Every finding on record at Nett Hands Home Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 09/20/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 09/20/24. Standard level deficiencies cited. Abbreviations: OASIS = Outcome and Assessment Information Set SN = Skilled Nurse Pt / Pts = Patient / Patients SOC = Start of Care LPN = License Practical Nurse OSHA = Occupational Safety and Health Administration POC = Plan of Care BP = Blood Pressure

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Agency's OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency's past 12 months OASIS submission report was reviewed on 09/20/24. The report contained information that out of the 74 Agency's OASIS assessment reports, 20 (27.03 %) were submitted beyond the required time frame of 30 days. 2. During an interview with the Clinical Manager on 09/20/24 at 1:00 PM. The Clinical Manager confirmed the Agency's late OASIS submission.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observation, Agency policy and staff interview, it was determined that in 1 of 3 (Pts. #1 and 2) home visits, the Agency failed to ensure infection control measures were observed to prevent the potential for cross-contamination, as per Agency policy. Findings include: 1. Pt. #1 was admitted to Home Health Services on 10/14/22 with the Diagnosis of: Heart Failure, unspecified. During a home visit conducted with Employee # 1 (Clinical Manager) on 09/18/24 at 2:30 PM, Employee # 1 was observed to put down nursing bag on top a box of gloves in Pt. #1’s home without placing a barrier. During an interview with Employee # 1 on 09/18/24 at 3:30 PM, Employee #1 confirmed that she did not put a barrier between nursing bag and box of gloves that was already in the Pt. #1’s home. 2. Pt. #2 was admitted to Home Health Services on 06/03/24 with the Diagnosis of: Cerebral Infarction, Unspecified. During a home visit conducted with Employee #2 (LPN) on 09/19/24 at 2:15 PM, Employee #2 was observed to put down nursing bag on top of a green plastic chair in Pt. #2’s home without placing a barrier or cleaning the surface. During an interview with Employee #2 on 09/19/24 at 2:30 PM, Employee # 2 confirmed that she did not put a barrier between nursing bag and plastic chair in Pt.#2’s home. 3. The Agency policy titled: “Exposure Control Plan: OSHA Regulations” was reviewed on 09/20/24 and required: “…..Nursing Bag Technique….2. Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used….” 4. During an interview with the Administrator and Clinical Manager on 09/20/24 11:00 AM, both confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews it was determined that in 4 of 7 (Pts # 6,1 ,2, and 5) clinical records reviewed, the Agency staff failed to provide services as ordered by the Physician. 2. Pt. #1 was admitted to Home Health Services on 10/14/22 with the Diagnosis of: Heart Failure, unspecified. The clinical record was reviewed on 09/18/24 and 09/19/24. The POC effective 08/04/24, required SN: “Notify Physician of vital sign parameters:…Heart Rate….Respirations…Systolic BP….Diastolic BP….” The SN visit note dated 08/22/24 lacked documentation of assessments for Heart rate, respirations, systolic and diastolic BP. The SN visit note dated 09/06/24, lacked documentation of a BP assessment. There was no modification of Physician orders or communication as to why assessment was not done as ordered. 3. Pt. #2 was admitted to Home Health Services on 06/03/24 with the Diagnosis of: Cerebral Infarction, Unspecified. The clinical record was reviewed on 09/19/24. The POC effective 08/02/24, required SN: “Notify Physician of vital sign parameters:….Heart Rate…Systolic BP….Diastolic BP….” The SN visit note dated 09/05/24, lacked documentation of a BP assessment. There was no modification of Physician orders or communication as to why assessment was not done as ordered. 4. Pt. # 5 was admitted to Home Health Services on 07/19/24 with the Diagnosis of: Systemic Lupus Erythematosus, Unspecified. The clinical record was reviewed on 09/18/24. The POC effective 09/17/24, required SN: “Notify Physician for vital sign parameters: ….Systolic BP….Diastolic BP….” The following SN visit notes dated: 09/29/24, 08/05/24, 08/13/24, 08/20/24, 08/29/24 and 09/10/24, lacked documentation of a BP assessment. There was no modification of Physician orders or communication as to why assessment was not done as ordered. 5. During interviews with the Clinical Manager on 09/19/24 at 2:00 PM and with the Administrator and Clinical Manager on 09/20/24 at 11:00 AM, both confirmed the above findings. Findings include: 1. Pt # 6. was admitted to Home Health Services on 03/19/24 with Diagnosis of Pressure Ulcer of Right Buttock stage 2. The clinical record was reviewed on 09/18/24. The clinical record contained a POC for certification period 03/19/24 to 05/17/24 that required SN visits 2 times a week for 9 weeks. The clinical record lacked SN visits for week of 05/08/24 (week 8).

