Every finding on record at New Glorious Home Health Inc

Purpose of visit: Recertification/Relicensure Survey Entrance: 06/07/2022 The agency's census was: L&C-33 LHHS-0 PAS-0 Exit: 06/08/2022 An entrance conference was conducted on 06/07/2022 at 9:49 AM with the Administrator and Alternate Administrator/ADON. The agency was informed that the purpose of the survey was to conduct a Recertification/Relicensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 06/08/2022 at 4:15 PM with the Administrator and Director of Nurses. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Emergency Preparedness plan (EPP)

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 comply with all Federal and State emergency preparedness requirements, in that: The hospice agency did not conduct an annual review of their emergency preparedness plan (EPP) for the calendar years 2020 and 2021. This failure placed the agency patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. Findings included: Record review of the EPP documents provided by the agency revealed there were no records to confirm that a review and update of the EPP for the years 2020 and 2021. During an interview on 06/08/22 at 1:27 p.m. with the Alternate Administrator/Alternate Director of Nursing, the Surveyor presented the above findings. The Alternate Administrator/Alternate Director of Nursing confirmed the most current EPP update was completed 2019. The Alternate Administrator/Alternate Director of Nursing stated,” The agency now have new management and we are in the process of updating the Emergency Preparedness Program. The surveyor asked when the new management assigned. The Alternate Administrator/Alternate Director of Nursing stated, “March 2022. We are having a drill today due to the dangerously high temperatures.” The Alternate Administrator/Alternate Director of Nursing agreed the staff and clients might not know what to do in a specific emergency if procedures had changed and the plan was not updated. The agency performed a EPP drill during the survey. Agency policy titled " 1.34: EMERGENCY DISASTER PLAN", undated, read in part: " ... .... PROCEDURE 1. A comprehensive emergency plan is prepared and updated annually.”

Purpose of visit: Recertification/Relicensure Survey Entrance: 06/07/2022 The agency's census was: L&C-33 LHHS-0 PAS-0 Exit: 06/08/2022 An entrance conference was conducted on 06/07/2022 at 9:49 AM with the Administrator and Alternate Administrator/ADON. The agency was informed that the purpose of the survey was to conduct a Recertification/Relicensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 06/08/2022 at 4:15 PM with the Administrator and Director of Nurses. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI). Emergency Preparedness plan (EPP)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce their written policy regarding coordination of services in one (Client Patient #5) of one record reviewed in which the client patient was dependent on out-patient renal dialysis. This failure placed Client #5 at risk of receiving inappropriate care. Findings include: Clinical Record #5 Review of the clinical record revealed a Plan of Care digitally signed and dated by the Assistant Director of Nursing on 3/13/2022, read in part,” Start of Care …Primary Diagnosis Heart Failure, Unspecified…. Orders for Discipline and Treatments….2. Patient goes for Hemodialysis every Monday, Wednesday, Friday…. The record contained a form titled “Referral Note for Client #5” read in part,"…. Most Recent Encounter 02/09/2022…Plan of Treatment…. Lab…. Patient goes to dialysis on M, W, F…. Problems…. Renal dialysis Active 06/0/2018…. The record also contained a form titled "Referral Order, from a clinic (Clinic A), dated and digitally signed by the Referring Provider (Nurse Practitioner A) on 2/12/2022. The form read in part,"…. Problems…...Renal Dialysis – Onset 06/05/2018." There was no evidence of coordination of care with the dialysis provider. On 06/08/2022 at approximately 1:05 p.m. during an interview with the Administrator and Alternate Administrator/Alternate Director of Nursing, the surveyor asked for the name and location of the dialysis provider Patient #5 attended on Mondays, Wednesdays, and Fridays. The Administrator and Alternate Administrator/Alternate Director of Nursing both answered that they didn’t know the name of the dialysis provider or the location. The surveyor asked where documentation of coordination of care with the dialysis provider could be found in the clinical record. The Administrator stated, "We don't have any coordination of care documented." The surveyor asked if the agency contacted the dialysis provider upon the admission of Client #5 to coordinate care. The Administrator stated "No." Asked how no coordination of care with the dialysis center could affect the client outcomes. The Administrator stated, "It could cause inconsistent care." The Agency's policy titled "Policy 4.18: Coordination of Services" undated, read in part, " .... Procedure……. 12. In an effort to provide coordinated services with the client, family and all other clinicians….to support the goals outlined in the plan of care and to achieve client outcomes…."

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain Quality Assessment Performance Improvement (QAPI) program that was on-going and focused on measurable client outcomes in calendar years 2020 and 2021. This failure has the potential to place the agency's patients at risk of receiving inadequate care and services due to the agency's inability identify potential problems and implement corrective actions to ensure the health and safety of patients. FINDINGS INCLUDED: QAPI binder review: 1. The binder did not contain an annual evaluation of the QAPI program for 2020 and 2021. 2. The binder did not contain any reports, reviews nor documentation that indicated the agency had maintained an QAPI program that included the regulatory requirements, for the year 2020. The binder did not indicate that the agency had conducted: 1. An analysis of a representative sample of services furnished to clients contained in both active and closed records. 2. A review of negative client care outcomes; 3. A review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed 4. A review of infection control activities; 5. A review of effectiveness and safety of all services provided, including: (-a-) the competency of the agency's clinical staff; (-b-) the promptness of service delivery; and (-c-) the appropriateness of the agency's responses to client complaints and incidents; 6. A determination that services had been performed as outlined in the individualized service plan, and 7. An analysis of client complaint and satisfaction survey data; and 8. An annual evaluation of the total operation, including services provided under contract or arrangement. (-a-) Used the evaluation to correct identified problems and, if necessary, revised policies. (-b-) Documentation of corrective action that ensured improvements were sustained over time. In an interview on 0608/22 with the Alternate Administrator/Alternate Director of Nursing at 2:05 p.m., the surveyor reviewed the findings regarding the lack of at least two QAPI Committee meetings per year in calendar years 2020 and 2021. The Alternate Administrator/Alternate Director of Nursing stated, “The previous management didn’t follow the agency policies and procedures. Now that the agency’s new management have already had scheduled one meeting so far. The consultant is in the process of reviewing clinical records for compliance.” The surveyor asked the effect of non-compliance of QAPI activities on clients, the Alternate Administrator/Alternate Director of Nursing stated the agency would not be able to identify trends and issues which could affect client care. Record review of agency policy titled, "Policy 5.0: Quality Assessment Performance Improvement Program," undated, read in part, "Policy: The performance improvement activities are in collaborative, interdisciplinary manner throughout the organization. 2. Meets quarterly…3. Provides minutes…."