Every finding on record at Multicare Home Health Services, Inc

A medicare recertification survey was conducted at your home health agency from 9/03/24 to 9/06/24, and included emergency preparedness. Multicare Home Health Services, inc. is in compliance with the emergency preparedness regulations found at 42 CFR §484.102. No deficiencies were cited.

The following deficiencies were cited during the medicare recertification survey conducted at your home health agency from 9/03/24 to 9/06/24. The following abbreviations were used in the report: c/o – complain of ED – Emergency Department ER – Emergency Room LPN – Licensed Practical Nurse OT – Occupational Therapy PCP – Primary Care Physician POA - Power of Attorney POC – Plan Of Care PT – Physical Therapy PTA – Physical Therapy Assistant RNCM – Registered Nurse Case Manager SN – Skilled Nurse SOC - Start Of Care

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of medical records and staff interview, it was determined the agency failed to ensure consents were properly completed in advance of treatment for 1 of 17 patients (Patient #7) whose records were reviewed. This caused possible misunderstandings of the care to be furnished for Patient #7 and had the ability to affect all patients receiving services from the agency. Findings include: Patient #7 was an 84 year old female admitted to the agency on 8/21/24. She had a primary diagnosis of sarcopenia, with additional diagnoses including dementia and atrial fibrillation. She received PT services. Her record for the certification period 8/21/24 to 10/19/24 was reviewed. Patient #7’c SOC note, dated 8/21/24 was reviewed. Under the section titled, “mental status,” it stated Patient #7 was disoriented to time and situation. It also stated she was forgetful and had short term memory loss. Patient #7’s SOC note also stated, “POA [name] is reporting she is unable to attend in person to sign her mother's admission paperwork. She also stated she did not want admission paperwork emailed to her or mailed to her to sign. POA reports her mom has worked with multi-care multiple times before and she would like for her mom to sign all of her own admissions paperwork.” Patient #7’s consent to treat was reviewed. Patient #7 signed her own consent despite having dementia and short-term memory loss and being disoriented to situation. It was unclear if Patient #7 understood what she consented to. The administrator was interviewed on 9/05/24 beginning at 1:46 PM and Patient #7’s medical record was reviewed in his presence. When asked if it was appropriate for Patient #7 to sign her own consent with her documented dementia and disorientation, he stated a verbal consent from the POA would have been more appropriate. The agency failed to ensure consents were properly completed for Patient #7.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined the agency failed to ensure patients received an comprehensive assessment after a fall with injury for 1 of 17 patients ( Patient #15) whose records were reviewed. This had the potential to have unmet needs go unaddressed for patients receiving services. A facility policy titled “Indications for other follow-up assessment” undated, included: "A comprehensive assessment must be collected when there is a significant change in the condition of the patient including either a major decline or improvement that is not anticipated and the patient is not hospitalized. Significant changes in condition are defined as unexpected events, episodes or exacerbations that impact care… Examples included but not limited to be:… Fall with injury…” This policy was not followed, an example includes. Patient #15 was a 88 year old female admitted to the agency on 4/09/24. Her primary diagnosis was Alzheimer’s disease. Additional diagnoses included venous insufficiency, pressure ulcer, and cellulitis. She received SN, and PT services. Her record for the certification period 4/09/24 – 6/07/24, including her POC, was reviewed. Patient #15’s medical record included a PTA visit note dated 4/30/24, signed by the PTA. The note included: “Patient was transferred to St Als ED at approximately 7pm 4/29/24 after a fall in the hallway while attempting to enter her room after dinner. This resulted in a closed head injury. “ Patient #15’s medical record included a SN visit note dated 5/02/24 signed by the LPN. The note included: “Fall reported from two days ago. Pt was found outside her door in hallway on her back. Pt did hit her head and was talked to the ER. Pt was released. Pt C/o of headache in back of head today… Pt is noticeably more confused than usual… PCP office notified.” There was no documentation the RN case manager was notified of the fall and noticeably increase in confusion. Patient #15’s medical record included a RN visit note dated 5/09/24 signed by the RNCM. There was no documentation regarding Patient #15’s fall on 4/29/24. There was no follow-up assessment to the fall. Additionally, there was no follow up assessment to Patient #15’s increased confusion. It was unclear if the RNCM was aware that Patient #15 had a fall with head injury, and increased confusion on 4/29/24. The Administrator was interviewed on 9/6/24 beginning at 9:00 AM and Patient #15’s medical record was reviewed in his presence. He confirmed the RN should have followed up on Patient #15’s fall and assessed the patient prior to 9 days post fall and confusion. The Agency failed to ensure Patient #15 received a comprehensive assessment after a fall with injury.

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 clinical record reviews, current guideline review, and staff interviews, it was determined the agency failed to ensure the patients' individualized plan of care/treatment included all the required interventions and medications to address the identified needs for 2 of 17 patients (Patients #8 and #10) whose records were reviewed. This caused potential for unmet patient needs and had the potential to affect all patients receiving services at the agency. Findings include: 2. Patient #10 was a 52 year old female admitted to the agency on 6/07/24 with a primary diagnosis of hypertensive heart and chronic kidney disease stage 5. Additional diagnoses included heart failure and type 2 diabetes. She also received hemodialysis treatments three times weekly. She received SN, PT, and OT services. Her record for the certification period 6/07/24 to her discharge on 7/05/24 was reviewed. According to the American Kidney Foundation, (https://www.kidney.org/news-stories/dos-and-don-ts-fluid-management-kidney-disease#:~:text=Most%20hemodialysis%20patients%20try%20to,need%20more%20fluid%20or%20salt. Accessed 9/10/24) “Most hemodialysis patients try to limit weight gain per treatment to no more than 2.2 pounds or 1 kilogram per day. Check your blood pressure along with daily weights. If it is low, contact your healthcare team as you may need more fluid or salt.” This guideline was not followed. According to the American Heart Association, (https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms accessed 9/10/24), “Daily weight. Many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week. This weight gain may be due to retaining fluids since the heart is not functioning properly. It’s a good idea to track your weight and check in with your health care professional if you notice sudden changes.” This guideline was not followed. Patient #10’s SOC note dated 6/07/24 was reviewed. The initial nursing assessment note stated, “she is weighed before and after each dialysis session every Tuesday, Thursday, and Saturday so no need to be weighed at home.” Patient #10’s record included weights on the SOC on 6/07/24 and again on 6/14/24. Her weights were 151 lbs and 143.7 lbs. These were the only weights recorded for Patient #10. Patient number 10s POC dated 6/07/24 was reviewed. The interventions did not include to weigh patient #10 to measure if her heart failure or kidney failure were worsening. The Administrator was interviewed on 9/05/24 beginning at 1:46 PM and Patient #10's record was reviewed in his presence. When asked if there should have been weights included on the POC for patient #10 he stated he didn't feel she needed to be weighed. After reviewing her diagnoses, he agreed daily weights should have been included on Patient #10’s POC. 1. Patient #8 was a 75 year old female admitted to the agency on 2/17/23. Her primary diagnosis was Amyotrophic lateral sclerosis. Additional diagnoses included breast cancer, hypertension, dysphagia, and a gastrostomy tube. She received SN, and PT services. Her record for the cert period 2/17/23 – 4/17/23 including her POC was reviewed. Patient #8’s POC did not include all necessary interventions and medications. Examples included: a. Patient #8’s medical record included a SN visit note dated 2/24/23 signed by the LPN. The note included Pt is getting some nausea from formula feedings. Pt taking Tums which has been effective. Pt also c/o pain at night only when sleeping on her right hip which is preventing her from getting a full night’s sleep. Pt will try taking Tylenol and Ibuprofen before going to bed.” Patient #8’s POC, historical medication list and current medication list. They did not include the Tums, Tylenol, and Ibuprofen medications. Additionally Patient #8’s POC and Medication list did not include the tube feed information, i.e. amount and frequency, of tube feedings for Patient #8. The agency clinical manager was interviewed on 9/6/24 beginning at 9:00 AM and patient #8’s medical record was reviewed in his presence. He confirmed the missing medications and information. Additionally, he stated the above medications should be on Patient #8’s medication list. The agency failed to ensure Patient #8’s POC included all medications. b. Patient SOC assessment dated 2/17/23 signed by the RNCM was reviewed. It included that Patient #8 “has had a 60 lb weight loss over the past 9 months and had an emergency g tube placed in early February.” The note also included that Patient #8 had a current weight of 160 lbs. Patient #8’s medical record included and SN visit on 2/24/23 signed by the LPN. The note included that Patient #8’s weight at the time of the visit was 154 lbs. Showing a 6 lb weight loss in 7 days. Patient #8’s POC was reviewed it did not include monitoring of weights based on her historical weight loss and gastrostomy tube, what was considered excessive weight loss, and when to notify md of weight loss. The agency clinical manager was interviewed on 9/6/24 beginning at 9:00 AM and Patient #8’s medical record was reviewed in his presence. He confirmed tracking of weight and parameters should have been listed on the POC for Patient #8. The agency failed to ensure Patient #8’s POC included interventions and parameters for the monitoring of her weight.

