Every finding on record at Oasis Hh Operations LLC

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on August 21-23 2023 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found not to be in compliance with 42 CFR 484.102 the Conditions of Participation: Emergency Preparedness for Home Health Agencies. Significant corrections are required for the substantial noncompliance identified and cited at the condition level for Establishing the Emergency Preparedness Program.

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, §485.542, §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 interviews and agency document reviews, it was determined the agency failed to develop an emergency preparedness program specific to the agency and failed to meet the requirements of: (1) a risk assessment and emergency preparedness plan, (2) required policies and procedures, (3) training of staff, and (4) testing and exercises of the plan. Due to the systemic nature of the deficiencies related to the development of an emergency preparedness program, it was determined the clinic staff failed to substantially comply with the Conditions of Participation for Home Health Agencies.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and review of the agency's emergency preparedness (EP) program, it was identified that the agency failed to maintain an emergency preparedness plan that was reviewed and updated every two years. The Findings: On 08/21-22/2023, the agency's emergency preparedness (EP) program plan and policies were reviewed in the agency. The agency provided the surveyor with a binder labeled, Meeting Minutes, agendas, and attendee signatures. A document labeled, "Company Meeting, Emergency Preparedness 12/20/22" however there was evidence of the EP policies and procedures were updated. On 08/22/2023 the Administrator confirmed the EP plan and policies have not been updated since last survey of 2020. The agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every two years. On 08/23/2023, at 1:15 PM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above noted findings

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), §485.542(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 staff interview and the agency's emergency preparedness (EP) program it was determined the agency's emergency preparedness plan failed to review and update the all-hazard approach to include emerging infectious disease threats. The findings: The agency's emergency preparedness (EP) program was reviewed in the agency on 08/21-22/2023. The EP failed to contain an all-hazard approach based on a community-based risk assessment to include identification of any specific emerging infectious disease threats that offered strategies that would affect the home health’s ability to be prepared for surge events. The lack of the above noted information was reviewed and acknowledged with the Administrator prior to and during the exit conference conducted in the agency on 08/223/2023.

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), §485.542(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 interview and review of the agency's emergency preparedness (EP) program it was revealed that the agency failed to have a process for cooperation and collaboration with local, regional state and federal emergency preparedness officials efforts to maintain an integrated response during a disaster/emergency situation. The Findings: On 08/21-22/2023, the agency's emergency preparedness (EP) program plan and policies were reviewed in the agency. The agency's EP policies and procedures failed to contain a process for emergency preparedness officials to maintain an integrated response if a situation arises. At a minimum the agency's EP contained a list of phone numbers of local, state and federal emergency officials from 2020. On 08/23/2022 at 12 PM the Administrator confirmed s(h)e was unable to follow up on the EP program plan since becoming the Administrator a few weeks ago.

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), §485.542(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 interview and review of the agency's emergency preparedness (EP) program it was revealed that the agency failed to have evidence that the policies and procedures included a risk assessment and a communication plan. On 08/21-22/2023, the agency's emergency preparedness (EP) program policies were reviewed in the agency. The The agency's emergency preparedness (EP) program failed to have evidence the policies and procedures included an up-to-date risk assessment and a communication plan. On 08/23/2023, at 1:15 PM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and review of the agency's emergency preparedness (EP) program it was determined the agency failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. The Findings: On 08/21-22/2023, the agency's emergency preparedness (EP) program policies were reviewed in the agency. The agency's polices failed to contain evidence within the EP policies the procedure to inform State and local officials of any on-duty staff or patients that they are unable to contact. On 08/23/2023 at 1:15 PM an interview was conducted with the Administrator, in the agency. The Administrator acknowledged the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on staff interview and review of the agency's emergency preparedness (EP) program, it was determined the agency failed to include the names and contact information for the following in their emergency preparedness communication plan: (1) Staff. (2) Entities providing services under arrangement. (3) Other agencies (4) Volunteers. The Findings: On 08/21-22/2023, the agency's emergency preparedness (EP) program plan and policies were reviewed in the agency. The communication plan failed to contain agency contact information on the following: staff, entities providing services under arrangement, other agencies and volunteers. At a minimum, the agency contained the patient's physician name and contact information. On 08/23/2023, at 1:15 PM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above noted findings.

