness communication plan that…is reviewed and updated at least every two years. Contact information for incoming new staff will be updated throughout the year and any other changes to information for those individuals and entities list on contact lists. All contact lists must be reviewed and updated at least annually. Review must be documented. Procedure 1. The Communication plan includes the following: Names and contact information for the…staff, Entities providing services under arrangement or contract. Patients’ physicians… During an emergency staff will primarily communicate by telephone or cellular phone… Review of the agency Active Employee List revealed a total of 22 employees, with title and hire dates, and included the following staff: One part-time Certified Occupational Therapist Assistant hire date 1/1/2020. One full time Home Care Assistants hire date was 11/2/21. One full time Home Care Assistants hire date was 9/1/21. One part-time Physical Therapy Assistant hire date 5/18/14. One full-time Speech Language Pathologist hire date 12/8/21. Review of the agency documents titled, Communication Plan: Staff Contact Information and PCH Employee Disaster Call/Text Back List found in the agency Emergency Preparedness Plan manual revealed no contact information for the 5 active employees listed above. An interview was conducted on 3/22/22 at 2:45 PM and EI # 1 confirmed the agency EOP Communication Plan Staff Contact information and Disaster Call/Text Back List did not include contact information for all active agency employees.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency policy and procedure titled, Emergency Operations Plan (EOP) Training Program last approved 2/19/21, the agency Emergency Preparedness Plan manual documentation, the agency Active Employee List, agency personnel records and interview with Employee Identifier (EI) # 1, Administrator, it was determined the agency failed to follow its own policy and procedure and conduct and document emergency preparedness training at least every 2 years for agency staff. This affected 4 of 8 personnel records reviewed which included EI # 3, EI # 5, EI # 8 and EI # 1. Findings include: Agency Policy Title: Emergency Operations Plan (EOP) Training Program 2.4.1 Date Approved: 2/19/21 Policy The Agency will ensure all staff are appropriately trained regarding their roles in the EOP. Training will be documented. Purpose …to have staff prepared to assist Agency in continuing to provide patient care during an emergency. Procedure 1. The Agency has developed and maintains an emergency preparedness training program…based on the EOP, risk assessment, policies…and the communication plan. 3. The Agency will do the following…Provide initial training in emergency preparedness policies and procedures to all new and existing staff providing services…consistent with their roles. Provide emergency preparedness training at least every two years…Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures. Review of the agency Emergency Preparedness Plan manual documentation revealed no evidence of emergency preparedness training for any active employee. An interview was conducted on 3/22/22 at 2:40 PM with EI # 1, and the surveyor asked when, by whom and how agency employees received training on the agency emergency preparedness program? EI # 1 reported new hire initial training was provided during the orientation period then training was yearly. EI # 1 responded he/she guessed the training would be provided by his/herself. The surveyor asked what staff were taught about the agency’s emergency preparedness program? EI # 1 stated we go over safety in the home, go over emergency care, emergencies in the home, anything that could happened like COVID and flu screening. On 3/22/22 at 3:20 PM, the surveyor requested the most current Emergency Preparedness Program training documentation for all active agency staff. Review of 8 agency staff personnel records on 3/23/22 revealed 4 of the 8 agency staff were hired prior to 1/1/2019 which would require evidence of ongoing emergency preparedness training in 2020 or 2021. There was no personnel record documentation for current emergency preparedness training in personnel records. In an interview on 3/23/22 at 1:17 PM, EI # 1 reported “I have been unable to locate training (emergency preparedness) on anyone”. The agency failed to provide evidence all active agency staff had current emergency preparedness training.

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), §485.625(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, 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 review of the agency Emergency Management policies and procedure last approved 2/19/21, the agency Emergency Preparedness Plan manual documentation and interview with EI (Employee Identifier) # 1, Administrator, it was determined the agency failed to document testing to include a second full scale exercise (table top, Mock, workshop) opposite year of the first exercise was completed. In addition, the agency failed to document that an analysis of all actual emergency events was completed. This had the potential to affect all patients admitted to the facility and staff. Findings include: Agency Policy Title: Testing Program for Emergency Operations Plan (EOP) Date Approved: 2/19/21 The Agency will ensure that the EOP is functional through testing and evaluation. Two tests will occur every two years, with one test occurring annually, which may either be one community-based full-scale exercise…or an individual facility-based functional exercise every other year, and in the opposite years. Procedure The Agency will conduct one exercise to test the EOP at least annually…Agency will do the following: Participate in a full-scale exercise that is community-based or when a community-based is not accessible, an individual, facility-based exercise…If the Agency experiences an actual natural or man-made emergency that requires activation of the EOP, the Agency is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one (1) year following the onset of the actual event… A full scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise… A facility-based functional exercise may include: Mock disaster drill or workshop. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically- relevant emergency scenario…designed to challenge the EOP…Exercises must sufficiently stress Agency’s plan to identify weakness…activate and test… Analyze the Agency’s response to and maintain documentation of all drills, tabletop exercises and emergency events. ...Revise the EOP as needed. 1. If Agency is part of a healthcare system consistently of multiple separately certified healthcare facilities that elects to have a unified and integrated EOP…the Unified and integrated EOP must do all of the following: Demonstrate that…separately certified facility within the system actively participated in the development of the unified and integrated EOP. Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient population and services offered. Demonstrate that each separately certified facility is capable of actively using the unified and integrated EOP and is in compliance with the program. Include a unified and integrated Emergency Plan that is based on and include all of the following: ...A documented individual facility-based risk assessment for each certified facility within the health system, utilizing an all-hazards approach. Include integrated policies and procedures, a coordinated communication plan and testing program. Review of the Agency Emergency Preparedness Plan manual documentation included the following 2020 and 2021 documentation: Sent 9/13/2020 via electronic communication from the Agency Office Manager to agency employees due to impending Hurricane Sally, the Agency EPP (Emergency Preparedness Program) would be initiated (activated) on 9/14/2020. On 9/14/2020 and 9/15/2020 there was documentation of service interruption, power outages, and on 9/16/2020 documentation of service interruption. There was no documentation an analysis of the 9/14/2020 EPP initiation was conducted and no documentation the Agency EOP was revised as a result of the actual weather event. An actual event occurred on 7/14/2021 code orange-physical threat, violent patient/individual at MCH (Monroe County Hospital), which was documented as a full scale internal event with participation by 4 Agency staff. and analysis of the event was documented. The last documented event was initiation of the Agency EPP plan on 8/27/21 in response with a weather event, Hurricane Ida. The electronic notice sent to staff on 8/29/21 revealed Agency closure 8/30/21 with service interruption 8/30/21. There was no documentation the agency staff conducted an analysis of the 8/27/21 emergency event and no documentation the Agency EOP was revised as a result of the actual weather event. In addition, there was no documentation provided to the survey the agency conducted/participated in any EPP testing such as Mock disaster drill, workshop, or tabletop exercise from 2019 to March 2022. In an interview on 3/23/22 at 8:30 AM the surveyor asked EI # 1 as part of a unified/integrated EPP did Agency staff participate in hospital emergency preparedness drills, workshops, or tabletop exercises and if so provide documentation? There was no documentation an agency-based and/or unified/integrated emergency preparedness test exercise was conducted 2019 to current. There was no documentation an after event analysis was conducted for actual emergency events on 9/14/2020 and 8/27/21.