The following deficiency was cited during a Medicare recertification survey of your agency, including Emergency Preparedness, which was conducted from 11/01/21 to 11/04/21. Surveyors conducting the survey were: 42371 39430 42316 Acronyms used in this report include: EP - Emergency Preparedness

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to establish and maintain a current, comprehensive Emergency Preparedness program including policies and procedures. Failure to meet this standard had the potential to hinder agency response during an emergency which requires coordination and cooperation with available local resources. This deficient practice had the potential to affect all patients on services during an emergency. 1. Refer to E0004 as it relates to the agency’s failure to develop and maintain the EP program. 2. Refer to E0006 as it relates to the agency’s failure to conduct a facility-based and community-based risk assessment which includes strategies identified under an all-hazards approach. 3. Refer to E0009 as it relates to the agency’s failure to establish a process for cooperation and collaboration. 4. Refer to E0013 as it relates to the agency’s failure to develop EP policies and procedures, based on an Emergency Plan. 5. Refer to E0019 as it relates to the agency’s failure to establish procedures to inform local and state officials for the need for potential evacuation. 6. Refer to E0024 as it relates to the agency’s failure to address use of volunteers and establish a process for the integration of State or Federally designated health care professionals to address surge needs during an emergency. 7. Refer to E0029 as it relates to the agency’s failure to establish a communication plan. 8. Refer to E0032 as it relates to the agency’s failure to establish primary and alternate means for communicating with other management agencies. 9. Refer to E0036 as it relates to the agency’s failure to have a training and testing program. 10. Refer to E0037 as it relates to the agency's failure to train staff. The cumulative effect of these systemic deficient practices could impede the agency's ability to meet the emergency preparedness standard(s) and the needs of patients during a disaster.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop, maintain, review, and update a current and comprehensive Emergency Preparedness program. Failure to meet this standard had the potential to hinder agency response during an emergency which requires coordination and cooperation with local resources available. This deficient practice had the potential to affect all patients on services during an emergency. The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to develop an EP plan that was reviewed and updated.

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 agency documentation review and staff interview, it was determined the agency failed to conduct a facility-based and community-based risk assessment which included identified strategies for response. Failure to conduct a facility and community-based risk assessment hinders facility response to localized disasters and emergencies for all patients on service during an emergency. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to conduct a facility-based and community-based risk assessment.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on agency documentation and staff interview, it was determined the agency failed to develop a current plan for cooperation and collaboration with local, tribal, regional, State, and Federal EP officials. Failure to develop a collaborative planning effort with multi-jurisdictional entities, had the potential to limit the agency’s options during an emergency for all patients on services. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have a current cooperation and collaborative plan with local, tribal, regional, State, and Federal EP officials.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on agency documentation review and staff interview, it was determined the agency failed to develop policies and procedures based on an Emergency Plan. Failure to develop current policies and procedures based on an emergency plan, and a communications plan, limits agency response capabilities in the protection of all patients on services during an emergency. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have EP policies and procedures.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on agency documentation and staff interview, it was determined the agency failed to develop procedures to inform state and local officials about homebound patients in need of evacuation. Lack of procedures had the potential to hinder the agency's ability to provide care and continuation of services during an emergency. This had the potential to affect all patients on services during emergency. Findings include: An agency policy, “Emergency Preparedness,” updated 5/2018, stated, “The agency will develop mutual aid or other agreements with other organizations as appropriate to insure [sic] the care of evacuated patients.” This policy was not followed. The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have a procedure to inform officials about homebound patients in need of evacuation.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on agency documentation and staff interview, it was determined the agency failed to develop, document, and maintain emergency policies, procedures and operational plans for the use of volunteers to address surge needs during an emergency. Lack of current plans and policies for the use of volunteers had the potential to hinder the agency's ability to provide continuation of care during an emergency for all patients on services. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have EP procedures or policies regarding the use of volunteers.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on agency documentation review and staff interview, it was determined the agency failed to have a plan for agency communications. Communication plans are an essential component during an emergency. Failure to have a current communication plan had the potential to hinder emergency response by staff. This deficient practice could affect all patients on service during an emergency. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have a communications plan.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on agency documentation review and staff interview, it was determined the agency failed to document a plan for primary and alternate means of communicating with federal, state, tribal, regional and local emergency management agencies during an emergency. Lack of a current plan for agency communication options had the potential to hinder response efforts by staff and emergency management agencies. This deficient practice could affect all patients on service during an emergency. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to have a plan to communicate with federal, state, tribal, regional and local emergency management agencies during an emergency.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on agency documentation review and staff interview, it was determined the agency failed to develop an emergency preparedness training and testing program. This had the potential to hinder staff response during a disaster. This deficient practice had the potential to affect all patients on services during an emergency. Findings include: The agency’s EP plan and any other EP documentation was requested at the entrance interview. A binder and a policy, “Emergency Preparedness,“ updated and approved by the Board of Directors in May 2018 was provided. The binder included information relating to a recently conducted phone tree test exercise as well as generic emergency plans for Ada and Canyon counties. No other documentation was provided. The Administrator was interviewed on 11/03/21, beginning at 1:50 PM. She stated that she was new to the Administrator position. She stated that she was not aware of any other agency EP related documentation or requirements. The agency failed to develop a staff emergency training and testing program.

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 personnel files and staff interview, it was determined the agency failed to ensure staff were trained in EP for 7 of 7 staff (Staff A - G) whose personnel files were reviewed. This created the potential for staff to be unaware of their role in an emergency event. Findings include: Staff A - G’s personnel files were reviewed. None of the personnel files included initial or annual training on EP. A human resources staff member was present for the personnel file review on 11/03/21 at 2:15 PM. She confirmed Staff A - G did not have initial or annual training on EP. She stated she thought the previous administrator had done the training. No documentation of staff training on EP was provided prior to survey exit. The agency failed to ensure initial and annual training on EP.