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), §485.542(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 staff interview and document review, it was determined the agency failed to develop and maintain an emergency preparedness communication plan to include all of the following: Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. The Findings: On 08/21-22/2023, the agency's emergency preparedness (EP) program plan and policies were reviewed in the agency. The communication plan failed to contain a primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. On 08/23/2023, at 1:15 PM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above noted findings.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure its emergency preparedness plan contained a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. The agency's emergency preparedness plan was reviewed in the agency 08/21/23 - 08/23/23. The emergency preparedness plan failed to contain a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. An interview was conducted with the agency's Administrator on 08/23/23 who confirmed the plan did not contain the above noted elements.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the agency's emergency preparedness plan failed to include a means of providing information about its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The agency's emergency preparedness plan was reviewed 08/21/23-08/23/23. The emergency preparedness plan failed to contain information related to a means of providing information about its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. An interview was conducted with the Administrator who confirmed the absence of the above noted information on 08/23/23.

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), §485.542(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, REHs at §485.542, 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 document review, policy and procedure review, and staff interview, it was determined the agency failed to conduct and document annual testing of the emergency preparedness plan (EPP). The surveyor requested the agency's Emergency Preparedness Materials to include training and testing exercises on 08/21/23 at 10:30 AM. At 3:05 PM on 08/21/23 the agency provided the surveyor with a binder labeled, Meeting Minutes, agendas, and attendee signatures. A document labeled, "Company Meeting, Emergency Preparedness 12/20/22" contained four (4) signatures. The document and binder failed to contain documentation of what was discussed during the meeting or what if any emergency testing exercise or drill was performed. The binder contained a document titled, Meeting Agenda May 16, 2022 that read in part: "EPP must keep current and have clinicians return paperwork with 48 hours of admission all patients including waiver and folder updates daily with initials on first page." No other information related to emergency preparedness was documented.

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), §485.542(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, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness (EP) program and staff interview it was determined the agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan. The findings: The agency's emergency preparedness (EP) program was reviewed in the agency on 08/21/2023. The agency’s EP binder contained a form in the front of the binder labeled “Meeting Minutes, agendas, and attendee signatures". A document labeled, "Company Meeting, Emergency Preparedness 12/20/22" contained four (4) signatures. The document and binder failed to contain documentation of the staff’s ability to demonstrate knowledge of the agency emergency preparedness plan. On 08/22/2023 at 1:40 PM the Medical Facilities Inspector (MFI) requested any documentation that demonstrated the staff’s knowledge on the emergency preparedness plan. The Administrator stated "We won't find it". The failure to maintain documentation of the staff’s ability to demonstrate knowledge of the agency’s emergency plan was acknowledged by the Administrator during the review of the agency’s EP and again during the exit conference conducted in the agency on 08/23/2023.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined the agency failed to conduct an additional emergency preparedness exercise to test their emergency plan at least annually. The agency's emergency preparedness plan was reviewed in the agency 08/21/23 - 08/23/23. The agency's emergency preparedness plan contained documentation of a table top exercise on 03/31/2022, however the emergency plan failed to contain documentation of an additional emergency preparedness exercise for 2021 that may have included, but was not limited to the following: a second full-scale exercise that is community-based or individual, an actual natural emergency that required the activation of the emergency plan and a set of problem statements, directed messages, or prepared questions designed to challenge their emergency plan and analysis of the agency's response to and revision of the agency's emergency plan, as needed. An interview was conducted in the agency on 08/23/2023 at 1:20 PM with the Administrator and stated, "It may be locked up" (regarding exercise for 2021). The lack of the above noted information was acknowledged by the Administrator prior to the exit and during the exit conference conducted in the agency on 08/23/2023.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on August 21-23, 2023 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. The agency reported 278 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of seven (7) patients, (11) personnel files, an agency admission packet, the complaint log and three (3) home visits and staff interviews were conducted. The agency operates a drop site and was visited by the MFI on August 22, 2023. The drop site's address is: 900 South Washington Street Ste 209 Falls Church, VA 22046 The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Significant corrections are required for the substantial non-compliance of the following Conditions of Participation: 484.60 Care planning, coordination of services, and quality of care; 484.65 Quality assessment and performance improvement; 484.70 Infection Prevention and Control; 484.105 Organization and administration of services. The following are repeat condition-level deficiencies previously identified in the recertification survey conducted in December 2020 that were again cited during this survey: care planning, coordination of services, and quality of care; Quality assessment and performance improvement; and organization and administration of services.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on a review of medical records and the agency's admission packet, it was determined the agency failed to ensure staff that have on-going contact with patients who have language barriers, should be trained in effective communication techniques, including the effective use of an interpreter for one (1) of (2) patients in the survey sample identified with a language barrier. Medical record #2. The Findings: Seven (7) medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #2 was reviewed for the certification period 08/04/23 to 10/02/23. The skilled nurse notes of 08/11/23 and 08/16/23 documented google translate was used for Vietnamese due to family was not at visit. The agency's policy, Non-Discrimination Policy and Procedure located in the patient orientation brochure partially reads as follows: "Bi-Lingual Interpretation Services Available At No Cost. Your ability to be understood is important to us! As part of your ongoing effort to ensure your needs are met, we provide interpretive services at no cost to you or your family. Please let us know if you are having problems communicating with us" An interview was conducted with the Administrator on 08/23/23 who confirmed no interpretation services for the agency.