A recertification survey was conducted on 3/21/22 through 3/23/22 at Monroe County Hospital Progressive Homecare, standard level deficiencies were cited and will require a Plan or Correction.

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 observations, agency policy and procedure, review of medical records (MR), and interviews it was determined the agency failed to ensure the medication list/profile for each patient was current and accurate. This affected 4 of 10 records including Home Visit (HV) # 1, MR # 5, HV # 4, MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency Policy Title: Medication Reconciliation Reviewed Date: 2/19/21 Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis... Procedure: 1. At the time of admission, the admitting...will create and document a complete list of medications that the patient is taking at home, including dose, strength, route and frequency. 2. Medications ordered...will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication... 3. HV # 4 was admitted to the agency 11/1/21 and recertified for continued care on 3/1/22 to 4/29/22 with diagnoses including Unspecified Dementia without Behavioral Disturbance, and Normal Pressure Hydrocephalus. Review of the 3/1/22 POC revealed weekly SN visits were ordered and PT (Physical Therapy) orders dated 3/14/22 revealed PT visits were two times a week. A HV was performed on 3/21/22 at 2:45 PM with EI # 5, LPTA (Licensed Physical Therapy Assistant) to observe care and conduct a medication review. Review of the home medications was completed with HV # 4's caregiver (CG). Donepezil 10 mg daily, last filled on 1/28/22, Cranberry Fruit 4200 mg plus Vitamin C daily and Senokot Gummies laxative daily were found in the home and in use per the CG since admission to the agency on 11/21/21. Review of the Medication Profile documentation provided included Donepezil 5 mg by mouth daily and not the Donepezil 10 mg. The Medication Profile documentation failed to include Cranberry tablets and Senokot laxative gummies. In an interview on 3/23/22 at 12:20 PM, EI # 1 and EI # 7, Clinical Manager confirmed HV # 4's Medication Profile was not current and accurate for all medications in use. 4. MR # 6 was admitted to the home care agency on 2/8/22 with diagnoses including Type 2 Diabetes without Complications and Atherosclerotic Heart Disease. Review of the POC dated 2/8/22-4/8/22 revealed orders for weekly SN visits and PT visits twice weekly. Review of the 3/1/22 PT Reassessment Visit documentation revealed a Medication Profile Review was conducted and MR # 6 “…has new medication for nausea prescribed by primary care physician, it is not helping…notified clinical manager who will pass on the SN for next visit”. There was no order for a new medication found in the record and no update to the Medication Profile was completed to include medication for nausea. MR review revealed the next SN visit completed was the 3/3/22 Licensed Practical Nurse (LPN) Visit, and Routine Licensed Physical Therapist Assistant (LPTA) visits were performed also on 3/3/22 and again 3/8/22. The LPN and LPTA both documented a Medication Profile Review was performed with “no issues identified” each visit. Review of the MR revealed a PT Routine Visit dated 3/10/22 at 12:45 PM, in which the PT documented Medication Profile Review performed, “no issues identified”. Further MR review revealed an LPN Routine Visit performed on 3/10/22 at 2:50 PM with documentation the Medication Profile Review included new/changed medications identified, and the Medication Profile was updated. This was 9 days after the PT notified the Clinical Manager of the new medication. In addition, the LPN documented a verbal order, dated 2/28/22 for Zofran 4 mg tablet, oral (by mouth) every 12 hours, start date-2/28/22-end date 3/12/22. The Zofran order was signed by the LPN on 3/10/22 and the Administrator on 3/11/22, which was day 9 and day 10 day after the PT identified Zofran in the home. In an interview on 3/23/22 at 12:28 PM, EI # 7, Clinical Manager, confirmed staff failed to ensure all medications were reconciled each visit and the Medication Profile was accurate and current. 1. HV # 1 was admitted 10/2/2021 and recertified for care 1/30/22 to 3/30/22 with diagnoses including Pressure Ulcer of Left Heel Stage 4, Acquired Absence of Right Leg Above Knee and Paraplegia. Review of the Home Health Certification and Plan of Care (POC) dated 1/30/22 revealed orders for the Skilled Nurse (SN) to visit 2 times per week for assessment, wound care, medication review/reconciliation each visit, and urinary catheter care and maintenance. A HV was conducted 3/21/22 at 3:00 PM with Employee Identifier (EI) # 3, Licensed Practical Nurse, to observe wound care and medication reconciliation. Medications were reviewed with the patient using the Patient Active Medication Sheet (med sheet) printed and provided by the agency on 3/21/22. The following discrepancies were found and verified by the patient: a. Lasix 20 mg (milligrams) one every morning, date filled 12/27/21, was in the home and not listed on the med sheet. Patient stated "I take it every day." b. Vancomycin 1 GM (gram) every day intravenous in 100 ml (milliliters) of NS (normal saline) over 1 hour times 6 weeks was on the med sheet with a start date of 11/3/21. The SN failed to update the active medication sheet when therapy completed. c. Ertapenem Sodium 1 GM every day intravenous in 100 ml of NS over 30 minutes times 6 weeks was on the med sheet with a start date of 11/3/21. The SN failed to update the active medication sheet when therapy completed. d. Heparin Lock Flush every day intravenous 5 ml after flushing with 10 ml NS to keep PICC (peripherally inserted central catheter) patent. The SN failed to update the active medication sheet when therapy completed and PICC removed. An interview conducted with EI # 3 on 3/21/22 at 4:15 PM confirmed the med sheet was not accurate and confirmed medications were to be reviewed during each SN visit. On 3/22/22 the surveyor requested the SN visit note dated 3/21/22 completed by EI # 3. Review of the note revealed medications "reviewed." The surveyor requested the med sheet for HV # 1 with the updated medications. None was provided. An interview conducted 3/23/22 at 12:10 PM with EI # 1, Administrator, confirmed EI # 3 failed to update the active medication sheet on 3/21/22. 2. MR # 5 was admitted 2/11/22 with diagnoses including Encounter for Management of VAD (Vascular Access Device), Cirrhosis of the Liver and Hepatic Failure. Review of the POC dated 2/11/22 revealed SN to visit 1 time per week and interventions included to assess pain. Review of the SN admission visit note dated 2/11/22 revealed a pain score of 6 out of 10 (0 being no pain and 10 the worst pain), location - back, daily, intermittently and interferes with activity or movement, somewhat relieved with rest and relaxation. Review of the SN visit note dated 2/14/22 reveled pain score 3 and Pain Management Relief Measures - OTC (Over the Counter) pain relievers, rest/relaxation. Review of the Medication Profile and POC dated 2/11/22 revealed no OTC pain medications listed. Review of the SN visit note dated 3/8/22 revealed a pain score of 5 and Pain Management Relief Measures - Narcotic analgesics, OTC pain relievers, rest/relaxation. Review of the Medication Profile printed 3/21/22 revealed no narcotic analgesics nor OTC pain medications listed. The SN failed to include the pain medications on the Medication Profile. An interview conducted 3/23/22 at 12:17 PM with EI # 1 confirmed the medication profile did not include the OTC and narcotic pain medications and should have included all medications the patient was taking.