As of 11/23/21, survey documentation has been modified to add language at G406. The following deficiencies were cited during the Medicare recertification and focused COVID-19 infection control surveys of your agency conducted on 11/01/21 to 11/04/21. Surveyors conducting the Medicare recertification survey were: 42371 39430 42316 Acronyms used in this report include: ADL - Activities of Daily Living APS - Adult Protective Services BKA - Below-knee amputation BM - Bowel Movement CAD - Coronary Artery Disease CDC - Centers for Disease Control and Prevention CHF - Congestive Heart Failure CKD - Chronic Kidney Disease COPD - Chronic Obstructive Pulmonary Disease COVID-19 - Coronavirus Disease 2019 CPAP - Continuous Positive Airway Pressure DM - Diabetes Mellitus EMR - Electronic Medical Record EMS - Emergency Management System EP - Emergency Preparedness HF - Heart Failure HH - Home Health HHAs - Home Health Agencys HTN - Hypertension IC - Infection Control LPN - Licensed Practical Nurse MAHC - Missouri Alliance for Home Care MSW - Medical Social Worker NA - Not Applicable OASIS - Outcome and Assessment Information Set OT - Occupational Therapy OSHA - Occupational Safety and Health Administration PA-C - Physician's Assistant, Certified PCP - Primary Care Physician PCS - Personal Care Services POC - Plan of Care PPE - Personal Protective Equipment PRN - As Needed PT - Physical Therapy Pt / pt - Patient PHE - Public Health Emergency QAPI - Quality Assessment Performance Improvement RN - Registered Nurse RNCM - Registered Nurse Case Manager SOC - Start of Care SN - Skilled Nursing ST - Speech Therapy SOC - Start of Care