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 Agency staff list, personnel file review, Home Health Agency license and Staff interview, it was determined that the Agency failed to ensure that the Administrator employed qualified staff to provide Home Health Aide services. Findings include: 1. On 09/19/24 at 10:15 AM, a review of Staff list and included Employee #3 (Home Health Aide / Date of Hire 02/14/24). The personnel file for Employee # 3 was reviewed on 09/19/24, included an undated printout from a public website, and an undated printout from IDPH Web Portal, indicated Employee #3, “….Competency: 04/23/2023….Result: Failed…. 2. The HHA original license number 1010766, indicated the Agency can provide Home Health Aide services. As of 09/19/24, the Agency lacked a qualified Home Health Aide to provide personal care for patients. 3. During an interview with the Administrator and Clinical Manager on 09/19/24 at 11:00 AM, the Clinical Manager stated that Employee #3 has not seen patients in the prior 12 months. On 09/19/24 at 11:00 AM, both confirmed the above findings.

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] 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: *[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: . A. Based on review of Agency's Emergency Preparedness Plan , Communication Plan, Inservice Education Binder and staff interview, it was determined the Agency failed to ensure the Communication Plan was updated and failed to ensure Training and Testing were completed. This has the potential to affect all patients receiving services. Findings Include: 1. The Agency failed to ensure the Communication Plan was updated (E0030). 2. The Agency failed to ensure Training and Testing were completed (E0036). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate direction or supervision in the event of an emergency or disaster.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the communication plan was updated. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 8/9/21 at 10:20 AM, a request was made to review the Agency's Emergency Preparedness plan. On 8/9/21 at 1:25 PM, the "Emergency Preparedness Packet" dated "01/06/2017" was presented and reviewed. On 8/12/20 at 10:20 AM, the Clinical Manager presented a different plan (a binder) and stated, "This is the Emergency Plan too, I must have missed it." A request was made to review the communication plan. As of 8/11/21, the communication plan lacked: The contact data of the direct staff, contractual staff, patients' physicians and volunteers. 2. During an interview with the Administrator on 8/12/21 at 10:20 AM, the Administrator and Clinical Manager confirmed the above finding.

EP Training and Testing CFR(s): 484.102(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, 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 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: . A. Based on review of the Agency's Emergency Preparedness plan, Inservice Education Binder and staff interview, it was determined the Agency failed to ensure Training and Testing were completed. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's "Emergency Preparedness Packet" (plan) dated "01/06/2017" was reviewed on 8/9/21 at 1:25 PM. The plan lacked any documentation the Agency had trained or tested the staff on the Agency's Emergency Preparedness plan. 2. On 8/12/21 at 10:20 AM, the Clinical Manager presented a different Emergency Preparedness Plan (a binder) last updated "2021". A request was made for staff training and testing of the Agency's Emergency Preparedness plan. As of 8/12/21, the Agency was unable to provide documentation the Agency trained and tested its Emergency Preparedness plan with its staff in 2018, 2019, 2020 and 2021. 3. The Agency's staff in-service binder was reviewed on 8/11/21 at 11:50 AM. As of 8/11/21, the binder lacked documentation the Agency had trained the staff on the Emergency Preparedness plan. 4. During an interview with the Administrator and Clinical Manager on 8/12/21 at 10:20 AM, the Administrative Staff confirmed the Agency was unable to provide documentation that staff received Emergency Preparedness plan training and testing.