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 review of the medical record (MR), agency policy and procedure and interviews with the staff it was determined the agency failed to ensure all physician orders were documented in the patient's MR for wound care provided. This affected MR # 4, 1 of 2 MR's reviewed with wounds and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Plan of Care CMS ( Centers for Medicare and Medicaid Services) Number 485 and Physician Orders Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources... Procedure: 2. Each patient must receive and 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... 4. The individualized plan of care must include the following: Types of services, supplies and equipment required... All patient care orders, including verbal orders, must be recorded in the plan of care. 5. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan... 1. MR # 4 was admitted to the agency on 4/22/21 with recertification dates of 6/21/21 to 8/19/21 and an admitting diagnosis of Alcohol Dependence with Alcohol Induced Persistent Dementia. Review of the SNV (skilled nurse visit) note dated 7/15/21 revealed the SN (skilled nurse) documented the patient had a blister to the left heel measuring 1 cm (centimeter) by 1 cm by 0 cm. Review of the SNV note dated 8/10/21 revealed in the wound care section of the note SN to perform left heel Stage II Pressure Ulcer wound care: SN using clean technique, clean with NS (Normal Saline), pat dry with gauze, apply collagen dressing to wound bed (lightly moistened with NS), cover with foam dressing with adhesive border with each visit. SN to reassess wound care in 2 weeks and implement change if no improvement as ordered. Review of the physician orders in the MR revealed no documentation of the above order for wound care. Employee Identifier (EI) # 1, Administrator, was asked for the order for the wound care and the order was not provided. An interview was conducted on 3/23/22 at 12:55 PM with EI # 1 who confirmed an order for the wound care to the left heel pressure ulcer was not written and in the MR.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of medical records (MR) and staff interivews, it was determined the agency failed to ensure staff followed the physician orders for care and: 1. Collected ordered lab(laboratory) specimens and reported results to the ordering physician. 2. Provided wound care as ordered per the physician. This affected MR # 2, MR # 4, in 2 of 10 records reviewed and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Assessment/Staging of Pressure Ulcers Policy Number: G-150 Policy: Pressure ulcers result from pressure applied with great force for short periods of time or less force over a longer period. Circulation is impaired depriving tissues of oxygen... Pressure Ulcer Assessment Guide: In assessing the pressure ulcer, the following parameters should be addressed consistently. Site, Stage of ulcer, and size of ulcer (including length, width and depth)... Drainage amount, color and odor. Pain Condition of surrounding tissue. Staging A Pressure Ulcer: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum filled blister... 2. MR # 4 was admitted to the agency on 4/22/21 with recertification dates of 6/21/21 to 8/19/21 and an admitting diagnosis of Alcohol Dependence with Alcohol Induced Persistent Dementia. Review of the Home Health Certification and Plan of Care dated 6/21/21 revealed the following physician orders: Skilled Nurse frequency of visit: 1W9 (One time a week for 9 weeks). SN to evaluate and perform wound care each visit. CG (Caregiver) to perform outside SNV (skilled nurse visit). Cleanse with NS (Normal Saline), apply Xeroform, apply sterile gauze. wrap lightly with Coban, tape to secure. (right upper anterior arm and forearm). SN to provide left buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid (twice a day) in SN absence as ordered. SN to provide right buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid in SN absence as ordered. SN to evaluate excoriation to peri area each visit. Clean with soap and water and apply barrier cream daily and after peri care. CG to monitor and perform peri care in SN absence. SN - skilled observation and assessment of left heel wound. SN- Teach CG ordered wound care, what to observe and report and when/who to notify. Review of the SN visit note dated 6/22/21 revealed SN to provide left buttock wound care to lesion/wound. SN documented unable to perform without assistance of another person. Further review of the SN visit note dated 6/22/21 revealed SN to provide right buttock wound care to lesion/wound. SN documented in the wound section of the note the SN was unable to perform without assistance of another person. Further review of the SN visit note dated 6/22/21 revealed SN to evaluate excoriation of peri area and clean per above order. In the wound section of the visit note the SN documented was unable to perform without assistance of another person. Further review of the SN visit note dated 6/22/21 revealed no documentation of return demonstration by the CG for ordered wound care. Review of the Home Health Aide (HHA) visit note dated 6/22/21 revealed the HHA documented the patient was able to transfer from the scooter to the bed with assistance of the HHA. Review of the SN visit note dated 7/6/21 revealed SN to provide right buttock wound care to lesion/wound. SN documented unable to perform without assistance of another person. Review of the SN visit note dated 7/6/21 revealed SN to provide left buttock wound care to lesion/wound. SN documented unable to perform without assistance of another person. Further review of the SN visit note dated 7/6//21 revealed SN to evaluate excoriation of peri area and clean per above order. In the wound section of the note the SN documented was unable to perform without assistance of another person. Further review of the SN visit note dated 7/6/21 revealed no documentation of return demonstration by the CG for ordered wound care. Review of the Occupational Therapy (OT) visit dated 7/12/21 revealed the OT documented Pt. (patient) performed transfer from motorized wheelchair to bed with moderate assistance. He then performed bed mobility by rolling to left and right sides with minimal assist. Review of the Occupational Therapy (OT) visit dated 7/14/21 revealed the OT documented Pt. (patient) performed transfer from motorized wheelchair to bed with moderate assistance. He then performed be mobility by rolling to left and right sides with minimal assist. Review of the SN visit note dated 7/15//21 revealed SN documented in the narrative section of the note SN unable to assess left and right buttocks due to no CG available at this time to assist with transfer. Erythema and excoriation noted to lower back. Barrier cream noted to the area. LE (Left extremity) purplish - red area noted to left heel. 1 cm (centimeter) by 1 cm. There was not documentation the SN performed wound care as ordered. Further review of the SN visit note dated 7/15/21 revealed SN to provide left buttock wound care to lesion/wound. SN failed to document any wound care provided to the left or right buttocks no there documentation the excoriation of the peri area was evaluated and care provided. Further review on the narrative revealed unable to perform wound care due to no CG present to assist with transfer and in the wound section the SN documented unable to perform due to no care giver for all wound care. Further review of the SN visit note dated 7/15/21 revealed no documentation of return demonstration by the CG for ordered wound care. Review of the SN visit note dated 7/20/21 revealed the SN documented in the narrative section of the note SN unable to perform total head-to-toe assessment without the assistance of another person. Further review of the SN visit note dated 7/20/21 revealed the SN documented for the left and right buttock care the SN was unable to perform without the assistance of another person. Further review of the SN visit note dated 7/20/21 