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on medical record review, agency policy review, and staff interview, it was determined the agency failed to meet discharge for cause criteria. This failure resulted in the violation of patients' rights. Findings include: Refer to G462 as it relates to the failure of the agency to ensure meeting discharge for cause criteria. Refer to G464 as it relates to the failure of the agency to notify the physician that a discharge for cause was being considered. Refer to G468 as it relates to the failure of the agency to provide contact information for other HHA agencies to patients that were discharged for cause. Refer to G470 as it relates to the failure of the agency to document efforts to resolve problems that lead to discharge for cause.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on policy review, record review, and staff interview, it was determined the facility failed to ensure proper steps were completed before a discharge for cause for 1 of 2 patients (Patient #16) who were discharged for cause and whose records were reviewed. This failure had the potential for patients to be discharged from the agency without necessary criteria being met. Findings include: An agency policy titled “DISCHARGE PLANNING, SUMMARY AND OASIS-C1,” undated, stated, “Agency may discharge if patient’s decision to decline services compromises agency’s ability to safely and effectively deliver care to the extent that the agency can no longer meet the patient’s needs…Agency will document…the interventions the agency attempted in order to obtain patient’s participation with the plan of care,” and, “Discharge for cause;…Uncooperative is defined as the patient’s repeated declination of services or persistent obstructive, hostile or contrary attitudes to agency caregivers that are counterproductive to the plan of care.” This policy was not followed. An example includes: Patient #16 was a 68 year old female admitted to the agency on 1/15/21 with a primary diagnosis of COPD. Additional diagnoses included DM type 2 and hypertension. She received SN, PT, and OT services. Her record for the certification period 1/15/21 to 3/12/21 was reviewed. She was discharged for cause from the agency on 3/12/21. Patient #16’s record included an LPN note dated 2/17/21. The note stated, “Patient verbalizes understanding of need to quit smoking, but is not interested.” The note did not indicate where Patient #16’s behavior was uncooperative to the extent it compromised the agency’s ability to safely and effectively deliver care. The note also stated, “patient does not smoke with oxygen in use and only smokes outside apartment,” indicating Patient #16 was properly following oxygen safety measures. Patient #16’s record included a communication note dated 5/20/21, over 2 months after her discharge. The note was signed by an RN and stated, “Patient will not be readmitted at this time due to previous noncompliance with health care recommendations from HH SN as well as PCP. Patient was/is in and out of the hospital frequently due in part to her refusal to quit smoking and to be compliant with COPD medications.” The note did not indicate where Patient #16’s behavior was uncooperative to the extent it compromised the agency’s ability to safely and effectively deliver care. There was no other documentation in Patient #16’s record that a discharge for cause was being considered prior to it happening. There was no documentation in Patient #16’s record that her behavior was uncooperative to the extent that it impeded the delivery of care. A Physical Therapist was interviewed on 11/04/21 at 11:24 AM. He stated Patient #16 was compliant with PT services. He stated SN was concerned with her issues with smoking, and scheduling with Patient #16 was a challenge with SN. He stated Patient #16 was discharged because she was in and out of the hospital and would not quit smoking. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed Patient #16 was a discharge for cause. She confirmed there was no documentation that Patient #16’s behavior was uncooperative to the point that it impeded the agency’s ability to safely and effectively deliver care. She confirmed Patient #16’s non-compliance with smoking cessation was not enough to warrant a discharge for cause. The agency failed to ensure that discharges for cause were properly implemented.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on medical record review, agency policy review, and staff interview, it was determined the agency failed to ensure patients' physicians were notified in advance that a discharge for cause was being considered for 2 of 2 patient (#15 and #16) who were discharged for cause and whose record was reviewed. This had the potential for a lack of opportunity for the patient to acquire other services or resources after discharge. Findings include: An agency policy titled “DISCHARGE PLANNING, SUMMARY, AND OASIS-C1”, undated, included: “Agency must notify the patient, patient’s representative, the physician issuing orders for the home health care and the patients primary care practitioner that the agency is considering discharge for cause.” This policy was not followed examples include: 1. Patient #15 was a 69-year-old female who was admitted to the agency on 3/22/21, with a primary diagnosis of Type 2 DM. Additional diagnoses included COPD, heart disease, and chronic kidney disease. She received SN, PT, and MSW services. Her record, including the POC, for the certification period 3/22/21 to 5/20/21, was reviewed. She was discharged from the agency on 4/07/21. Patient #15’s medical record included a communication note dated 4/07/21 signed by the RNCM. The note included “Call placed to patient and discussed that HH cannot help her as her needs are too high for home health and she needs a higher level of care.” The note also included “Phone call to PCP explaining the situation and that I discharged her today.” There was no documentation in Patient #15's medical record that a discharge for cause was being considered. The Nursing Manager was interview 11/04/21 beginning at 9:00 AM and Patient #15’s medical record was reviewed in her presence. When asked if Patient #15’s physician was notified prior to discharge that a discharge for cause was being considered, she confirmed there was no documentation Patient #15’s Physician was notified. 2. Patient #16 was a 68 year old female admitted to the agency on 1/15/21 with a primary diagnosis of COPD. Additional diagnoses included DM type 2 and hypertension. She received SN, PT, and OT services. Her record for the certification period 1/15/21 - 3/12/21 was reviewed. She was discharged for cause from the agency on 3/12/21. Patient #16’s record included a communication note dated 5/20/21, over 2 months after her discharge. The note was signed by an RN and stated, “Patient will not be readmitted at this time due to previous noncompliance with health care recommendations from HH SN as well as PCP. Patient was/is in and out of the hospital frequently due in part to her refusal to quit smoking and to be compliant with COPD medications.” There was no documentation Patient #16 nor her physician were notified of her discharge for cause was being considered prior to the discharge for cause. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed there was no documentation Patient #16 and her physician were notified a discharge for cause was being considered. The agency failed to notify patients and their physicians a discharge for cause was being considered.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on policy review, record review, and staff interview, it was determined the agency failed to provide contact information or referrals for 2 of 2 patients (Patients #15 and #16) who were discharged for cause and whose records were reviewed. This caused a potential for lack of follow up care for patients who were discharged for cause. Findings include: Patient #15 was a 69-year-old female who was admitted to the agency on 3/22/21, with a primary diagnosis of Type 2 DM. Additional diagnoses included COPD, heart disease, and chronic kidney disease. She received SN, PT, and MSW services. Her record, including the POC, for the certification period 3/22/21 to 5/20/21, was reviewed. She was discharged from the agency on 4/07/21. Patient #15’s medical record included a communication note dated 4/07/21 signed by the RNCM. The note included “Call placed to patient and discussed that HH cannot help her as her needs are too high for home health and she needs a higher level of care.” The note also included “Phone call to PCP explaining the situation and that I discharged her today.” The MSW for Patient #15 was interviewed 11/04/21 beginning at 9:30 AM, and Patient #15's medical record was reviewed in her presence. When asked if Patient #15 was provided a list of contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient, she stated she did not remember providing numbers, and confirmed there was no documentation in the record those numbers were provided. Patient #15 was not provided with contact information for other agencies or providers who may have been able to provide care after her discharge for cause. An agency policy titled “DISCHARGE PLANNING, SUMMARY AND OASIS-C1,” undated, stated, “the discharge summary will include…any continuing care needs, instructions, or referrals regarding the patient’s needs.” This policy was not followed. Examples include: 1. Patient #16 was a 68 year old female admitted to the agency on 1/15/21 with a primary diagnosis of COPD. Additional diagnoses included DM type 2 and hypertension. She received SN, PT, and OT services. Her record for the certification period 1/15/21 - 3/12/21 was reviewed. She was discharged for cause from the agency on 3/12/21. Patient #16’s record included a communication note dated 5/20/21, over 2 months after her discharge. The note was signed by an RN and stated, “Patient will not be readmitted at this time due to previous noncompliance with health care recommendations from HH SN as well as PCP. Patient was/is in and out of the hospital frequently due in part to her refusal to quit smoking and to be compliant with COPD medications.” There was no documentation in Patient #16’s record indicating her continuing care needs or referrals given. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed there was no documentation of Patient #16’s discharge for cause, including contact information for other agencies or referrals regarding Patient #16’s needs, prior to her discharge. The agency failed to provide contact information or referrals for other HHA’s for a patient who was discharged for cause.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, record review, and staff interview, it was determined the agency failed to document efforts made to resolve problems to prevent discharges for cause for 2 of 2 patients (#15 and #16) who were discharged for cause and whose records were reviewed. This resulted in a failure to effectively manage identified problems and to potentially prevent a discharge for cause. Findings include: Findings include: Patient #15 was a 69-year-old female who was admitted to the agency on 3/22/21, with a primary diagnosis of Type 2 DM. Additional diagnoses included COPD, heart disease, and chronic kidney disease. She received SN, PT, and MSW services. Her record, including the POC, for the certification period 3/22/21 to 5/20/21, was reviewed. She was discharged from the agency on 4/07/21. Patient #15s medical record included an SOC comprehensive assessment, dated 3/22/21, signed by an RN. The SOC comprehensive assessment included a section related to ADL’s. The SOC included: - “Someone must help the Patient put on upper body clothing - Someone must help the patient put on undergarments, slacks, socks or nylons and shoes - Patient “Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair or on commode with the assistance or supervision of another person.” - When reminded, assisted or supervised by another person able to get to and from the toilet and transfer. - “Someone must help the patient to maintain toileting hygiene and/or adjust clothing. Patient #15’s SOC also included in the narrative section. “Pt sitting on bed on arrival. Pt has left BKA. Pt is pretty much dependent on others for all ADL’s” Patient #15’s medical record included her POC, dated 3/22/21, and signed by the patients attending provider. The POC included “Pt needs assistance with all ADL’s.” It also included “Pt needs assistance with transportation and ADL’s” Patient #15’s record included a communication note dated 3/25/21, signed by the RNCM. The note included that she received a call from the local fire station reporting “they have been receiving calls and going out daily to get this patient up and clean her up because she is usually found sitting in her urine and/or BM.” The note includes that the MSW is working on setting up PCS services for Patient #15. Patient #15’s record included a SN visit note dated 3/26/21, signed by the RNCM. The note included: “House has an overwhelming odor of animal and human urine, Patients depends and chucks are so wet that the urine has soaked through. Patient stated that she hasn’t had anyone over to change her yet but her granddaughter will be there shortly. Patient states that her bottom hurts but is unable to move from her current position for an assessment. I crawl into bed and she leans fwd. and I can visualize some excoriation at her coccyx area. I am unable to reach the area to provide any appropriate treatment or assessment… Told patient that a hospital bed with a trapeze would held[sic] her reposition as well as help me assess and treat her bottom. Patient agreed and PT[physical therapy] was consulted to get the ball rolling on getting her he a hospital bed.” Patient #15’s medical record included a communication note dated 3/26/21 that included the MSW was working on setting up Patient #15’s PCS services. Patient #15’s medical record included a communication note dated 3/31/21 signed by the MSW. The note included that Patient#15’s PCS services were not available due to the PCS did not have the staff to care for the patient. The note included that the MSW notified the physician and called APS due to the MSW’s concerns for Patient #15’s safety. There was no documentation in Patient #15’s medical record that she was offered or refused Aide services or Occupational therapy services for assistance with her ADL’s while her PCS services were being set up. Patient #15’s medical record included a SN visit note dated 4/05/21 signed by the RNCM. It included: “Patient c/o [complains of] pain to buttocks but patient is unable to move enough so that I can even see the area let alone treat. Asked patient if she had any ideas on how I was to care for her and she stated that she didn’t know. Told patient that the hospital bed could have helped that so that se [sic] could lay her down and turn her. Patient stated that the hospital bed just didn’t work for her… Patient had removed the Unna boot as it was too uncomfortable and stated she did not want another one placed…Asked patient would be in to help her going fwd [forward] and she stated that she did not know…” There was no documentation of why the hospital bed did not work for Patient #15. There was no documentation of efforts made to resolve Patient #15’s identified problem with the hospital bed or usage of UNNA boot. Patient #15’s medical record included a communication note dated 4/07/21 signed by the RNCM. The note included “Call placed to patient and discussed that HH cannot help her as her needs are too high for home health and she needs a higher level of care.” The note also included “Phone call to PCP explaining the situation and that I discharged her today.” Patient #15's medical record included a communication note date 4/08/21, the day after discharge from the agency, signed by the MSW. The note included that the MSW called APS again to report the MSW's concerns for Patient #15's safety The MSW for Patient #15 was interviewed 11/04/21 beginning at 9:30 AM. The MSW stated she was working on getting Patient #15’s PCS services set up. She stated she had concerns for Patient #15’s safety and that is why she called APS initially on 3/25/21. She stated the patient lacked a full time caregiver and her family was not readily available to help the patient in a consistent manner. The MSW stated Patient #15 was discharged from the agency skilled services while she was working on the PCS services so she could no longer see the patient, and was unable to continue working with Patient #15's PCS services. The MSW stated she called APS again when Patient #15 was discharged because she did not believe the patient was in a safe living environment. When asked if she thought Patient #15s discharge from the agency was appropriate she stated "no". The Nursing Manager was interview 11/04/21 beginning at 9:00 AM and Patient #15’s medical record was reviewed in her presence. When asked what interventions were done to help Patient #15 with her ADL’s, she confirmed there was no documentation of services offered for Patient #15. She stated Patient #15 should have been offered OT and bath aide services, and she did not know why the services were not offered. The Nursing Manager confirmed there was no documentation on efforts to resolve Patient #15's identified problems prior to discharge. Additionally the Nursing manager stated that Patient #15’s discharge “was not handled correctly” Patient #15's clinical record did not include documentation of efforts to resolve identified problems with Patient #15 prior to discharging her from the agency. An agency policy titled “DISCHARGE PLANNING, SUMMARY AND OASIS-C1,” undated, stated, “Agency will document…the measures the agency took to investigate the patient’s refusal, and interventions the agency attempted in order to obtain patient’s participation with the plan of care.” This policy was not followed. Examples include: 1. Patient #16 was a 68 year old female admitted to the agency on 1/15/21 with a primary diagnosis of COPD. Additional diagnoses included DM type 2 and hypertension. She received SN, PT, and OT services. Her record for the certification period 1/15/21 - 3/12/21 was reviewed. She was discharged for cause from the agency on 3/12/21. Patient #16’s record included a communication note dated 5/20/21, over 2 months after her discharge. The note was signed by an RN and stated, “Patient will not be readmitted at this time due to previous noncompliance with health care recommendations from HH SN as well as PCP. Patient was/is in and out of the hospital frequently due in part to her refusal to quit smoking and to be compliant with COPD medications.” Patient #16’s record did not include documentation of efforts made to resolve the problems that led to the discharge for cause. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed there was no documentation of Patient #16’s discharge for cause, including efforts made to resolve the problems that led to the discharge for cause, prior to the communication note on 5/20/21. Patient #16's clinical record did not include documentation of efforts to resolve identified problems with Patient #16 prior to discharging her from the agency.

