Every finding on record at Morris Infinite Healthcare Services Incorporated

A recertification survey entrance conference was conducted on 10/14/2024. The census was - 137 Licensed and Certified patients – 39 No deficiencies were cited.

Purpose of visit: Recertification survey Entrance conference date: 10/14/2024 The census was - 137 Licensed and Certified patients – 39 Licensed Home Health patients - 10 Personal Assistance Services patients – 88 Abbreviations: ADM – Administrator Alt ADM - Alternate Administrator CMS - Centers for Medicare & Medicaid Services DON - Director of Nurses ADON – Alternate Director of Nurses HHA – Home Health Agency IQIES - IQIES - Internet Quality Improvement and Evaluation System OASIS - Outcome and Assessment Information Set PT – Physical Therapy OT - Occupational Therapy COTA – Certified Occupational Therapy Assistant OM – Office Manager

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 52.21% (213 of 408) of assessments transmitted during 10/01/2023 – 10/14/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 10/14/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 10/01/2023 – 10/14/2024. The HHA Error Summary by Agency report included 213 of 408 OASIS assessments (52.21%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the ADM/DON on 10/14/2024 at 12.20 pm. The ADM/DON said she was responsible for OASIS assessment submission to the CMS system. An interview was conducted with the ADM and Alt DON on 10/14/2024 at 3.30 PM and the surveyor reviewed the error summary report which included 52.21% OASIS assessments submitted late. The DON stated she received it late for review from the RN who did the OASIS assessments, which resulted in the agency not following its policy. The surveyor asked what tracking system DOM had to ensure timely submission of assessments. The ADM said she was re-orienting and re-training the nurse for timely return of the assessments. Agency Policy titled, "Timelines IM.35" with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to coordinate missed skilled PT and OT evaluation and visits with the patient’s Physician in two (Patient # 1, and 2) of 5 active skilled patient records reviewed. Failure of the agency to ensure the clinical record included effective interchange and coordination placed patients at risk of negative patient care outcomes to meet the patient-specific health needs. Findings include: Patient record # 1: Record review of the electronic health record included a Plan of Care (POC) with a start of care (SOC) date of 06/03/2024 and a certification period from 08/02/2024 thru 09/30/2024. The POC revealed Patient 1 has the following diagnosis: “Essential Primary Hypertension, Hemiplegia (partial or total loss of muscle function in one or more parts of the body) affecting right dominant side, generalized muscle weakness, unsteadiness on feet, … “. The POC was electronically signed by the RN A on 08/02/2024. The POC included physician orders for PT and OT evaluation and treat. The electronic record included a PT referral sent on 08/20/2024 requesting “PT to continue as per Re-Eval”. 1. Patient’s entire clinical record did not include a PT evaluation or re-evaluation. There was no documentation of why the PT services were not provided staring the week of 08/02/2024. 2. Patient’s entire clinical record did not include an OT evaluation or treatment performed. There was no documentation of why the OT services were not provided staring the week of 08/02/2024. Further review of Patient 1’s record revealed there was no interchange of coordination of care delivery with the physician of delay in PT and OT referral and PT and OT evaluation and treatment. During home visit on 10/15/2024 at approximately 9.45 am, in an interview with Patient 1, the patient said he was not receiving PT or OT services. Patient said he need PT because he has muscle weakness, right sided weakness, unstable gait and had multiple falls. Patient stated he requested DON, and the nurse practitioner that he wanted outpatient therapy, but he was informed the insurance was delaying it. Patient record # 2: Record review of the electronic health record included a Plan of Care (POC) with a start of care 08/21/2024 and a certification period from 08/21/2024 thru 10/19/2024. The POC revealed Patient 2 has the following diagnosis: “Essential Primary Hypertension, generalized muscle weakness, Scoliosis, … “. The POC was electronically signed by the RN A on 08/21/2024. The POC included physician orders for PT and OT evaluation and treat. Further review of the electronic record PT and OT referral was sent on 09/12/2024. OT evaluation was performed on 09/17/2024. Review of OT evaluation on 09/17/2024, recommendation