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 medical record reviews, it was determined the agency failed to ensure that patients were informed about and consented to the frequency of proposed visits in advance of starting care in one (1) of seven (7) medical records reviewed in the survey sample. Medical Record # 1. The Findings: Seven (7) medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #1 was reviewed for the recertification period of 04/03/2023 to 06/01/2023. Patient #1's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however it was left blank. Patient #1's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The above noted findings regarding the lack of providing patients a written notice in advance of the proposed frequencies of disciplines to furnish care was acknowledged by the Administrator during the exit conference conducted on 8/23/2023.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure patients were advised of the names, address, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Aging and Disability Resource Center, and Quality Improvement Organization. The agency's admission package materials were reviewed 08/21/23. The admission package provided by the agency failed to contain the following elements: the names, address, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides: Agency on Aging, Center for Independent Living, Aging and Disability Resource Center, and Quality Improvement Organization. An interview was conducted with the Administrator on 08/23/23 who confirmed the admission package was missing the required contact information and that the agency was not currently providing patients with the required contact information for the state and federally funded entities.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure documentation of the existence of and the resolution to each patient complaint. Additionally, the agency failed to ensure it followed its own complaint handling policies in one (1) of one (1) complaint reviewed in the survey sample. Findings: The agency's complaint log was reviewed 08/21/23. The complaint log contained no documented complaints for 2022 or 2023. The last complaint logged was documented on 06/23/21 as "nursing care." The resolution was documented as "ordered supplies. Skilled nurse visited patient on 06/23." The complaint documentation did not contain further information related to the nature of the complaint, the investigation of the complaint, or notification to the complainant of the proposed resolution. The agency's policy, Handling Consumer Complaints Policy and Procedures was reviewed and reads in part, "Oasis established and maintains consumer complaint handling policies and procedures which includes the: System for logging receipt, investigation, and resolution of complaints. Written record of the findings of each complaint investigated. The nursing supervisor is designed [sic] staff responsible for complaint resolution including: Complain [sic] intake, including acknowledgement of complaints. Investigation of complaints. Review of the investigation of findings and resolution of the complaint. Notification to the complainant of the proposed resolution with [sic] 30 days from the date of receipt of the complaint." The above noted complaint handling deficiency was discussed with the Administrator on 08/23/23 who confirmed the absence of the required elements when documenting a complaint.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on staff interview, observation, and document review, it was determined the agency failed to ensure each patient had a complete and accurate medication profile in two (2) of seven (7) medical records reviewed in the survey sample. Medical Record #'s 1 and 5. Findings: Seven (7) medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #5 was reviewed for the certification period 07/03/23 to 08/31/23. The patient's medication profile contained on order for Quetiapine 200 mg one tablet daily and Quetiapine 200 mg two tablets daily. The medication profile did not contain further instructions regarding the timing of the different doses of the medication. A home visit was conducted with patient #5 and staff member #2 on 08/22/23 at 2:45 PM. Staff member #2 filled the patient's pill box with medications to include Haldol and Gabapentin. These medications were not listed on the patient medication profile. Staff member #2 did not consult the patient's medication profile when filling the medication box. An interview was conducted with staff member #2 regarding the patient's Quetiapine dose prior to the home visit. The staff member stated the patient took two tablets in the evening and one tablet in the morning. Staff member #2 confirmed this information was not documented on the medication profile. Staff member #2 stated she read the directions on the pill blister packs when filling the pill box. An interview was conducted with the Administrator on 08/23/23 regarding the expectation of keeping a current medication profile and filling a medication box for a patient. The Administrator stated that a medication reconciliation should be completed each visit and the medication profile should be updated with changes at each visit as applicable. The surveyor asked the nurse what list the nurse should consult or how the nurse would know what medications to fill the patient's pill box with and what the agency's expectation is when there is a discrepancy between the medication profile and the medications present in the patient's home. The Administrator stated the nurse should have called the doctor to ensure the medication profile was accurate prior to filling the patient's pill box. The medical record for patient #1 was reviewed for the recertification period 04/03/23 to 06/01/23. The skilled nurse note of 04/06/23 documented the patient has a tracheostomy that the caregiver manages on oxygen at 2 lpm (liter per minute). The medication profile did not contain oxygen at 2 lpm. On 08/23/2023 the Administrator provided the surveyors with the medication profile policy and procedure. The agency's policy, Medication Profile partially read as follows: "The agency provides a mechanism for documentation of patient prescriptions, nonprescription (over the counter) medications and home remedies, including vitamins and herbs. The nurse or therapist will add all new/changed medication(s) to the medication profile. The medication profile will be reviewed every home visit and updated as changes occur".