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 review of medical records and staff interview, it was determined the agency failed to ensure the POC was accurate and included all pertinent interventions and goals for 5 of 17 patients (#12, #2, #8, #10, and #15) whose POCs and records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: Patient #15 was a 69-year-old female who was admitted to the agency on 3/22/21, with a primary diagnosis of Type 2 DM. Additional diagnoses included COPD, heart disease, and chronic kidney disease. She received SN, PT, and MSW services. Her record, including the POC, for the certification period 3/22/21 to 5/20/21, was reviewed. She was discharged from the agency on 4/07/21. Patient #15s medical record included an SOC comprehensive assessment, dated 3/22/21, signed by an RN. The SOC comprehensive assessment included a section related to ADL’s. The SOC included: - "Someone must help the Patient put on upper body clothing." - "Someone must help the patient put on undergarments, slacks, socks or nylons and shoes" - Patient “Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair or on commode with the assistance or supervision of another person.” - "When reminded, assisted or supervised by another person able to get to and from the toilet and transfer." - “Someone must help the patient to maintain toileting hygiene and/or adjust clothing. " Patient #15’s medical record included her POC, dated 3/22/21, and signed by the patients attending provider. The POC included “Pt needs assistance with all ADL’s.” It also included “Pt needs assistance with transportation and ADL’s” There was no documentation in Patient #15’s medical record that she was offered or refused Aide services or Occupational therapy services for assistance with her ADL’s. The Nursing Manager was interview 11/04/21 beginning at 9:00 AM. When asked what interventions were done to help Patient #15 with her ADL’s, she confirmed there was no documentation of services offered for Patient #15. She stated Patient #15 should have been offered OT and bath aide services. Patient #15's POC was not comprehensive to address all of her needs. 1. Patient #12 was a 43 year old female admitted to the agency on 8/17/21 with a primary diagnosis of management of a ventricular assist device. Additional diagnosis included familial dysautonomia, major depressive disorder, polyneuropathy, and Chron’s disease. She received SN services. Her record, including the POC, for the certification period of 10/16/21 to 12/14/21 was reviewed. a. Patient #12’s record included a comprehensive recertification assessment, dated 10/15/21, signed by the RNCM. The assessment included a Nutritional Health Screen which rated Patient #12’s nutritional risk status as 35, a moderate Nutritional risk. Patient #12’s POC did not include intervention or goals for her moderate nutrition risk. b. Patient #12’s comprehensive recertification assessment included a, “Neuro/Emotional/Behavioral” status that documented Patient #12 was “depressed … Demonstrated/Expressed Anxiety … Insomnia … “ Patient #12’s POC did not include intervention or goals for her mental health status. c. Patient #12’s comprehensive recertification assessment, rated Patient #12’s rheumatoid arthritis as a severity level 2, indicating symptoms were controlled with difficulty, affecting daily functioning and requiring ongoing monitoring. Patient #12’s POC did not include interventions or goals for her rheumatoid arthritis. d. Patient #12’s comprehensive recertification assessment included a Braden Scale risk score of 17, indicating a risk of developing a pressure ulcer. Patient #12’s POC did not include interventions to assess her skin and reduce her risk of developing pressure ulcers. e. Patient #12's comprehensive recertification assessment included a fall risk assessment. A score of 4 or more is considered at risk for falling. Patient #12’s fall risk score was 8, indicating a risk for falls. Her POC did not include interventions or goals to address her fall risk. f. Patient #12's comprehensive recertification assessment included a pain assessment. The pain assessment documented that Patient #12’s pain interfered with her activity or movement daily, but not constantly. Patient #12’s POC did not included goals or interventions to address her pain. The RNCM was interviewed on 11/04/21, beginning at 8:20 AM, and Patient #12’s record was reviewed in her presence. She confirmed that Patient #12’s POC did not include goals or interventions to address her nutrition risk, mental health, rheumatoid arthritis, risk of developing pressure ulcer, fall risk, or pain. Patient #12's POC was not comprehensive to address all of her needs. 2. Patient #2 was an 86 year old female admitted to the agency on 7/13/21 with a primary diagnosis of DM type 2 with a foot ulcer. Additional diagnoses included gout, CKD, HF, HTN, atrial fibrillation, and hypothyroidism. She received SN services. Her record, including the POC, for the certification period of 9/11/21 to 11/09/21 was reviewed. a. Patient #2’s record included a comprehensive recertification assessment, dated 9/07/21, signed by the RNCM. The assessment rated Patient #8's gout a severity of 3, indicating symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring. The assessment also rated Patient #2’s CKD, HF, HTN and hypothyroid as a severity level 2, indicating symptoms were controlled with difficulty, affecting daily functioning and requiring ongoing monitoring. Patient #2’s POC did not include interventions or goals for her gout, CKD, HF, HTN and hypothyroidism. b. Patient #2’s comprehensive recertification assessment included a Braden Scale risk score of 14, indicating a moderate risk of developing a pressure ulcer. Patient #2’s POC did not include interventions to assess her skin and reduce her risk of developing pressure ulcers. c. Patient #2's comprehensive recertification assessment included a fall risk assessment. A score of 4 or more is considered at risk for falling. Patient #2’s fall risk score was 8, indicating a risk for falls. Her POC did not include interventions or goals to address her fall risk. The Nursing Manager was interviewed on 11/04/21, beginning at 9:25 AM, and Patient #2’s record was reviewed in her presence. She confirmed Patient #2’s POC did not include interventions or goals for her gout, CKD, HF, HTN and hypothyroidism. Patient #2's POC was not comprehensive to address all of her needs. 3. Patient #8 was an 87 year old male admitted to the agency on 10/20/20 with a primary diagnosis of a diabetic foot ulcer. Additional diagnoses included DM type 2, venous insufficiency, heart failure, and Alzheimer’s. He received SN services. His record, including the POC, for the certification period of 10/15/21 to 11/21/33 was reviewed. a. Patient #8’s record included a comprehensive recertification assessment, dated 10/13/21, signed by the RNCM. The assessment rated Patient #8's DM type 2 and his venous insufficiency as a severity level 2, indicating symptoms were controlled with difficulty, affecting daily functioning and requiring ongoing monitoring. Patient #8’s POC did not include interventions or goals for her DM type 2 outside wound care for his diabetic ulcer or his venous insufficiency. b. Patient #8’s comprehensive recertification assessment also included a Braden Scale risk score of 16, indicating a risk of developing a pressure ulcer. Patient #8’s POC did not include interventions to assess her skin and reduce her risk of developing pressure ulcers. The Nursing Manager was interviewed on 11/04/21, beginning at 9:25 AM, and Patient #8’s record was reviewed in her presence. She confirmed Patient #8’s POC did not include interventions or goals for her DM type 2 outside of wound care or address Patient #8’s risk of developing pressure ulcers. Patient #8's POC was not comprehensive to address all of her needs. 4. Patient #10 was a 98 year old female admitted to the agency on 10/22/21, with a primary diagnosis of acute upper respiratory infection. Additional diagnoses included heart disease, macular degeneration, muscle weakness, and stress incontinence. She received SN and PT services. Her record, including the POC, for the certification period 10/22/21 to 12/20/21, was reviewed. a. Patient #10's record included an SOC comprehensive assessment, dated 1/22/19, signed by the RNCM. The assessment included a Braden Scale. The Braden Scale is a validated tool used by clinicians to evaluate a patient's risk of developing a pressure ulcer. The total score can range from 6 to 23 with a lower score indicating a higher risk. Patients scoring 18 or less are at risk of developing pressure ulcers. Patient #10's Braden Scale score was 18, indicating a risk of developing a pressure ulcer. Her POC did not include interventions to assess her skin and reduce her risk of developing pressure ulcers. b. Patient #10's SOC comprehensive assessment also included a fall risk assessment. A score of 4 or more is considered at risk for falling. Patient #10’s fall risk score was 9, indicating a risk for falls. Her POC did not include interventions or goals to address her fall risk. The Nursing Manager was interviewed on 11/04/21, beginning at 9:25 AM, and Patient #10’s record was reviewed in her presence. She confirmed Patient #10’s POC did not address Patient #10’s risk of developing pressure ulcers and her fall risk. Patient #10's POC was not comprehensive to address all of her needs.