for the visit frequency was twice a week for five weeks. COTA visits 09/20/24, 09/25/24, 09/28/24, 10/03/24 and 10/05/24 were missed visit. OT skilled visits was completed only on 09/17/2024. Further review of Patient 2’s record revealed there was no interchange of coordination of care delivery with the physician of delay in OT and PT referral and OT missed visits. During home visit on 10/15/2024 at approximately 11.10 am, in an interview with Patient 2, the patient stated she has muscle weakness, and she uses walker and cane to ambulate. Patient not aware who the OT therapist is and why not providing OT services. An interview with ADM / DON on 10/16/2024 at approximately 2 pm surveyor asked why Patient #1’s PT referral was sent on 08/20/2024 when certification period started from 08/02/2024. The ADM/DON stated she did not remember she had to check. The surveyor asked why Patient #2’s OT and PT referral sent on 09/12/2024 when the certification period started from 08/21/2024. The ADM/DON stated she did not remember she had to check. The surveyor asked who is responsible to send out the referral. The ADM /DON said the OM is responsible. An interview was conducted with the ADM/DON and AADM/ ADON on 10/17/2024 at approximately 4.45 PM. The surveyor asked why OT and PT referral was not sent out per agency policy. The ADON stated RN A did the assessment and notified OM late which resulted in the agency not following its policy. The surveyor asked why Patient #1 was not provided PT and OT services and no interchange of coordination of care delivery with Patient #1’s physician. The ADON/ AADM said patient wants outpatient PT. The Physician was aware but the communication with the physician was not documented. The surveyor asked why Patient #2 was not provided OT services and no interchange of coordination of care delivery with Patient #2’s physician. The ADM/DON and AADM / ADON stated they were not aware that patient was not receiving OT services. The COTA did not inform DON or ADON. Review of agency policy titled:” Policy 4.18: Coordination of Services” of the Clinical Policy and Procedure read in part:” Policy: All skilled clinicians ……. Outlined in the plan of care. Procedure: Referrals: 6. If the evaluation is unable …... physician. 12. In an effort …... client outcome. 14. l. communicate changes …. clinicians involved in care”. Review of agency policy titled:” Patient/ Client Assessment Guidelines PE.10” revised on 05/01/24 of the Administrative Policy Manual read in part: Purpose: To provide accurate and consistent patient /client assessments. Procedure: The scope of other discipline’s assessment ……. PT, OT, SLP etc. IX. An assessment performed …... as follows: A. Nursing – 48 hours; B. Physical Therapy – four days; C. Occupational Therapy – four days; Speech-language pathology – four days; Medical Social Worker – four days”.

Purpose of Visit: Recertification Survey Entrance Date: 09/07/2021 An entrance conference was conducted with the agency Adm at 12:15 p.m. The Adm was informed that the purpose of the survey was for a 36-month recertification. L&C Census: 23 Exit Date: 09/13/2021 An exit conference was conducted at 2:45 p.m. with the Adm, Alt Adm and PAS Sup. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, agency admission paperwork documents. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Violations within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Violations. Abbreviations: EP- Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a written emergency preparedness and response plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. The risk assessment was not updated to include the Novel Coronavirus of 2019 pandemic. The failure could result in the agency being unable to properly prepare for an outbreak of COVID-19 among its clients or staff. The failure could also place clients' health and safety at risk. FINDINGS INCLUDED: During the entrance conference at 12:15 p.m. on 09/07/2021, the Adm self-identified as the disaster coordinator. The Adm identified the Alt Adm as the alternate disaster coordinator. Review of the agency's EP binder revealed the following: An "All Hazards Facility/Community Based Risk Assessment for Potential Disasters" dated 01/22/2019. The risk assessment read in part: " ...D. Epidemic or Pandemic ..." the risk level for epidemic or pandemic was not addressed on the risk assessment. The binder did not include any other risk assessments. In an interview on 09/13/2021 at 1:40 p.m., with the Adm the surveyor discussed the above findings of why the agency's risk assessment not updated to include the COVID-19 pandemic. The Adm replied, "I just haven't had the time to update it."