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on staff interview and clinical record review it was determined the agency failed to ensure adequate care planning for patients. The agency failed to ensure that each patient's plan of care was individualized, complete, and accurate (refer to G572); failed to ensure all patients' individualized plans of care included all medication and treatments and the types of supplies and equipment required (refer to G574). The cumulative effect of this systemic problem resulted in the agency's inability to adequately meet the patient's medical, nursing, rehabilitative and social needs.

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: Based on review of medical records and staff interview it was determined the agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for two (2) out of seven (7) medical records in the survey sample. Medical record #s 3 and 5. The Findings: Seven (7) medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #3 was reviewed for the certification period 06/19/23 to 08/17/23. The plan of care contained skilled nurse orders for parameters to notify physician: Blood Pressure The medical record for patient #5 was reviewed for the certification period 07/03/23 to 08/31/23. The plan of care contained skilled nurse orders for medication management and blood sugar monitoring. The medical record failed to document blood sugar monitoring for this entire certification period. In addition, the skilled nurse documented visits on 07/05/23 and 07/24/23 whereas the patient was not home and the skilled nurse filled the medication box. These visits are considered missed visits since the patient was not home. The clinical record failed to contain missed visits documentation or notification to the physician of the missed visits. On 08/22/2023 at 12 PM, the Administrator stated, "The blood sugars maybe written down in a book at the patient's house and those two visits should have been counted as missed visits". A home visit was conducted with patient #5 and staff member #2 on 08/22/23 at 2:45 PM. The surveyor confirmed there was no documentation of blood sugar monitoring in the home.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy and procedure review, it was determined the agency failed to include all required elements on each patient's individualized plan of care. Specifically, the agency failed to include a type of foley catheter, size and how often to change with instructions on the plan of care for one (1) of one (1) patient receiving foley catheter care in the survey sample. Medical Record #1. The Findings: Seven (7) medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #1 was reviewed for the recertification period 04/03/23 to 06/01/23. The plan of care contained order for a skilled “nurse to change foley catheter size FR ____ml balloon to change every wks (weeks) and prn for malfunction”. On 08/22/23 at 8:55 AM, the surveyor asked the Administrator to fill in the blanks of what should be on the plan of care regarding the catheter. The Administrator stated, “It is a suprapubic catheter 16 French with 5 cc added to the balloon and changed every month and as needed”. On 08/23/2023 the Administrator provided the surveyors with the plan of care policy and procedure. The agency's policy, Plan of Care-CMS #485 and Physician Orders partially read as follows: "The individualized written plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment. The individualized plan of care must include the following: The types of services, supplies and equipment required". The above orders failed to specify the type of foley catheter, size, routine change frequency and instructions for malfunction.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on document review and staff interview, it was determined the agency's QAPI program failed to show measurable improvement (refer to G642); failed to ensure its QAPI program resulted in sustained improvements to its performance and failed to conduct performance improvement projects (refer to G658) and the agency's governing body failed to ensure resources were available to implement and maintain quality improvement activities (refer to G660). In the agency's previous two (2) recertification surveys (2017 and 2020) condition-level deficiencies were identified and cited at care planning, coordination of services, and quality of care and were again identified as condition level deficiencies during the current survey for the third consecutive time. Additionally, two Condition level findings related to organizational management and quality assessment and performance improvement were identified in the previous recertification survey and again during the current survey. Multiple deficiencies with the agency's emergency preparedness program have been identified and cited during each recertification survey since 2017 and the initiation of the Emergency Preparedness regulations for Home Health Agencies. The agency failed to provide evidence that its QAPI program addressed high-risk and problem-prone areas, that the corrective actions identified during the plan of correction resulting from previous survey findings were integrated into the agency's QAPI program, and that sustained improvements occurred as a result of performance improvement actions, or that performance improvement projects conducted in the last three years were amended when improved performance was not achieved. The cumulative effect of the lack of an effective, ongoing, Agency-wide, data-driven QAPI program resulted in the agency's failure to identify and correct areas of concern and to improve upon substandard practices. This failure affected the agency's ability to provide quality care to its patients.