revealed the SN documented unable to perform and evaluation and provide treatment to peri area due to SN unable to perform without the assistance of another person. Further review of the SN visit note dated 7/20/21 revealed no documentation of return demonstration by the CG for ordered wound care. Review of the SN visit note dated 7/27/21 revealed the SN documented in the narrative the SN was unable to assess left and right buttock because patient is unable to transfer self and no available CG to assist at this time. Excoriation noted to lower back and superior area of buttocks. Barrier cream noted to area. Upon assessment of peri area (groin) erythema noted, skin intact and barrier cream observed. There was no documentation in the wound section of the note the SN provided any wound care as ordered. Further review of the SN visit note dated 7/27/21 revealed the SN failed to document wound care to left and right buttock and to evaluate the peri area and provide treatment as ordered. SN documented the patient is unable to transfer from wheelchair without 2 person assist. Further review of the SN visit note dated 7/27/21 revealed no documentation of return demonstration by the CG for ordered wound care. Review of the SN visit note dated 8/3//21 revealed in the narrative section of the note the SN documented the SN unable to perform total head - toe without assistance of another person. Further review of the SN visit note dated 8/3//21 in the wound care section of the note revealed the SN's documentation revealed the SN was unable to perform without assistance of another person for the left and right buttocks wound care, the evaluation and wound care of the peri area and no documentation of the pressure ulcer to the left heel nor was there measurements of the pressure ulcer to the left heel. Further review of the SN visit note dated 8/10//21 revealed in the narrative section of the note the SN documented the patient was sitting in the wheelchair and upon assessment excoriation and erythema noted to right lower back and left heel pressure injury noted. SN unable to observe right and left buttocks due to no CG available for transfer. Review of the SN visit note dated 8/10/21 in the wound section of the note the SN documented for the wound care to the left and right buttocks unable to perform due to no CG available for transfer. Further review of the wound care documentation revealed the nurse observed the peri area and barrier cream present. No wound care was performed by the SN. Further review of the wound section of the 8/10/21 note the SN documented the left heel was now a stage 2 pressure wound and the following wound care was performed. SN using clean technique, clean with NS, pat dry with gauze, apply collagen dressing to wound bed (lightly moistened with NS), cover with foam dressing with adhesive border with each visit. SN to reassess wound care in 2 weeks and implement change if no improvement as ordered. Review of the SN Comprehensive Discharge visit note dated 8/19//21 revealed in the narrative section of the SNV note revealed the SN documented SN attempts to perform full body assessment. Pt unable to assist with turning and unable to follow simple commands. CG not available to assist. Upon assessment of the groin area, skin dry and intact, barrier cream observed. Excoriation and erythema noted to lateral sides of left and right buttocks and barrier cream observed. Unable to observe medial back and coccyx area due to patient unable to assist and no available CG. Further review of the SNV note dated 8/19/21 revealed no documentation the SN cleaned the areas to the groin or the excoriation and erythema to lateral sides of left and right buttocks or the medial back and coccyx and applied barrier cream as ordered. Review of the wound section of the SN visit noted dated 8/19/21 revealed the dressing change to the stage II pressure ulcer to the left heel was completed using NS, applied a foam dressing and an adhesive border. Further review revealed no documentation of the collagen dressing to the wound bed moistened with NS. An interview was conducted on 3/23/22 at 12:55 PM with EI # 1 who confirmed schedules for the HHA and the SN could have been made for the same day and time for assistance, the wound care should have been completed per the physician orders, the wound cart to the excoriated area was to be cleaned per the SN and barrier cream applied. 1. MR # 2 was admitted to the agency 6/12/21 to 8/10/21 with diagnoses including Type 2 Diabetes Mellitus with Chronic Kidney Disease and Major Depressive Disorder, recurrent, unspecified. MR review revealed a handwritten physician’s order dated 8/9/21 for a CBC (complete blood count), CMP (comprehensive metabolic panel), FLP (fasting lipid panel), AIC (a measure of blood glucose), UA (urinalysis), and Anemia Profile. Review of the 8/9/21 SN (Skill Nurse) Comprehensive Recertification Visit failed to include documentation the 8/9/21 lab tests were obtained and results were reported to the ordering physician. Review of the 2 next SN Routine Visits dated 8/18/21 and 8/25/21 failed to include documentation lab ordered 8/9/21 was obtained and no 8/9/21 lab test results were identified in the record. In an interview on 3/23/22 at 12:46 PM, EI (Employee Identifier) # 1 Administrator confirmed staff failed to follow the 8/9/21 physician orders and collect the ordered labs.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), and staff interview, it was determined the agency failed to ensure staff promptly notified the patients' physician with continued medication noncompliance and worsening depressive symptoms and change to wounds and wound care not provided. This affected 1 of 1 records reviewed with Major Depressive Disorder including MR # 2 and 1 of 2 medical records with wounds including MR # 4 and had the potential to negatively affect all patients with behavioral health needs and wounds. Findings include: 2. MR # 4 was admitted to the agency on 4/22/21 with recertification dates of 6/21/21 to 8/19/21 and an admitting diagnosis of Alcohol Dependence with Alcohol Induced Persistent Dementia. Review of the Home Health Certification and Plan of Care dated 6/21/21 revealed the following physician orders: Skilled Nurse frequency of visit: 1W9 (One time a week for 9 weeks). SN to evaluate and perform wound care each visit. CG (Caregiver) to perform outside SNV (skilled nurse visit). Cleanse with NS (Normal Saline), apply Xeroform, apply sterile gauze. wrap lightly with Coban, tape to secure. (right upper anterior arm and forearm). SN to provide left buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid (twice a day) in SN absence as ordered. SN to provide right buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid in SN absence as ordered. SN to evaluate excoriation to peri area each visit. Clean with soap and water and apply barrier cream daily and after peri care. CG to monitor and perform peri care in SN absence. SN - skilled observation and assessment of left heel wound. SN- Teach CG ordered wound care, what to observe and report and when/who to notify. Review of the SNV (skilled nurse visit) notes dated 6/22/21, 6/29/21,/7/6/21, 7/15/21, 7/20/21,/7/27/21 and 8/3/21 revealed the wound care had not been completed per the physician orders and no documentation the physician was notified the wound care to the left and right buttocks and the excoriation to the peri area had not been completed in 7 weeks since admission. Review of the SN visit note dated 7/15//21 revealed SN documented in the narrative section of the note SN unable to assess left and right buttocks due to no CG available at this time to assist with transfer. Erythema and excoriation noted to lower back. Barrier cream noted to the area. LE (Left extremity) purplish - red area noted to left heel. 1 cm (centimeter) by 1 cm. Further review of the SN visit note dated 7/15/21 revealed no documentation the physician was notified of the development of a pressure ulcer to the left heel. An interview was conducted on 3/23/22 at 12:55 