Purpose of Visit: Recertification Survey Entrance Date: 09/07/2021 An entrance conference was conducted with the agency Adm at 12:15 p.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 23 Exit Date: 09/13/2021 An exit conference was conducted at 2:45 p.m. with the Adm, Alt Adm and PAS Sup. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, agency admission paperwork documents. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Violations within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Violations. Abbreviations: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nurses (Supervising Nurse) ADON-Assistant Director of Nurses (Alternate Supervising Nurse) L & C- Licensed and Certified EHR- Electronic Health Record Registered Nurse (RN) Licensed Vocational Nurse (LVN) Occupational Therapist (OT) CNA/hha (Certified Nurse Aide/Home Health Aide) PAS SUP- Personal Assistance Services Supervisor POC- Plan of Care SOC- Start of Care HHA's- Home Health Agencies NOMNC- Notice of Medicare Non-Coverage OASIS -outcome and assessment information set PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement Coronary artery bypass grafting (CABG) CMS- Center for Medicare and Medicaid Services COVID-19- Novel Coronavirus Disease 2019 QIO-Quality Improvement Organization

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to respect the patient's right to receive proper written notice, in advance of terminating on-going care in three of three (Patients #6, 7 and 12) inactive patient records reviewed. The agency failed to provide the Centers for Medicare and Medicaid form titled "Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record #6: Record review 09/08/2021. Record review of the EHR for Patient #6 revealed a POC for the certification period of 08/26/2020 to 10/24/2020 with a SOC date of 06/27/2020 and signed by RN B. The POC was dated 08/26/2020. Patient #6's record included a discharge OASIS that was digitally signed by RN B and dated 10/22/2020. The record also included an OT discharge summary dated 10/24/2020 and showed a discharge date of 10/24/2020. Patient #6's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 10/24/2020. The record did not include a written NOMNC. Clinical Record #7: Record review 09/08/2021. Record review of the EHR for Patient #7 revealed a POC for the certification period of 02/25/2021 to 04/25/2021 with a SOC date of 02/25/2021 and signed by the ADON. The POC was dated 04/20/2021. Patient #7's record included a discharge OASIS that was digitally signed by the ADON and dated 06/22/2021. The OASIS revealed a discharge date of 06/22/2021. Patient #7's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 06/22/2021. The record did not include a written NOMNC. Patient #12: Review of the agency's discharged patient roster revealed that Patient # 12 was discharged on 05/05/2021. Clinical Record #12: Record review 09/08/2021. Record review of the EHR for Patient #12 revealed a POC for the certification period of 07/10/2021 to 09/07/2021 with a SOC date of 01/27/2018 and signed by the ADON. The POC was dated 07/10/2021. The POC had a note on it that read "can discharge from home health services at this time. Patient now stable and taking Eliquis." Patient #12's record did not include a discharge OASIS or discharge summary. Patient #12's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 05/05/2021. During an interview on 09/13/2021 at approximately 2:15 p.m., the surveyor asked the ADON if Patient #12 was an active patient. The ADON stated that the patient was not an active patient with the agency. The surveyor discussed the above findings of why Patient # 12 was listed on the discharge roster as discharged on 05/05/2021 but there was no documentation of discharge in the record and why there was continued documentation of services provided after the date of discharge. The ADON replied, "It was scheduled as a recert, but it should have been a discharge, so I could not document it." In an interview on 09/13/2021 at approximately 2:15 p.m. with the DON and ADON, the surveyor discussed the above findings of why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients #6, 7 and 12. The DON replied, "I didn't know about a two-day."

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: advised of federally funded and state-funded entities that service the area where the patient resided in three (Patients # 1, 2 and 3) of three patients who received home visits. The failure did not conform to the patients' right to be advised regarding the entities contact information in the event such information was needed by the patient. The failure could result in the patients' missed opportunities to obtain and access extra services from the community that were not provided by the agency. FINDINGS INCLUDED: On 09/07/2021 the surveyor reviewed the agency's sample Medicare admission packet. The sample packet included the following entities listed by title and a telephone number: Agency on Aging Center for Independent Living Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. The packet did not include the names and/or updated contact information of the QIO and other entities for the service area where the patients resided. Patient #1: Review of the clinical record for Patient # 1 revealed a POC with a SOC date of 03/02/2020, with the primary diagnosis of Non-pressure chronic ulcer of left foot. The POC for certification period 08/24/2021 to 10/22/2021 was electronically signed by RN A on 08/24/2021. During a home visit conducted on 09/10/2021 at approximately 9:00 a.m., the surveyor observed and reviewed Patient #1's home admission folder. The home folder did not include updated names, addresses, and/or telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. Patient #2: Review of the clinical record for Patient # 2 revealed a POC with a SOC date of 08/18/2020, with the primary diagnosis of Hypertensive chronic kidney disease. The POC for certification period 06/14/2021 to 08/12/2021 was electronically signed by the ADON on 06/14/2021. During a home visit conducted on 09/09/2021 at approximately 10:45 a.m., the surveyor observed and reviewed Patient #2's home admission folder. The home folder did not include updated names, addresses, and/or telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. Patient #3: Review of the clinical record for Patient # 3 revealed a POC with a SOC date of 07/30/2021, with the primary diagnosis of Atherosclerosis of CABG without angina pectoris. The POC for certification period 07/30/2021 to 09/27/2021 was electronically signed by RN A on 07/30/2021. During a home visit conducted on 09/09/2021 at approximately 9:00 a.m., the surveyor observed and reviewed Patient #3's home admission folder. The home folder did not include updated names, addresses, and/or telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. During an interview on 09/13/2021 at 1:20 p.m., the surveyor discussed the above findings with the Adm, Alt. Adm and PAS Sup. The surveyor presented the above findings of why the sample admission packet and the home folders for Patients # 1, 2 and 3 did not include the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area where the patients resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Organization. The PAS Sup stated that it had been changed. She left the room to get the changed form. The updated form did not include the specific name, addresses and updated phone numbers for the entities in the patients' service area. The Adm replied, "We did not know that it had to be updated." Review of agency undated policy titled " ...Bill of Rights" read in part: " ...PROCEDURE...16. Be advised of the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that serve the area where the patient resides including (1) Agency on Aging; (2) Center for Independent Living; (3) Protection and Advocacy Agency; (4) Aging and Disability Resource Center; and e. Quality Improvement Organization ..."

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review, observations at home visits and interviews the agency failed to provide written information in three (Patients # 1, 2 and 3) of three patients who received a home visit. The HHA failed to provide the patient and caregiver with a copy of written instructions which outlined the patients' visit schedule and medication schedule/instructions. The failure could place the patients at risk to be uninformed and/or unable to identify the staff scheduled to provide care and services on the behalf of the agency while in the patient's homes. The failure could place the patients and patient representative at risk to be uninformed of the patient's medication name, dosage and frequency and which medications might be administered by HHA personnel and personnel acting on behalf of the HHA. FINDINGS INCLUDED: On 09/07/2021 the surveyor reviewed the agency's sample Medicare admission packet. The packet did not contain a form for visit schedules. It did contain a form for medication schedule/instructions. Patient #1: Review of the clinical record for Patient # 1 revealed a POC with a SOC date of 03/02/2020, with the primary diagnosis of Non-pressure chronic ulcer of left foot. The POC for certification period 08/24/2021 to 10/22/2021 was electronically signed by RN A on 08/24/2021. The EHR also contained a medication list/profile dated 08/24/2021 and digitally signed by RN A. During a home visit conducted on 09/10/2021 at approximately 9:00 a.m., the surveyor observed and reviewed Patient #1's home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. The home folder included all forms that were in the agency's admission packet. Patient #2: Review of the clinical record for Patient # 2 revealed a POC with a SOC date of 08/18/2020, with the primary diagnosis of Hypertensive chronic kidney disease. The POC for certification period 06/14/2021 to 08/12/2021 was electronically signed by the ADON on 06/14/2021. The EHR also contained a medication list/profile dated 06/25/2021 and digitally signed by the ADON. During a home visit conducted on 09/09/2021 at approximately 10:45 a.m., the surveyor observed and reviewed Patient #2's home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. The home folder included all forms that were in the agency's admission packet. Patient #3: Review of the clinical record for Patient # 3 revealed a POC with a SOC date of 07/30/2021, with the primary diagnosis of Atherosclerosis of CAGG without angina pectoris. The POC for certification period 07/30/2021 to 09/27/2021 was electronically signed by RN A on 07/30/2021. The EHR also contained a medication list/profile dated 07/30/2021 and digitally signed by RN A. During a home visit conducted on 09/09/2021 at approximately 9:00 a.m., the surveyor observed and reviewed Patient #3's home admission folder. The folder did not include a visit schedule or updated medication schedule/instructions. The home folder included all forms that were in the agency's admission packet. During an interview on 09/13/2021 at approximately 2:00 p.m., with the DON and ADON, the surveyor discussed the above findings of why the agency had not provided a visit schedule or updated medication schedule/instructions to Patients # 1, 2 and 3. The ADON replied, "I did not know that [that the visit schedule was required]." The DON stated that the nurse who saw the patients were responsible for updating the medication schedule/instructions.