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 document review and staff interview, it was determined the agency's QAPI program failed to show measurable improvement. Specifically, the agency failed to address areas of concern identified during the previous recertification survey in 2020 where condition-level deficiencies were cited. Findings: The MFI requested the agency's QAPI program documentation for review. The MFI received documentation titled, Data Collection Tool: QAPI Project. The documentation indicated the QAPI project was: All Patients Will Have an Individual Emergency Preparedness Plan. The tool indicated that ten charts were audited in January 2022 for the presence of an Emergency Plan. The agency also produced a document to track chart reviews. The document was labeled 2023 with no additional date information and indicated seven (7) charts had been audited. The following condition level deficiencies were identified in the 2020 Recertification survey: 484.60 Care planning, coordination of services, and quality of care; 484.65 Quality assessment and performance improvement; and 484.105 Organization and administration of services. The facility's QAPI program failed to include or address performance improvement activities aimed at correcting these deficiencies. The MFI interviewed the Administrator regarding the agency's QAPI program on 08/23/23. The MFI asked the Administrator about the facility's current QAPI project. The Administrator stated the agency selected the high risk, problem prone area of the individual emergency preparedness plan as the current project. The administrator acknowledged this was the same project the agency documented in 2021 and 2022. The agency produced no further documentation related to QAPI activities to include QAPI activities directed toward the previously cited condition level deficient practices. .

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 staff interview and document review, it was determined the agency's QAPI program failed to conduct Performance Improvement Projects (PIPs) each year. Specifically, the agency's PIPs were not modified from year to year or in response to desired outcomes not being achieved. Findings: The MFI requested the agency's QAPI program documentation for review. The MFI received documentation titled, Data Collection Tool: QAPI Project. The documentation indicated the QAPI project was: All Patients Will Have an Individual Emergency Preparedness Plan. The tool indicated that ten charts were audited in January 2022 for the presence of an Emergency Plan. The agency also produced a document to track chart reviews. The document was labeled 2023 with no additional date information and indicated seven (7) charts had been audited. The MFI interviewed the Administrator regarding the agency's QAPI program on 08/23/23. The MFI asked the Administrator about the facility's current QAPI project. The Administrator stated the agency selected the high risk, problem prone area of the individual emergency preparedness plan as the current project. The administrator acknowledged this was the same project the agency documented in 2021 and 2022. The agency had no documentation of what activities were implemented to improve compliance with staff members completing the emergency preparedness plan for patients. The agency had no documentation of what the desired outcome of the project was. The agency had no documentation of the outcome of the project. The Administrator was interviewed regarding the current performance improvement project (PIP). The administrator stated charts were audited for the presence of an Emergency Plan for patients. Clinicians were sent email reminders if the plan was not completed. The MFI asked the administrator about the results of the project. The Administrator stated there was some improvement, then less improvement, and recently more improvement. The Administrator confirmed the same project was selected for the last three years and could produce no documentation that interventions related to the project had been amended when improvement activities were not sustained. .