PM with EI # 1 who confirmed the SN should have notified the physician when wound care was not performed and when the pressure ulcer developed to the left heel. 1. MR # 2 was admitted to the agency 6/11/21 with and was recertified for continued care 8/11/21 to 10/9/21 with diagnosis including Major Depressive Disorder, recurrent, unspecified. Review of the 8/9/21 SN (skill nurse) Comprehensive Recertification Visit revealed documentation the SN asked the patient about depression and anxiety and the patient stated he/she is not depressed however, the patient becomes tearful and states he/she cannot stop crying a lot of the time. The SN notified the physician's office, communicated with the office nurse and the SN documented “it was decided for patient to take half of 25 mg (milligram-which was 12.5 mg) (Zoloft-an antidepressant medication) and increase (Zoloft) to 25 mg as ordered" . The SN documented will check back with patient next week for compliance and monitor for side effects. Review of the next SN Routine Visit documentation dated 8/18/21 revealed behavioral assessment normal. There was no documentation of abnormal findings related to depression or noncompliance with the ordered antidepressant dosage decrease, and no medication side effects were documented. Review of the SN Routine Visit dated 8/25/21 revealed MR # 2 reports not taking prescribed Zoloft, feeling like he/she doesn’t need anything, denies depression or ideas of self harm. There was no documentation the SN notified the physician of the noncompliance with Zoloft 25 mg 1/2 tablet daily for depression. Review of the SN Routine Visits dated 9/1/21, 9/9/21 and 9/17/21 revealed MR # 2's behavioral assessment was within normal limits and patient denies depression. Review of the SN Routine Visit documentation dated 9/22/21 revealed the patient was very tearful and sad, that he/she cried for at least half of the visit, expressing missing his/her family. There was no documentation the SN notified the physician about the patient’s depression status and no documentation regarding antidepressant medication compliance. In an interview conducted 3/23/22 at 12:46 PM, EI (Employee Identifier) # 1 Administrator confirmed there was no documentation staff notified the physician for continued antidepressant medication noncompliance with depression symptoms including excessive crying which was reported by the patient and observed during a SN visit.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policies and procedures and staff interview, it was determined the agency failed to ensure services were provided to meet the patient needs. This affected HV (home visit) # 4, in 1 of 5 records reviewed with Physical Therapy (PT) services orders and had the potential all patients with orders for PT services. Findings include: Agency Policy and Procedure Title: Coordination of Patient Care Home Care Policy and Procedure last approved 2/19/21 Policy Agency staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outline in the plan of care. Procedure 1. The Agency must: ...Integrate orders from all physicians…to assure coordination of all services and interventions provided to the patient. Integrate services…to assure…patient needs…and coordination of care provided by all disciplines. Coordinate care delivery to meet the patients’ needs, and involve the patient…caregiver…in the coordination of care activities… 2. The Director of Clinical Services provides oversight of all patient care services…includes: Coordinating patient care. Coordinating referrals. Ensuring that patient needs are continually assessed. Ensuring the development, implementation, and updates of the individualized plan of care. 6. Staff provides the physician with patient information on an ongoing basis regarding: Current condition and changes in condition. Outcomes of care and services… Agency Policy and Procedure Title: Rehabilitation Services Home Care Policy and Procedure last approved 2/19/21 Policy Patients receiving rehabilitation services (PT...SLP[Speech Language Pathologist]) will have appropriate assessments, evaluations, care planning... 8. Services provided will be planned to meet each patient's individualized needs... Procedure 1. Each patient admitted will receive a comprehensive assessment... 2. The comprehensive assessment will identify the patient's need for...Rehabilitative (services) 5. A RN (Registered Nurse), PT or SLP must conduct the initial assessment visit within 48 hours of referral...within 48 hours of the patient's return home or on the physician ordered start of care date The initial assessment visit is conducted to determine the immediate care and support needs of the patient... 1. HV # 4 was admitted to the agency 11/1/21 and recertified for continued care on 3/1/22 to 4/29/22 with diagnoses including Unspecified Dementia without Behavioral Disturbance, and Normal Pressure Hydrocephalus. MR review revealed Case Communication documentation dated 2/15/22 with team participation including the SN (skill nurse) the PT and LPTA (Licensed Physical Therapist Assistance) and discussion that included request for more therapy due to poor balance with hydrocephalus. The team recommendations for anticipated discipline involvement for recertification were SN and PT. Review of the Recertification SN visit dated 2/25/22 which was 10 days later revealed narrative note documentation “…patient mobility has decreased, PT to evaluate and treat patient as appropriate…” Review of the Home Health Certification and Plan of Correction (POC) dated 3/1/22-4/29/22 revealed orders for SN and PT to assess and evaluate 3/7/22 through 3/11/22. Review of the SN Visit Note dated 3/9/22, which was 8 days later revealed SN narrative note documentation the spouse inquires about PT for patient, SN advised patient scheduled for PT evaluation Friday. MR review revealed on 3/11/22 the PT Evaluation was completed, and the PT documented patient was referred to home PT from primary care physician with a decline in transfer/gait and balance. PT services were ordered 2 times a week for 3 weeks. On 3/22/22 the surveyor requested the primary care physician PT referral. EI # 1, Administrator provided a verbal order dated 3/7/22 for PT to assess and evaluate. The 3/7/22 PT order was added to the 3/1/22 HHC and POC 6 days after the 2/25/22 SN comprehensive assessment recertification visit was completed which identified the need for PT services. The PT evaluation was completed on 3/11/22, 9 days after the 3/1/22 update to the HHC and POC. There was no documentation staff communicated and coordinated the delay in scheduling PT evaluation visit with the patient/family or physician. The PT evaluation was not completed within 48 hours of the 3/7/22 verbal order date. In an interview on 3/23/22 at 12:20 PM, EI (Employee Identifier) # 1 Administrator verified the record documentation revealed coordination of care with PT however, there was no reason documented for the delay in PT service initiation/evaluation. EI # 1 confirmed the agency policy was completion of the initial assessment visit within 48 hours of referral which was not completed per policy.