. Recertification survey completed. A determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.102 Emergency Preparedness. A focused Infection Control Survey (FIC) was conducted on 8/12/21. Standard level deficiencies written. Abbreviations: w = week () = greater BP = blood pressure T = temperature MAR = Medication Administration Record TAR = Treatment Authorization Request # = number pt's = patient's AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care OASIS= Outcome and Assessment Information Set PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist COVID-19 = Coronavirus Disease 2019

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: . A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure informed consents contained the disciplines that will furnish care and the frequency of visits. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 8/10/21 at 11:36am to 8/11/21 at 2:15 PM. Pt. #1 SOC: 07/29/21 Pt. #2 SOC: 08/04/21 Pt. #3 SOC: 07/28/21 Pt. #4 SOC: 07/30/21 Pt. #5 SOC: 08/03/21 Pt. #6 SOC: 12/29/20 Pt. #7 SOC: 01/12/21 The records lacked documentation of patient consenting to the disciplines that will furnish care and the frequency of visits. 2. During an interview with the Administrator and the Clinical Manager on 8/12/20 from 10:15 AM to 12:00 PM, the Administrative Staff confirmed records lacked documentation of patients' consent to services to be provided prior to SOC.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 6 of 7 (Pts. #1, 2, 7, 3, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 7/29/21. Primary Diagnosis: Unspecified Heart Failure. The clinical record was reviewed on 8/11/21 at 1:40 PM. The record contained 2 referrals for services. First, a referral dated 6/17/21 from an inpatient facility which included: "Clinical information for Patient...D/C on 6/15/21". Secondly, a Face-to-Face form completed by the Physician Assistant and dated 7/7/21, requiring the Pt. to have SN and PT services. The SOC comprehensive assessment form completed by the RN was dated 7/29/21 (42 days after the first referral and 42 days after the second referral). As of 8/11/21, the record lacked documentation the Agency initiated service within 48 hours of either referral. 2. Pt. #2. SOC 8/4/21. Primary Diagnosis: Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 8/11/21 at 2:15 PM. The record contained a referral dated 7/29/21 from an inpatient facility that included, a Physician order for the Agency to provide a "nurse and physical therapy". The SOC comprehensive assessment form completed by the RN was dated 8/4/21 (6 days after the referral was received). As of 8/11/21, the record lacked documentation the Agency initiated service within 48 hours after receipt of the referral. 3. Pt. #7. SOC 1/12/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 8/11/21 at 10:20 AM. The record contained a referral dated 1/8/21 from an inpatient facility included: "Agency Names... and Date for each one arranged... Home Health... Provided copies of MARs & TARs as of : 01/08/2021". , a Physician order for the Agency to provide a "nurse and physical therapy". The SOC comprehensive assessment form completed by the RN was dated 1/12/21 (4 days after the referral was received). As of 8/11/21, the record lacked documentation the Agency initiated service within 48 hours after receipt of the referral. . 4. Pt. #3. SOC 7/28/21. Diagnosis: Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 8/9/21 at 11:36 AM. The record included the SOC comprehensive assessment dated 7/28/21 which included, the referral date of 7/20/21. The record lacked a Physician ordered SOC date or documentation of discharge date from an inpatient facility. As of 8/12/21, the Agency failed to start service within 48 hours of the referral date. 5. Pt #4. SOC 7/30/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/11/21 at 10:55 AM. The record included the SOC comprehensive assessment dated 7/30/21 which included, the referral date of 7/20/21. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 8/12/21, the Agency failed to start service within 48 hours of the referral date. 6. Pt #5. SOC 8/3/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/11/21 at 11:45 AM. The record included the SOC comprehensive assessment dated 8/3/21 which included, a Pt. profile, with referral date of 7/15/21. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 8/12/21, the Agency failed to start service within 48 hours of the referral date. 7. During an interview with the Administrator and the Clinical Manager on 8/12/20 from 10:15 AM to 12:00 PM, the Administrative Staff confirmed the initial assessment visits were conducted, after 48 hours of the referral date.