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the facility failed to ensure the agency's quality improvement program was defined, implemented, and maintained. Findings: The agency's quality assessment performance improvement (QAPI) materials were reviewed 08/23/23. Limited quality improvement activities were conducted in 2021, 2022, and thus far in 2023 (refer to G642 and G658). Additionally, all Registered Nurses, Physical Therapists, Occupational Therapists with the exception of the agency's Administrator were employed as contractors of the agency (refer to G982). The agency had no predesignated person to act in the absence of the Administrator (refer to G954). The agency had very limited personnel to participate in quality improvement activities to include no clinical personnel employed directly by the agency. An interview was conducted with the Administrator regarding quality improvement activities on 08/23/23. The Administrator stated that the lack of directly employed staff and the status of all skilled personnel as contractors limited quality improvement activities that could be conducted and that contracted staff were not as invested in the agency as directly employed personnel might be. The governing body failed to employ an adequate type and number of skilled personnel to implement and maintain a quality improvement 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 staff interview and document review, it was determined the agency failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. Specifically, the agency failed to use standard precautions to prevent the transmission of infections and communicable diseases to include appropriate sharps disposal (refer to G682); failed to maintain an agency wide infection control program that included a method for identifying infectious and communicable diseases (refer to G684); and failed to provide infection prevention and control education to employees (refer to G686). The cumulative effect of this systemic problem resulted in the agency's potential inability to prevent and control infections in agency staff, its patients, and the general public.

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 and staff interview, it was determined the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. Specifically, the agency failed to minimize potential infectious exposure by failing to ensure patients disposed of used sharps appropriately in one (1) of one (1) home visits conducted involving the use of a medical sharp. Findings: A home visit was conducted to patient #6 on 08/22/23 at 2:45 PM. During the home visit, the Registered Nurse (staff member #2) instructed the patient to take her blood glucose level. The patient removed her glucometer, lancet, and testing strip from a soft storage pouch. The patient stuck her finger with the sharp lancet and put a drop of blood on the test strip. The lancet was not retractable and had no safety feature with an exposed blade. The patient then put the used lancet back into the soft storage pouch with other used lancets with exposed blades and unused lancets and zipped the pouch. There was no sharps disposal box or impervious container to dispose of the sharps in any view of the surveyor. The Registered Nurse did not intervene or advise the patient on proper sharps disposal after the patient put the used lancet back into the soft pouch. The patient's personal care aide then came to the patient's table and placed her hand on top of the soft pouch housing the used, exposed blade lancets potentially placing the aide at risk for exposure to bloodborne pathogens. At no point during the visit did the Registered Nurse provide education to the patient or the personal care aide regarding proper sharps disposal. An interview was conducted with the Administrator following the home visit on 08/22/23. The Administrator confirmed used sharps should not be placed back into a soft container with clean equipment. The Administrator stated the lancet should have been placed into a sharps container. The Administrator stated the patient is forgetful and likely had been provided education on sharps disposal in the past but may have forgotten. The surveyor informed the Administrator there was no sharps container in the proximity of the patient during the visit.