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on Home Visit (HV) observations, agency policy and procedure and interviews it was determined the agency failed to ensure staff performed hand hygiene after glove removal. This deficient practice affected 2 of 4 HV including HV # 1, HV # 3,and had the potential to affect all patients served by the agency. Findings include: Agency Policy Title: Hand Hygiene Policy and Compliance Program Reviewed Date: 2/19/21 Policy: Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands, and forearms. Purpose: To prevent transfer of germs and transmission of infections to patients and caregivers and to implement a hand hygiene compliance program. Procedure: 7. The Agency will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. CDC Hand Hygiene Guidelines After removing gloves 2. HV # 3 was admitted to the agency on 12/22/21 with recertification dates of 2/20/22 to 4/20/22 and an admitting diagnoses of Alzheimer's Disease, Unspecified and Adult Failure to Thrive. Review of the Home Health Certification and Plan of Care dated 2/20/22 revealed orders for the Home Health Aide (HHA) to visit 2 W 9 W ( two times a week for 9 weeks). A HV was conducted on 3/21/22 at 11:55 AM with EI # 2, HHA , to observe a bed bath and care provided. EI # 2 provided a bed bath and once EI # 2 completed the peri care and bathed the patient's buttocks EI # 2 removed gloves and donned clean gloves without sanitizing hands prior to donning the clean gloves. Once EI # 2 completed the bed bath EI # 2 removed gloves and donned 1 clean glove and failed to sanitize hands. EI # 2 emptied the bath basins using one glove. An interview was conducted on 3/23/22 at 1:00 PM with EI # 1 who confirmed hand hygiene should be performed every glove change prior to donning clean gloves and two gloves should have been worn to empty and clean the bath basins. 1. HV # 1 was admitted 10/2/2021 and recertified for care 1/30/22 to 3/30/22 with diagnoses including Pressure Ulcer of Left Heel Stage 4, Acquired Absence of Right Leg Above Knee and Paraplegia. Review of the Home Health Certification and Plan of Care (POC) dated 1/30/22 revealed orders for the Skilled Nurse (SN) to visit 2 times per week. The POC included the following orders for wound care: a. Left heel stage IV pressure ulcer- using clean technique clean wound with NS (normal saline), pat dry, apply promogram (a collagen dressing) to wound bed, cover with dry gauze, apply allevyn foam or foam padding to heel and wrap with rolled gauze and tape daily and prn (as needed). b. Stage IV pressure ulcer sacral wound VAC (vacuum assisted closure device) - using clean technique clean wound with NS, pat dry with gauze, cut the black foam to fit the wound bed, cut to fit transparent drape material over the wound, cut a small hole into top of drape/foam, apply the pad over foam and connect to drainage canister tubing. Be sure to unclamp tubing. Turn wound vac machine on, and ensure that it is suctioning properly at a setting of 125 mmHg (milliliters of mercury). Secure wound vac in place in more transparent drape material and tape...wound vac to be changed three times per week as ordered. The order failed to include if the suction was to be administered continuously or intermittently. A HV was conducted 3/21/22 at 3:00 PM with Employee Identifier (EI) # 3, Licensed Practical Nurse, to observe wound care. HV # 1 had a total of 3 wounds including a stage IV sacral wound, a stage IV left heel wound and a wound to the left 4th toe. EI # 3 completed wound care to the left heel first, the left toe, and the sacral wound last. EI # 3 was observed removing gloves a total of 12 times and 5 of the 12 times EI # 3 failed to perform hand hygiene after glove removal. An interview conducted 3/23/22 at 12:05 PM with EI # 1, Administrator, confirmed hand hygiene should be performed after glove removal as directed by agency policy.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of Quality Assessment and Performance Improvement (QAPI),Infection Contral data collection, Agency Policy, and interviews, it was determined the agence failed to ensure: 1. An ongoing system for identification, prevention, and control was part of the agency QAPI program. 2. Data collected was analyzed quarterly per agency policy. This deficient practice had the potential to affect all patients admitted to this agency. Agency Policy: Infection Control Surveillance System: Prioritized Risks Defined Last reviewed: 12/22/2021 Policy: The Agency will implement an infection control surveillance system for patients and staff... Procedure: 1. Agency will perform tageted infection control surveillance as follows: Patient infections to be reported at time of admission...Patient infections to be reported while patient is on service...Employee infections to be reported...3. At least quarterly, the Director of Clinical Services and infection control QAPI (Quality Assurance and Performancy Improvement) Committee will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form. 4. Problems and/or undesirable trends is infections will be identified... 5. The committees will make recommendations for and implement improvement activities. Review of the agency Second Quarter data collection and analysis dated 9/13/2021 revealed 7 of the 44 infections were repeat infections. The plan was to continue to monitor. There was no analysis of the data collected of the 2021 third and fourth quarter provided to the surveyors. There was no documentation provided of the committee's recommendations for improvement. In an interview conducted on 3/23/22 at 9:20 AM, Employee Identifier (EI) # 1, stated no Performance Improvement Projects had been implemented and were unable to retrieve data from the new computer system to track improvements. EI # 1 stated the agency was planning to implement tracking of wounds including measurements and signs and symptoms of infection starting in April. EI # 1 confirmed there was no documentation of analysis of the 2021 third and fourth quarter and no recommendations from the committee for improvement.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and interviews with the staff it was determined the agency failed to ensure: 1. The staff documented education to the patient and caregiver when education was performed. 2. The staff documented all return demonstrations of the caregiver for wound care to be provided. This deficient practice affected 2 of 10 MR's reviewed and did affect MR # 4, MR # 1 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Plan for Patient/Family Education Policy: The agency will educate and train patient/family according to the needs assessed by the Agency staff and as appropriate to the required services. Procedure: 2. The Agency staff understands that the assessment of patient/family's education needs are ongoing and will be regularly reassessed as needs change. 3. All patient/family education, the perceived comprehension, ability to demonstrate a taught skill and verbal recall will be documented in the patient's medical record... 1. MR # 4 was admitted to the agency on 4/22/21 with recertification dates of 6/21/21 to 8/19/21 and an admitting diagnosis of Alcohol Dependence with Alcohol Induced Persistent Dementia. Review of the Home Health Certification and Plan of Care dated 6/21/21 revealed the following physician orders: SN (skilled nurse) to evaluate and perform wound care each visit. CG (Caregiver) to perform outside SNV (skilled nurse visit). Cleanse with NS (Normal Saline), apply Xeroform, apply sterile gauze. wrap lightly with Coban, tape to secure. (right upper anterior arm and forearm). SN to provide left buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid (twice a day) in SN absence as ordered. SN to provide right buttocks lesion/wound care: SN using clean technique, clean with NS or mild soap and water, pat dry, apply barrier cream with each visit, CG to perform Bid in SN absence as ordered. SN to evaluate excoriation to peri area each visit. Clean with soap and water and apply barrier cream daily and after peri care. CG to monitor and perform peri care in SN absence. Review of the SN visit notes dated 6/22/21, 6/29/21, 7/6/21, 7/15/21,7/20/21, 7/27/21,8/3/21 and 8/10/21 revealed no documentation by the SN of education to the CG for each wound care to be provided and no return demonstration of wound care per the CG. An interview was conducted on 3/23/22 at 12:55 PM with Employee Identifier (EI) # 1, Administrator, who confirmed the education/teaching provided each visit is to be documented in the MR and a return demonstration for the wound care should have been performed by the CG. 2. MR # 1 was admitted to the agency on 2/21/22 with admitting diagnoses of Generalized (Osteo) Arthritis and Fibromyalgia. Review of the Home Health Care Certification (HHCC) and Plan of Care (POC) dated 2/21/22 revealed the following orders/treatments. Interventions: Teach disease process including