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct PIP (s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk of not improving and providing quality care and services to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 09/07/2021 at approximately 12:15 p.m., the surveyor requested all agency QAPI/documents/reports/binders. The surveyor requested the QAPI records again at approximately 3:40 and 4:15 p.m. Record review of the agency's QAPI records did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. On 09/10/2021 the surveyor also reviewed the agency's business profile binder. The binder also did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 09/07/2021 at 1:30 p.m., with the Adm and the Alt Adm the surveyor discussed the above findings. The surveyor discussed why the agency had not ensured that the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. The Adm replied, "COVID came. We were out of the office a lot." Review of agency undated policy titled " ...Quality Assurance Performance Improvement Program" was not updated to include the federal regulatory requirements for PIPs beginning July 13, 2018.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed in one of one (CNA) to maintain documentation which demonstrated that the requirements for home health aide competency evaluation had been met. The failure placed patients that received home health aide services at risk for receiving unsafe care from the home health aide. FINDINGS INCLUDED: Clinical Record # 3 Review of Patient # 3's record included a POC with a SOC date of 07/30/2021 for the certification period of 07/30/2021 to 09/27/2021. The POC was digitally signed by RN A and dated 07/30/2021. The POC included an order for home health aide services for two times a week for nine weeks (2W9). On 09/09/2021 at approximately 9:00 a.m., the surveyor conducted a home visit with Patient # 3. The CNA was present and provided home health aide care to Patient # 3. CNA Personnel Record: Review of the personnel record for CNA included a signed home health aide job description that was dated 10/05/2016. The personnel record also included a document which indicated the hire date for CNA was 10/05/2016. Continued review of the personnel record for CNA revealed a " ...Competency Skills Evaluation" dated 10/05/2016 and a "Competency Exam" dated 10/05/2016. The competency evaluation and competency exam were not scored (competency determined and documented) by an agency RN. The personnel record also contained an "In-service mandatory prior to patient care" dated 10/05/2016. The mandatory in-service was not scored or graded by an agency RN In an interview on 09/09/2021 at approximately 1:52 p.m., with the DON, the surveyor discussed the above findings of the CNA competency evaluation and exam. The DON replied, "I forgot to score it." Review of agency undated policy titled ""COMPETENCY/Skill EVALUATION" did not include the regulatory requirement to maintain documentation which demonstrated that the requirements of this standard have been met.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that one of one home health aide (CNA) whose record was reviewed, had completed at least 12 hours of in-service training during each 12-month period for the years 2019 and 2020. The failure could place patients who received care from the employee at risk to not receive safe, quality and appropriate care and services due to lack of continuing education. FINDINGS INCLUDED: Clinical Record # 3 Review of Patient # 3's record included a POC with a SOC date of 07/30/2021 for the certification period of 07/30/2021 to 09/27/2021. The POC was digitally signed by RN A and dated 07/30/2021. The POC included an order for home health aide services for two times a week for nine weeks (2W9). On 09/09/2021 at approximately 9:00 a.m., the surveyor conducted a home visit with Patient # 3. The CNA was present and provided home health aide care to Patient # 3. CNA Personnel Record: Review of the personnel record for CNA included a signed home health aide job description that was dated 10/05/2016. The personnel record also included a document which indicated the hire date for CNA was 10/05/2016. The personnel record for CNA did not include any in-service hours for 2019 and 2020. Review of agency in-service records on 09/09/2021 revealed the following "Inservice Sign In List(s)" for CNA: Training dated 01/20/2019; 02/2019; 06/2019; 07/2019; 08/2019; 09/2019; 10/2019 and 11/2019. The training lists did not include the number of hours for the training. Training dated 01/2020 and 02/2020. The training lists did not include the number of hours for the training. During an interview with the DON on 09/13/2021 at approximately 1:45 p.m., the surveyor discussed the above findings of why the in-service training for CNA was not completed. The DON replied, "I thought they were done. Before COVID everything was done timely and documented." Review of agency undated policy titled "MONITORING OF CHHA AND CNA IN-SERVICE HOURS." The policy read in part: "PURPOSE: To provide a permanent record of ...CNA continuing education programs ...POLICY: Every ...CNA will be required to attend, at a minimum, three hours of inservices per quarter ...PROCEDURE ...The aide will sign an attendance sheet at each in-service attended. The date, subject material, and length of the in-service are recorded on a sign-in sheet by the designated in-service coordinator. The Director of Patient Care Services ...will monitor hours of inservice attended to ensure compliance. A copy of the record of in-service attendance will be retained in each aide's personnel file. The original sheet is retained in the education Department."