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 staff interview and document review, it was determined the agency failed to ensure it established and maintained 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. Findings: An interview was conducted with the agency's Administrator on 08/23/23 regarding infection prevention and control. The information from the quality assessment performance improvement (QAPI) program reviewed by the surveyors failed to contain documentation related to infection control and prevention. The Administrator stated that the facility tracked employee infections, but the tracking was limited to COVID-19 infections. The Administrator stated the agency tracked patient infections, but no tracking information was presented to the surveyors. During record review, patient #7 was identified as having an active infection and receiving intravenous antibiotics. The facility's QAPI program did not contain a plan for appropriate actions that are expected to result in improvement and disease prevention. The Administrator acknowledged the above noted deficiency during the exit conference on 08/23/23.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on personnel file review, and staff interview, it was determined that the agency failed to provide infection control education to their staff for seven (7) of (11) personnel files reviewed for which infection control was applicable for job specific tasks. Personnel files #s: 2, 3, 4, 5, 6, 7 and 8. The Findings: Eleven personnel file records were reviewed in the agency on 08/22/2023. The personnel files noted below failed to contain documentation of infection education. Personnel file for employee #2 who is a skilled nurse with a date of hire of 02/01/2023 failed to contain documentation of infection control education. Personnel file for employee #3 who is a skilled nurse with a date of hire of 05/01/2023 failed to contain documentation of infection control education. Personnel file for employee #4 who is an occupation therapist with a date of hire of 03/20/2023 failed to contain documentation of infection control education. Personnel file for employee #5 who is an occupation therapist with a date of hire of 12/28/2021 failed to contain documentation of infection control education. Personnel file for employee #6 who is a personal care aide with a date of hire of 10/28/2022 failed to contain documentation of infection control education. Personnel file for employee #7 who is a personal care aide with a date of hire of 02/21/2019 failed to contain documentation of infection control education. Personnel file for employee #8 who is a personal care aide with a date of hire of 07/19/2019 failed to contain documentation of infection control education. In an interview conducted in the agency on 08/22/2023 at 1:35 PM during the personnel file reviews, the surveyor asked the Administrator why personnel file #s: 6, 7 and 8 were labeled home health aides when the documentation in their files displayed 40 hours instead of 75 hours as mandated for home health aides. The Administrator provided the surveyor with no reply. The Administrator was unable to provide evidence of staff infection control education documented in the above noted personnel files. The above noted findings regarding the lack of documentation for infection control education was reviewed with the Administrator during the exit conference conducted on 08/23/2023.

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on a review of personnel files and interview, the agency failed to accurately differentiate personal care aides from home health aides with documented required 75 hours of classroom and supervised practical training for home health aides for three (3) out of six (6) in the survey sample. Personnel Records #s 6, 7, and 8. The findings: Six (6) personnel files of the agency’s Home Health Aide (HHA) were reviewed in the agency. The Administrator provided the MFI with the agency's active employee list on 08/21/2023 and was reviewed on 08/22/2023 at 1:35 PM. Personnel file for employee #6 with the title of HHA (home health aide) and a date of hire of 10/28/2022 contained a job description for an HHA. However, the file contained 40 hours classroom training as opposed to 75 hours required for an HHA. Personnel file for employee #7 with the title of HHA and a date of hire of 02/21/2019 contained a job description for an HHA. However, the file contained 40 hours classroom training as opposed to 75 hours required for an HHA. Personnel file for employee #8 with the title of HHA and a date of hire of 07/19/2019 contained a job description for an HHA. However, the file contained 40 hours classroom training as opposed to 75 hours required for an HHA. In an interview conducted in the agency on 08/22/2023 at 1:35 PM during the personnel file reviews, the surveyor asked the Administrator why personnel file #s: 6, 7 and 8 were labeled home health aides when the documentation in their files contained 40 hours instead of 75 hours as required for home health aides. The Administrator provided the surveyor with no reply. The Administrator acknowledged the lack of documented hours for the home health aides requirements on 08/3/2023.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the Home Health Agency failed to ensure the agency's appliance for conducting testing had been cleared for that purpose by the Food and Drug Administration. Specifically, the agency conducted tests on patients with the agency's appliance without a CLIA (Clinical Laboratory Improvement Amendments) certificate. The findings: On 08/21/2023 at 4:30 PM the MFI (Medical Facilities Inspector) asked for a CLIA waiver. The Administrator stated, "What is that for, I don't think we have one". The MFI asked if they owned a PT/INR (PT-test used to detect bleeding disorder and INR-test calculated from the PT to monitor how well the blood thinning medicine is working) machine. The Administrator stated, yes we do, we have two machines". On 08/23/2023 the Administrator provided the surveyors with the CLIA policy and procedure. The agency's policy, Waived Testing: Blood Glucose Monitors and/or Coagulation Testing partially read as follows: "The agency will perform only laboratory tests considered waived tests under the Clinical Laboratory Improvement Amendments of 1988. This may include blood glucose monitoring via a glucometer/or coagulation testing (PT/INR). The agency will obtain CLIA waiver for analysis of blood glucose levels and/or coagulation testing via finger stick. The Director of Clinical Services will be responsible for reviewing any orders for laboratory services when it is unclear whether they meet CLIA requirements. CLIA requirements apply to agency owned, staff owned or patient owned glucometers (when the nurse utilizes the patient's glucometer." The above noted findings regarding the lack of a CLIA waiver for testing appliances was reviewed with the Administrator during the exit conference conducted on 08/23/2023.