causes, prognosis, symptoms, treatment and complications. Teach pain management and comfort measures. Instruct patient/caregiver on safety awareness and safety measures... Teach regarding degenerative joint disease process including prognosis, symptoms, treatment and complications. Teach regarding medication and medication administration... Review of the OASIS (Outcome and Assessment Information Set) dated 2/21/22 revealed under instructions provided regarding disease process, signs and symptoms of exacerbation and Musculoskeletal interventions, the SN documented "Patient Instructed". The SN failed to document specific teaching related to the above mentioned education. Review of the SNV note dated 3/8/22 revealed under the Care Plan Documentation the for Degenerative Joint Disease instructions, and disease regarding degenerative joint disease process including prognosis, symptoms, treatment and complications and teaching regarding medication administration, teach patient/caregiver regarding proper handwashing, the SN documented under each intervention "patient instructed". The SN failed to document specific instructions to the patient/caregiver. Review of the SNV note dated 3/15/22 revealed the interventions for teaching of repositioning every 2 hours, management of moisture, to prevent skin breakdown, pressure relief measures and techniques for positioning and alignment. The SN documented "completed under each intervention. The SN failed to document specific instructions. An interview was conducted on 3/23/22 at 1:10 PM with EI # 1 who confirmed the agency staff is suppose to document specific education/teaching each time a visit is made.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on Home Visit (HV) observations, agency policy and procedures, Alabama Board of Nursing Administrative Code 610-X-6, medical record (MR) review and interview with staff it was determined the agency failed to ensure nursing staff documented assessments and wound care provided in an accurate, thorough and clear manner. This affected 1 of 1 HVs with wound care including HV # 1, and had the potential to affect all patients requiring wound care. Findings include: Agency Policy Title: Plan of Care - CMS # 485 and Physician Orders Reviewed Date: 2/19/21 Policy: Skilled nursing...will be in accordance with a Plan of Care based on the patient's diagnosis and assessment... Procedure: 2. Each patient must receive an individualized written plan of care...must specify the care and services...Services must be furnished in accordance with accepted standards of practice. V.A.C. Wound Therapy (Vacuum Assisted Closure) Wound vacuum assisted closure speeds wound healing by applying localized negative pressure...The negative pressure can be continuous or intermittent... Documentation Guidelines 1. Document in the clinical record a. Date and time of therapy. b. Amount of negative pressure applies. Alabama Board of Nursing Administrative Code Chapter 610- X- 6 Standards of Nursing Practice 610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice) (1) The practice of practical nursing includes, but is not limited to: (a) Acts designed to promote and maintain health. (d) Conducting and documenting focused nursing assessments, to include the patient’s health status. (e) Collecting and documenting data elements of a comprehensive assessment. (h) Documentation of nursing interventions and responses to care in an accurate, timely, thorough, and clear manner. 610-X-6-.06 Documentation Standards. (1) The standards for documentation of nursing care provided to patients by licensed nurses are based on principles of documentation, regardless of the documentation format. (2) Documentation of nursing care shall be: (a) Legible. (b) Accurate. (c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete. 1. HV # 1 was admitted 10/2/2021 and recertified for care 1/30/22 to 3/30/22 with diagnoses including Pressure Ulcer of Left Heel Stage 4, Acquired Absence of Right Leg Above Knee and Paraplegia. Review of the Home Health Certification and Plan of Care (POC) dated 1/30/22 revealed orders for the Skilled Nurse (SN) to visit 2 times per week. The POC included the following orders for wound care: a. Left heel stage IV pressure ulcer- using clean technique clean wound with NS (normal saline), pat dry, apply promogram (a collagen dressing) to wound bed, cover with dry gauze, apply allevyn foam or foam padding to heel and wrap with rolled gauze and tape daily and prn (as needed). b. Stage IV pressure ulcer sacral wound VAC (vacuum assisted closure device) - using clean technique clean wound with NS, pat dry with gauze, cut the black foam to fit the wound bed, cut to fit transparent drape material over the wound, cut a small hole into top of drape/foam, apply the pad over foam and connect to drainage canister tubing. Be sure to unclamp tubing. Turn wound vac machine on, and ensure that it is suctioning properly at a setting of 125 mmHg (milliliters of mercury). Secure wound vac in place in more transparent drape material and tape...wound vac to be changed three times per week as ordered. The order failed to include if the suction was to be administered continuously or intermittently. Review of the SN visit notes (SNVN) dated 1/31/22, 2/4/22, 2/7/22, 2/9/22, 2/11/22, and 2/14/22 revealed the nurse failed to document the specific wound care provided to the sacral wound and the left heel wound. There was no documentation of the color of foam used in the sacral wound nor amount of suction applied and if the suction was continuous or intermittent. Review of the physician's order dated 2/18/22 revealed wound care to left 4th toe as follows: using clean technique, clean wound with NS, pat dry with gauze, apply collagen to wound bed, cover with dry gauze, and secure with rolled gauze and tape...daily... Review of the SNVNs dated 2/21/22, 2/23/22, 2/25/22, 2/28/22, 3/4/22, 3/7/22, 3/9/22, 3/14/22, 3/16/22, and 3/18/22 revealed the nurse failed to document the specific wound care provided to the sacral wound, left heel and left 4th toe wound. There was no documentation of the color of foam used in the sacral wound nor the amount of suction applied and if the suction was continuous or intermittent. A HV was conducted 3/21/22 at 3:00 PM with Employee Identifier (EI) # 3, Licensed Practical Nurse, to observe wound care. HV # 1 stated he/she bumped his/her heel while out of the home this morning and the wound had been bleeding. The patient was in bed with the left foot on 2 blue chux with bright red blood soaked through the dressing and sock. There was bright red bloody drainage approximately the size of a grapefruit in the chux pad. The nurse removed the old dressing which consisted of a thick layer of gauze pads soaked with bright red drainage. Wound care was provided and the wound was padded with a thick layer of dry gauze sponges. Review of the SNVN dated 3/21/22 revealed the following documentation of the left heel wound: Dressing Appearance - dry, intact; Drainage - Serosanguineous, thin; Drainage Amount - minimal; Wound care performed. There was no documentation regarding the injury to the wound and the blood soaked dressing that was removed. Further review of the SNVN dated 3/21/22 revealed the nurse failed to document the specific wound care provided to the sacral, left heel and left 4th toe wounds. Further, there was no documentation of the color or amount of foam used in the sacral wound, nor the amount of suction applied and if the suction was continuous or intermittent. An interview conducted 3/23/22 at 12:10 PM with EI # 1, Administrator, confirmed the SN failed to document the specific wound care provided and the documentation should include what the nurse did for each wound.