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service as ordered by the Physician and/or indicated on the POC. This was found in 2 of 7 (Pts. #6 and 7) clinical records reviewed. Findings include: 1. Pt. #6. SOC 12/29/20. Primary Diagnosis: Acute Diastolic (Congestive) Heart Failure. The closed clinical record was reviewed on 8/11/21 at 11:10 AM. The record contained the referral dated 12/28/20 from an inpatient facility, whereas the Physician ordered: "Skilled Nursing, Physical Therapy, Occupational Therapy". As of 8/11/21, the record lacked documentation the Agency offered or provided Physical Therapy and Occupational Therapy. The POC for the certification period of 12/29/20 to 2/26/21 required: "1week1, Physical Therapy evaluation..." As indicated above the record lacked documentation the Agency offered or provided Physical Therapy. 2. Pt. #7. SOC 1/12/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 8/11/21 at 10:20 AM. The record contained the POC for the certification period of 1/12/21 to 3/12/21 required, "SN Frequency: 1w9". The record lacked documentation the SN provided service during the week of 2/14/21 to 2/20/21. The POC effective 1/12/21 required, "Notify Physician of vital sign parameters out of range: Heart Rate: Greater Than (>) 100 Less Than () 100.5 Less Than () 30 Less Than () 180 Less Than () 100 Less Than (<) 60". The SN visit note date 2/4/21 lacked any vital signs to assess whether out of range. The POC effective 1/12/21 required, "HHA Frequency: 2w9". The record lacked documentation the HHA provided any service after 2/11/21. 3. During an interview with the Administrator and the Clinical Manager (Administrative Staff) on 8/12/21 at 10:15 AM, the Administrative Staff confirmed service was not provided as ordered by the Physician and/or indicated on the POC.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff conducted Pt. immunization screening at the SOC, as required by the Agency. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 8/10/21 at 11:36 AM to 8/11/21 at 2:15 PM and contained: Pt. #1. SOC comprehensive assessment dated 07/29/21. Pt. #2. SOC comprehensive assessment dated 08/04/21. Pt. #3. SOC comprehensive assessment dated 07/28/21. Pt. #4. SOC comprehensive assessment dated 07/30/21. Pt. #5. SOC comprehensive assessment dated 08/03/21. Pt. #6. SOC comprehensive assessment dated 12/28/20. Pt. #7. SOC comprehensive assessment dated 01/12/21. Each SOC comprehensive assessment lacked an inquiry regarding the patient's Influenza and Pneumococcal Pneumonia status, as required by the Agency. 2. During the entrance interview with the Clinical Manager on 8/9/21 at 10:20 AM. The Clinical Manager stated Agency staff are required to ask patient's their Influenza and Pneumococcal Pneumonia status at the SOC, and this information is documented in the "SOC OASIS" (SOC comprehensive assessment). Staff also re-inquire during the "Flu (Influenza) season". 3. During an interview with the Administrator and the Clinical Manager on 8/12/21 from 10:15 AM to 12:00 PM, the Administrative Staff confirmed the SOC comprehensive assessments lacked an assessment of the patient's Influenza and Pneumococcal Pneumonia status.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff screened Pts. for COVID-19, prior to providing Pt. care and services. This was found in 2 of 7 (Pts. #7 and 2) clinical records reviewed. Findings include: 1. Pt. #7. SOC 1/12/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 8/11/21 at 10:20 AM. The record contained the PT visit note dated 2/8/21, PT Reassessment/Re-Evaluation forms dated 2/17/21 and 3/10/21. The Agency lacked documentation the PT screened the Pt. for COVID-19 symptoms, prior to providing service on 1/18/21, 2/8/21, 2/17/21 and 3/10/21. . 2. Pt #4. SOC 7/30/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/11/21 at 10:55 AM. The record lacked documentation the SN screened Pt. #4 for signs and symptoms of COVID-19, prior to the SOC visit on 7/30/21. 3. During an interview with the Administrator and the Clinical Manager on 8/12/21 from 10:15 AM to 12:00 PM, the Administrative Staff confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 12/29/20. Primary Diagnosis: Acute Diastolic (Congestive) Heart Failure. The closed clinical record was reviewed on 8/11/21 at 11:10 AM. The record/Agency lacked documentation a copy of the Discharge Summary to the Physician. Pt. #2 was discharged from the Agency on 2/26/21. 2. Pt. #7. SOC 1/12/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 8/11/21 at 10:20 AM. The record/Agency lacked documentation a copy of the Discharge Summary to the Physician. Pt. #2 was discharged from the Agency on 5/11/21. 3. During an interview with the Administrator and Clinical Manager on 8/12/21 at 10:20 AM, the Clinical Manager was unable to provide documentation a copy of the Discharge Summary was sent to the Physician.