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 staff interview, review of personnel files, and review of clinical records, it was determined the Governing Body and/or Administrator failed to ensure the overall management and organization of resources in order to attain and provide the highest practicable functional status of the agency. The agency failed to ensure the Administrator was responsible for day-to-day operations in order for the agency to run at its highest practicable functional capacity (refer to G948); failed to ensure the Alternate Administrator was predesignated in writing (refer to G954); and failed to ensure at least one skilled service was provided in its entirety by directly employed agency staff (refer to G982). The cumulative and systemic effect of the lack of the Governing Body/Administrator performing their roles and duties resulted in the overall failure of the agency to provide quality services and negatively impacted the staff, patients, patient care, and community relationships and responsibilities.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the Administrator responsible for the day-to-day operations of the HHA failed to ensure the accuracy of public information materials. Findings: The agency's website (www.oasishhi.com) was reviewed 08/21/23. The website indicated the agency operated a corporate location in Ashburn, Virginia and a "satellite office" at 900 S Washington Street Suite 209 Falls Church, VA 22046. The facility has no CMS approved branch locations. An interview was conducted with the Administrator on 08/21/23 at 10:30 AM. The Administrator stated that the agency has a location in Falls Church where clinicians can pick up supplies and drop off paperwork. The Administrator confirmed no patient care was performed from the Falls Church location and the location was not a branch of the HHA. The MFI visited the Falls Church location on 08/22/23 at 9:00 AM. The location was advertised on the posted building directory. At the time of the visit, the door was locked and no staff was present. A list of current employees provided to the MFI was reviewed on 08/22/23. One staff member was identified as the "branch manager," despite the agency having no approved branches. The Administrator stated that the branch manager worked at the Falls Church location four days per week. The above noted deficiency was acknowledged by the Administrator during the exit conference on 08/23/23.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to designate a qualified person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the Administrator. Findings: The surveyor requested the name and personnel file for the Alternate Administrator from the Administrator on 08/21/23 at 3:05 PM. The Administrator stated that the Alternate Administrator was recently terminated, and there currently is no individual designated to assume the responsibilities of the Administrator if needed. The agency provided a document, Lines of Authority, that was reviewed 08/21/23 and reads in part: In the absence of the Administrator, the Director of Clinical Services will assume his/her administrative duties. The agency's employee list provided to the surveyor 08/21/23 at 3:05 PM was reviewed and no Alternate Administrator or Director of Clinical Services was included on the list. The Administrator confirmed the lack of a predesignated alternate Administrator during the exit interview on 08/23/23

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the agency failed to ensure it furnished a skilled service in its entirety directly by agency staff. Findings: An entrance conference was conducted with the Administrator on 08/21/23 at 10:30 AM. During the entrance conference, the Administrator stated that the agency provided skilled nursing, physical therapy, and occupational therapy services. The Administrator stated all personnel were independent contractors and the agency did not employee any of these skilled disciplines directly. The agency Administrator completed the form CMS-1572, Home Health Agency Survey Report and returned it to the surveyors on 08/23/23. The form indicated that Registered Nurse and Aide services were provided by both agency and contracted staff and that operational therapy and physical therapy staff were all contracted employees. No service was documented as staffed by only agency employees. The Administrator confirmed the above noted deficiency during the exit conference on 08/23/23.

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: Based on a review of medical records and staff interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for one (1) of two (2) closed medical records reviewed in the survey sample. Medical Record # 3. Two (2) closed medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. Two (2) closed medical records were reviewed 08/22/23 to 08/23/23 with the Administrator assisting in the navigation of the electronic record. The medical record for patient #3 was reviewed for the certification period of 06/19/2023 to 08/17/2023. The medical record revealed that the patient was discharged from the agency on 08/05/2023. The discharge summary was sent to the primary physician on 08/23/2023; 17 days later. During the review on 08/22/2023 at 10:27 AM, the administrator acknowledged the discharge summary was not sent to the physician. The administrator sent the discharge summary via fax when surveyor noted the deficiency. The lack of providing a discharge summary within 5 business days of the patient's discharge acknowledged prior to and during the exit conference with the Administrator on 08/23/23.