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and interviews with the staff it was determined the agency failed to ensure all Home Health Aide (HHA) Plan of Care (POC) were individualized to meet the patient's needs to include parameters of vital signs (VS) and frequency of each task to be performed by the HHA. This affected 3 of 4 MR's reviewed with HHA and did affect Home Visit (HV) # 3, HV # 2, MR # 3, and had the potential to negatively affect all patients served by the facility. Findings include: Agency Policy: Plan of Care-CMS # 485 and Physician Orders Policy: Skilled nursing and other home health services will be in accordance with the Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources... Procedure: 2. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized POC 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 measurable outcomes that the Agency anticipates will occur as a result of implementing and coordination of the plan of care. 3. 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... 2. HV # 2 was admitted to the agency on 3/6/2020 and recertified for home care from 2/24/22 to 4/24/22 with diagnoses including Alzheimer's Disease, Dementia, and Cognitive Social or Emotional Deficit Following Cerebral Infarction. Review of the HHC and POC revealed orders for HHA 1 x a week for 1 week then 2 x a week for 8 weeks. HHA Interventions included: Hygiene: Bath: Shower chair, shampoo, and skin care. Vital signs: Pulse, Respirations, Temperature, and report abnormal findings to nurse. There was no frequency of how often the tasks were to be completed and no documentation of the the vital sign parameters that were to be reported to the nurse. In an interview conducted on 3/23/22 at 1:00 PM, EI # 1 stated the task were to be completed every visit but were not stated on the Care Plan. EI # 1 confirmed VS parameters for the HHA to report had not been placed on the HHA care plan. 3. MR # 3 was admitted to the agency on 4/1/2021 with diagnoses including Acute Puncture and Laceration of a Digestive System, Left Lower Quadrant Pain, and Essential (Primary) Hypertension. Review of the HHC and POC dated 4/1/2021 revealed HHA 2 x a week for 8 weeks. Review of the Care Plan Active from 4/1/2021 to 05/26/2021 revealed HHA to obtain Vital Signs and Pulse Ox (Oximetry), Reporting to MD if pulse ox less than 90 percent. Review of the Aide Routine Visit notes dated 4/6/2021, 4/9/2021, 4/13/2021, 4/16/2021, 4/20/2021, 4/23/2021, 4/27/2021, 4/30/2021, 5/6/2021, 5/11/2021, 5/18/2021, 5/21/2021, and 5/25/2021 revealed no documentaion of the Pulse ox. In an interview conducted on 3/23/22 at 1:10 PM, EI # 1 confirmed the HHA did not follow the POC and obtain the Pulse ox on any of the visits. 1.HV # 3 was admitted to the agency on 12/22/21 with recertification dates of 2/20/22 to 4/20/22 and admitting diagnoses of Alzheimer's Disease, Unspecified and Adult Failure to Thrive. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/20/22 revealed the following orders for the HHA. Aide 2 wk 9 wk (2 times a week for 9 weeks) start date 2/21/22. On the HHC and POC dated 2/20/22 revealed the following aide interventions. Elimination: Incontinent Care Home Management: Change patient linen and make patient bed Hygiene: Bed Bath, Perineal care, shampoo Safety: Standard Precautions Vital Signs: Report abnormal VS to nurse, Respirations, Temperature, Pulse. Review of the HHA POC reveals no documentation of Vital Sign parameters to ensure the nurse is notified of any abnormal VS and no documentation of how often the HHA is to perform each task assigned. Review of the HHA visit notes dated 2/22/22, 2/24/22, 3/2/22, 3/8/22, 3/10/22, 3/17/22 and 3/21/22 revealed no parameters of VS on each note and no frequency of each task to be performed. An interview was conducted on 3/23/22 at 12:40 PM with Employee Identifier (EI) # 1, Administrator, who confirmed all of the above tasks are to be performed by the HHA on every visit and there should have been VS parameters in each POC. EI # 1 also confirmed when a patient is admitted the nurse enters the frequency of each task and the VS parameters into the system which will print on the HHA POC and this was not completed.

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 agency policy and procedure, review of medical records (MR) and interviews it was determined the agency failed to ensure patient documentation was submitted within 2 calendar days as directed in agency policy. This affected 5 of 10 records reviewed including Home Visit (HV) # 1, MR # 5, MR # 2, MR # 6, MR # 4 and had the potential to affect all patients served by the agency. Findings include: Agency Policy Title: Timely Submission of Patient Documentation Reviewed Date: 2/19/2021 Policy: The Agency will ensure timely and proper submission of patient documentation. Procedure: 2. All patient documentation (visit notes, Plan of Care, coordination notes) must be submitted to the Agency within 1 calendar day, not exceeding two (2) calendar days... Agency Policy: Initial Assessments/Comprehensive Assessments Reviewed Date: 2/29/2021 ...6. Completion of the Comprehensive Assessment ...Must be completed in a timely manner consitent with the patient's needs, but no later thatn five (5) calender days after the start of care... 5. MR # 4 was admitted to the agency on 4/22/21 with recertification dates of 6/21/21 to 8/19/21 and an admitting diagnosis of Alcohol Dependence with Alcohol Induced Persistent Dementia. Review of the SNVN dated 6/22/21 reveled the nurse signed the note on 6/27/21 which was 5 days later. Review of the SNVN dated 7/6/21 reveled the nurse signed the note on 7/11/21 which was 5 days later. Review of the SNVN dated 7/27/21 reveled the nurse signed the note on 7/30/21 which was 3 days later. Review of the SNVN dated 8/10/21 reveled the nurse signed the note on 8/14/21 which was 4 days later. Review of the SNVN dated 8/19/21 reveled the nurse signed the note on 8/22/21 which was 3 days later. An interview was conducted on 3/23/22 at 12:55 PM with EI # 1 who confirmed the nursing notes were not signed within the time frame of 2 days per the policy. 3. MR # 2 was recertified for continued care on 8/11/21 to 10/9/21 with diagnoses including Major Depressive Disorder and Other Intervertebral Disc Degeneration, Lumbar region. Review of the 8/9/21 SN Comprehensive Recertification Visit performed by the Registered Nurse (RN) revealed the documentation was electronically signed by the RN on 8/24/21 which was 15 days later. In an interview on 3/23/22 at 12:46 PM, EI # 1 Administrator reported staff have 5 days to complete the Comprehensive Assessment visit documentation and confirmed the documentation was not completed per policy within 5 days. 4. MR # 6 was admitted to the agency on 2/8/22 with diagnoses including Type 2 Diabetes without Complications and Atherosclerotic Heart Disease. Review of the 2/8/22 SOC (start of care) Assessment visit documentation revealed the RN electronically signed the visit on 2/25/22, which was 17 days later and not completed per policy within 5 days. During an interview on 3/23/22 at 12:28 PM, EI # 7, Clinical Manager, confirmed staff failed to ensure the comprehensive assessment documentation was completed within 5 days. 1. HV # 1 was admitted 10/2/2021 and recertified for care 1/30/22 to 3/30/22 with diagnoses including Pressure Ulcer of Left Heel Stage 4, Acquired Absence of Right Leg Above Knee and Paraplegia. Review of the Skilled Nurse visit note (SNVN) dated 2/14/22 revealed the nurse signed the note on 2/21/22 which was 7 days after the visit. Review of the SNVN dated 2/28/22 revealed the nurse signed the note on 3/6/22 which was 6 days after the visit. An interview conducted 3/23/22 at 12:15 PM with Employee Identifier (EI) # 1, Administrator, confirmed the visit notes were not signed within 2 days as directed in agency policy. 2. MR # 5 was admitted 2/11/22 with diagnoses including Encounter for Management of VAD (Vascular Access Device), Cirrhosis of the Liver and Hepatic Failure. Review of the nurse admission visit note dated 2/11/22 revealed the nurse signed the note on 2/27/22, 16 days after the visit. Review of the SNVN dated 2/21/22 revealed the nurse signed the note on 3/2/22, 8 days after the visit. An interview conducted 3/23/22 at 12:17 PM with EI # 1 confirmed visit note documentation should be completed within 2 days.