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 review of QAPI documentation, CMS memo, governing body meeting minutes, and staff interview, it was determined the agency failed to ensure performance improvement projects were conducted as an ongoing effort to measure progress achieved. This had the potential to result in missed opportunities for improvement in patient care and safety, and agency operations. Findings include: A CMS memo titled “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers” Included a section that applied to Home Health Agencys, it included: “Quality Assurance and Performance Improvement (QAPI). CMS is modifying the requirement at 42 CFR §418.58 for Hospice and §484.65 for HHAs, which requires these providers to develop, implement, evaluate, and maintain an effective, ongoing, hospice/HHA-wide, data-driven QAPI program. Specifically, CMS is modifying the requirements at §418.58(a)–(d) and §484.65(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. This modification decreases burden associated with the development and maintenance of a broad-based QAPI program, allowing the providers to focus efforts on aspects of care delivery most closely associated with COVID-19, and tracking adverse events during the PHE. The requirement that HHAs and hospices maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain. “ Quality documents were reviewed there was no evidence the agency was actively working on a performance improvement project. Governing body meeting minutes were reviewed. The meeting minutes discussed quality of care related issues, however there was no documentation of a specific performance improvement project the agency was working on. The Administrator and Assistant Administrator were interviewed together on 11/01/21 beginning at 2:00 PM. When asked what performance improvement projects the agency was working on currently, the administrator stated they did not have any ongoing projects. They confirmed the agency IC policy had not been updated to reflect the COVID-19 pandemic and the agency did not have any written policies or procedures relating to COVID-19. They stated that their EMR had been updated and the agency’s current procedure was for clinician to create included reports created in their EMR, but that the policy and procedure had not been updated They confirmed they the agency was collecting infection data, but data was not being analyzed to determine possible process improvement. The agency failed to maintain an ongoing, agency wide, data-driven QAPI program.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on review of agency policy, QAPI data, governing body meeting minutes, agency documents, medical records, and staff interview, it was determined the agency failed to update, maintain, and execute a comprehensive infection control program, including measures to prevent the spread of COVID-19 and to identify and control infections. This resulted in a lack of analyzed infection-related data to accurately determine if delivered services and interventions were safe and effective and could affect all patients on services. This also resulted in staff not following IC accepted standards of practice. Findings include: 1. Refer to G682, as it relates to the agency's failure to ensure accepted IC standards of practice were followed. 2. Refer to G684 as it relates to the agency's failure to identify, prevent, control, and investigate infections, failure to update the Infection Control Program during a PHE, and the agency's failure to ensure adequate surveillance screening for COVID-19 was completed on all patients and visitors. The cumulative effect of these deficiencies resulted in the inability of the agency to adequately identify infection control needs, develop patient specific interventions, and seriously impeded the ability of the agency to prevent the spread of COVID-19.

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, policy review, and staff interview, it was determined the agency failed to ensure infection control measures were performed by agency staff to prevent the transmission of infection in 1 of 7 patients (#8) whose care was observed. This had the potential to place all agency patients and staff at increased risk of infections. Findings include: 1. Infection control measures were not performed by agency staff to prevent the transmission of infection - An agency policy, “OSHA Regulations/Infection Control/Exposure Control Plan,” undated, stated: “Patient infection control procedures include, but not limited to: Wearing and changing gloves as necessary during the delivery of patient care … Appropriate patient wound and skin care and dressing techniques following sterile or clean dressing procedures, as appropriate … “ - The CDC website, accessed on 11/10/21, stated the following guidelines for performing hand hygiene in healthcare settings: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient’s immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal The policy and guidelines were not followed. Examples include: Patient #8 was an 87 year old male admitted to the agency on 10/20/20 with a primary diagnosis of a diabetic foot ulcer. Additional diagnoses included Type 2 DM, venous insufficiency, HF, and Alzheimer’s. He received SN services. His record, including the POC, for the certification period of 10/15/21 to 11/21/21 was reviewed. A home visit was made to Patient #8’s home with an LPN to observe wound care on 11/01/21 on his right foot. The following infection control breaches were observed: - LPN did not perform hand hygiene after removal of the soiled dressing and prior to donning new gloves - LPN did not perform hand hygiene after removing gloves, touching the bed, and donning new gloves. - LPN did not perform hand hygiene after applying new dressing and then accessing her nursing bag and donning new gloves. The LPN did not perform hand hygiene according to policy and CDC IC guidelines. The Nursing Manager, an RN, was interviewed on 11/03/21 at 11:05 AM. She stated that agency followed CDC guidelines for hand hygiene and wound care. She stated it was agency expectation to perform hand hygiene between glove changes. The HHA failed to ensure accepted standards of practice for infection control were followed.

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 agency policy, IC documents, QAPI data, governing body meeting minutes, observation, medical charts, and staff interview, it was determined the agency failed to identify, prevent, control, and investigate infections and failed to ensure its Infection Control Program was an integral part of the agency's QAPI program. Additionally, agency failed to ensure all disciplines completed COVID-19 screening on patients for 4 of 11 patients #5, #7, #9, and #10) whose records were reviewed. This had the potential for incomplete patient assessment, treatment, and unmet patient needs. Findings include: Patient #5 was a 92 year old female who was admitted to the agency on 9/28/21, with a primary diagnosis of COVID-19 acute respiratory disease. Additional diagnoses included pneumonia due to coronavirus disease and Alzheimer’s. She received SN, PT, and Aide services. Her record, including the POC, for the certification period 9/28/21 to 11/26/21, was reviewed Patient #5s record included home health aide visits on 10/05/21, 10/08/21, 10/12/21,10/18/21, and 10/19/21. There was no documentation of a COVID-19 screening within the visit notes. The Nursing Manager was interviewed on 11/04/21 beginning at 9:00 AM. She confirmed there was no COVID-19 screening from the home health Aide on the above dates. She confirmed Patient #5 should have been screened every visit. 1. Patient #7 was a 64 year old male admitted to the agency on 9/23/21 with a primary diagnosis of COPD and an additional diagnosis of dysphagia. His record for the certification period 9/23/21 to 11/21/21 was reviewed. He received ST and PT services. Patient #7’s record included an OT eval, dated 9/27/21, signed by the Occupational Therapist. There was no documentation of a COVID-19 screening within the visit note. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed there was no COVID-19 screening from the OT eval on 9/27/21. She confirmed Patient #7 should have been screened every visit. x. Patient #9 was a 74 year old female admitted to the agency on 9/29/21 with a primary diagnosis of COVID-19. Additional diagnoses included pneumonia, heart disease, and DM type 2. Her record for the certification period 9/29/21 to 11/27/21 was reviewed. She received HHA, PT, and OT services. Patient #9’s record included an HHA care plan effective 10/03/21, signed by the Occupational Therapist. The care plan stated, “PREVISIT SCREEN OF PATIENT/FAMILY/CG [caregiver] FOR COVID19 S/S [signs/symptoms] MUST BE COMPLETED PRIOR TO EACH VISIT - REPORT ANY S/S IN HOME TO ADMIN/CM [case manager] BEFORE PROCEEDING WITH SCHEDULED APPOINTMENT.” This requirement was not followed. Patient #9’s record included the following: - 10/07/21 HHA visit note did not include COVID-19 screening - 10/13/21 HHA visit note did not include COVID-19 screening - 10/16/21 HHA visit note did not include COVID-19 screening - 10/18/21 HHA visit note did not include COVID-19 screening - 10/21/21 HHA visit note did not include COVID-19 screening - 10/25/21 HHA visit note did not include COVID-19 screening - 10/28/21 HHA visit note did not include COVID-19 screening The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She confirmed there was no COVID-19 screening on the above dates for Patient #9. She confirmed Patient #9 should have been screened every visit. 1. The agency's policy "INFECTION CONTROL PROGRAM," undated, stated: - “Multicare will maintain and implement an Infection Control Program that will be based upon current scientific knowledge for surveillance and prevention of adverse outcomes related to infections. The program will be appropriate to the demographics f the patient population and address epidemiological issues that are relevant to the organization.” - The infection control objectives listed, “To maintain written policies and procedures based on infection control practices related to the care/services provided. These policies and procedures will be reviewed at least annually for revisions as appropriate.” - “The risk for and trends of infections are used to study ways to improve both prevention and control activities and to reduce the risk and occurrence of infections to the lowest possible levels.” - "MultiCare's leaders and information management systems will demonstrate support of the Infection Control Program for aggregate, comparative and knowledge-based data and will employ knowledgeable staff to interpret findings." This policy was not followed. Examples include: The infection control program was not updated to reflect the current COVID -19 pandemic. The agency did not have written policies or protocols regarding staff or patient COVID-19 screening. The agency did not have written policies procedures or protocols relating to the prevention and controlling the COVID-19 virus. There was no documentation that infection data was analyzed and used to improve prevention and control activities. 2. The agency’s policy and procedure, “Infection Control Event Reporting,” approved by Governing Body 12/2018 outlined policy and procedures to identify and tract patient infections. The document outlined a procedure to report infections via Tiger Text, develop Infection Control Event Reports, and QAPI would monitor the agencies Infection Control Reports to, “… identify any need for additional follow-up/education or policy changes to address identified practices that increase risk for infection.” This policy was not followed. Examples include: The policy had not been updated to reflect the agency’s current procedure of using their EMR to report infections. A “Board of Directors and Professional Advisory Committee Meeting Minutes,” dated 5/21/21, stated, “[name of employee] asked about the numbers on infections and [name of employee] mentioned that it could be caused by a number of things such as UTI, a wound infection, COVID etc.” It was unclear how QAPI would identify the need for follow-up/education or policy changes if infection data was not separated by infection type. The Administrator and Nursing Manager were interviewed on 10/31/18, beginning at 10:01 AM, and the agency's infection control program was reviewed in their presence. They confirmed the agency IC policy had not been updated to reflect the COVID 19 pandemic and the agency did not have any written policies or procedures relating to COVID-19. They stated that their EMR had been updated and the agency’s current procedure was for clinician to create included reports created in their EMR, but that the policy and procedure had not been updated They confirmed they the agency was collecting infection data, but data was not being analyzed to determine possible process improvement. 3. Governing Body meeting minutes, dated 5/22/18, were reviewed. The meeting minutes did not include discussion of the agency's infection control plan. Previous 2018 Governing Body meeting minutes were requested, however due to a recent data breach, were not available. It could not be determined how the Governing Body provided oversight of the agency's infection control plan. The Administrator and Nursing Manager were interviewed on 10/31/18, beginning at 10:01 AM, and the agency's infection control program was reviewed in their presence. They confirmed the agency was collecting infection control data, but were not analyzing, presenting, or measuring the data. They stated that staff/patient COVID-19 infections were logged, but not tracked or surveilled. They stated that their new procedure included reports created in their EMR, but policy and procedure had not been updated. The agency failed to identify, prevent, control, and investigate infections and failed to ensure its Infection Control Program was an integral party of the agency's QAPI program. 4. An agency QAPI document "QAPI – Quality Improvement, Performance Improvement 2018, 2019, 2020”, was reviewed. It included data for 3 PI projects related to infections. - "Infections – started 72 hours after admission to HH services (included data beginning first quarter 2019 to 3rd quarter 2020) - COVID 19 Employee Positives (including data beginning 1st quarter of 2020 to 3rd quarter 2020) - COVID 19 Patient Positives (including data beginning 1st quarter of 2020 to 3rd quarter 2020) The Administrator and Nursing Manager were interviewed on 10/31/18, beginning at 10:01 AM, and the agency's infection control program was reviewed in their presence. They confirmed the agency was collecting infection control data, but were not analyzing, presenting, or measuring the data. Infection control was not integrated into the agency's QAPI program. 5. COVID-19 screening not performed on surveyors prior to 3 of 7 home visits. The Administrator was interviewed on 11/4/21, beginning at 11:50 AM. She confirmed there was no written policy, but surveyors should have been screened prior to attending home visits. The agency's failed to identify possible COVID-19 positive visitors, and potentially result in the spread of COVID-19 to staff, patients, and the community. 6. COVID-19 screening documentation of patients was absent, incomplete or inaccurate. Agency documentation included information and instructions related to patient screening as follows: - A letter to patients, family, and caregivers dated April 2020, stated, “We are screening all patients and prospective patients for COVID-19 symptoms or risk factors before providing care … “ - A Home Health and Personal Care Services joint meeting agenda, dated 11/12/20, stated, “Everyone should be calling ahead or speaking with patient/family before entering the home and screening for the COVID19 s/s and notify the COVID19 group if there are any symptoms.” These procedures were not followed. Examples include: a. Patient #10 was a 98 year old female admitted to the agency on 10/22/21, with a primary diagnosis of acute upper respiratory infection. Additional diagnoses included heart disease, macular degeneration, muscle weakness, and stress incontinence. She received SN and PT services. Her record, including the POC, for the certification period 10/22/21 to 12/20/21, was reviewed. i. Patient #10’s record included a SOC comprehensive assessment, dated 10/22/21, signed by RNCM. There was no documentation of a COVID-19 screening within the visit note. ii. Patient #10’s record included a bath aide visit note, dated 10/29/21, signed by the bath aide. There was no documentation of a COVID-19 screening within the visit note. The Clinical Manager was interviewed on 11/0421 at 10:30 AM. She confirmed there was no COVID-19 screening on the above dates for Patient #10. She confirmed Patient #10 should have been screened every visit.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on review of medical records, policies, QAPI documents, Governing Body meeting minutes, agency emergency preparedness documents, agency personnel file review and staff interviews, it was determined the Governing Body failed to provide effective administrative oversight of the agency. This resulted in a lack of support and guidance to agency personnel and had the potential for poor outcomes for all patients receiving agency services. Findings include: 1. The agency's organizational chart, dated,11/01/21, was reviewed. The chart included individual clinicians in several columns. It could not be determined what delineated lines of authority were approved by the governing body for the agency. Examples include: - The organization chart included a column that included “Social Services”, “Bath Aides”, and Speech Therapy”. It was unclear who the staff reported to. A member of the governing body was interviewed on 11/03/21 beginning at 3:00 PM. She confirmed the lines of authority were unclear in the organizational chart. The agency failed to document clear lines of authority 2. Refer to E0001 as it relates to the governing body’s failure to maintain a comprehensive emergency preparedness program. 3. Refer to G406 as it relates to the agency’s failure to protect patients’ rights. 4. Refer to G658 as it relates to the governing body’s failure to maintain an ongoing, agency wide data-driven QAPI program 5. Refer to G680 as it relates to the failure of the governing body to maintain and document a comprehensive infection control plan to identify and control infections. 6. Refer to G952 as it relates to the failure of the governing body to ensure HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. 6. Refer to G958 as it relates to the failure of the governing body to ensure a qualified person or persons was authorized in writing to act as clinical manager

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on review of policy, personnel files, human resource documents, and staff interview, it was determined the agency failed to ensure staff competencies for 2 of 7 staff (Staff B and C) whose personnel files were reviewed. This created a lack of oversight to ensure nursing staff were able to perform duties as required by agency policy. Findings include: An agency policy titled “SUPERVISION AND EVALUATION OF STAFF,” undated, stated, “Initial and ongoing staff competency is monitored and evaluated through a formalized agency competency evaluation process. Based upon job requirements outlined by MultiCare’s job descriptions, MultiCare’s competency evaluation process identified the job skills and the frequency for demonstration of proficiency by the employee.” Staff B and C’s job descriptions were reviewed. Staff B’s LPN job description addressed competencies only for intravenous therapy. There were no other competencies for nursing tasks addressed in Staff B’s job description. Staff C’s RN job description did not include a competency evaluation process. Staff B and C’s personnel files were reviewed. Neither of the personnel files included nursing competencies. The Clinical Manager was interviewed on 11/04/21 at 9:45 AM. She stated nursing staff did not have competencies. She confirmed there were no competencies for Staff B and C. The agency failed to ensure staff were competent to perform job duties as required by agency policy.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on review of agency documents and staff interview, it was determined the agency failed to ensure a qualified person was authorized in writing to act as the agency clinical manager, or approval of a qualified person to act in the absence of the Administrator. This had the potential to interfere with the agency's ability to provide clear direction and guidance to staff. Findings include: The agency’s governing body meeting minutes for 2020 and 2021 were reviewed. They did not include documentation of the governing body's approval of the home health administrator, and approval of a qualified person to act in the administrator's absence. A member of the governing body was interviewed 11/03/21, beginning at 3:00 PM. She stated they had a turnover of staff approximately 6 weeks ago and the current administrator has been in that position for 6 weeks. When asked who the clinical manager was she stated the nurse manager, and 2 physical therapists who provide oversite for therapy services. The governing body member stated there was no documentation the 3 staff members were approved by the governing body to act as the clinical manager, or documentation they were approved to act in the administrator's absence. The agency failed to ensure a qualified person or persons was designated in writing to act as clinical manager, and approval of a qualified person to act in the administrator's absence. .

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 record review and staff interview, it was determined the agency failed to ensure entries in the patient record were clear for 1 of 2 patients (Patient #16) who were discharged for cause and whose records were reviewed. This created a lack of clear documentation as to why Patient #16 was discharged for cause while also having a signed recertification order. Findings include: Patient #16 was a 68 year old female admitted to the agency on 1/15/21 with a primary diagnosis of COPD. Additional diagnoses included Type 2 DM and HTN. She received SN, PT, and OT services. Her record for the certification period 1/15/21 to 3/12/21 was reviewed. She was discharged for cause from the agency on 3/12/21. Patient #16’s record included an OASIS Discharge dated 3/12/21, signed by the RN. There was a section titled “Discharge Planning” which was left blank. The section titled “Reason for Discharge” stated, “Goals met / max potential reached.” In the narrative section, the note stated, “Pt being recertified for continued COPD education and care, and DM education and care.” It was unclear why the discharge note stated Patient #16 was being recertified. Patient #16’s record included a communication note dated 5/20/21, over 2 months after her discharge. The note was signed by an RN and stated, “Patient will not be readmitted at this time due to previous noncompliance with health care recommendations from HH SN as well as PCP. Patient was/is in and out of the hospital frequently due in part to her refusal to quit smoking and to be compliant with COPD medications.” There was no documentation that Patient #16’s physician was notified when a discharge for cause was being considered, or when Patient #16 was discharged for cause. Patient #16’s record included a recertification order dated 3/12/21 and signed by the RN. The recertification order was signed by a PA-C on 3/25/21, indicating Patient #16 was supposed to be recertified. The RN who completed the OASIS discharge was interviewed on 11/04/21 at 1:29 PM. He stated he remembered Patient #16 was discharged. He stated he was unsure why he would have discharged Patient #16 with a current recertification order. He confirmed the documentation was unclear as to why Patient #16 was discharged with a recertification order. Documentation in Patient #16’s record was unclear.