Every finding on record at Ohio Valley Home Health Services, Inc

An emergency preparedness survey was conducted at East Liverpool Home Health from 6/21/21 to 6/23/21 as part of a recertification survey. One (1) Condition level deficiency was cited at E 001 with six (6) standard level deficiencies cited at E 007, E 019, E 023, E 030, E 031 and E 037.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review, document review and staff interview it was determined the facility failed to provide a documented comprehensive emergency preparedness program. This failure creates the potential for harm or injury to all patients due to inadequate or inappropriate response during an emergency (See Tags E 007, E 019, E 023, E 030, E 031 and E 037).

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of clinical record and patient and staff interview it was determined the agency failed to have policies and procedures in place to protect its vulnerable home health population in seven (7) out of nine (9) records reviewed (Patients #1, 2, 3, 6, 7, 8 and 9). This failure places all patients at risk for harm or injury from inadequate or inappropriate response to their individual requirements during an emergency. Findings include: 1. Review of the clinical record for Patient #1 revealed the start of care (SOC) date was 6/15/21. The patient's plan of care (POC) did not include a triage level. 2. Review of the clinical record for Patient #2 revealed the SOC date was 6/7/21. The patient's POC did not include a triage level. 3. Review of the clinical record for Patient #3 revealed the SOC date was 6/12/21. The patient's POC did not include a triage level. 4. Review of the clinical record for Patient #7 revealed the SOC date was 5/11/21. The patient's POC did not include a triage level. 5. Review of the clinical record for Patient #8 revealed the SOC date was 1/15/20 with a discharge date of 3/12/20. The patient's POC did not include a triage level. 6. Review of the clinical record for Patient #9 revealed the SOC date was 1/27/21 with a discharge date of 2/4/21. The patient's POC did not include a triage level. 7. An interview was conducted with Patient #6 and the patient's spouse on 6/22/21 at 1:15 p.m. during a home visit. Patient #6 stated he/she was "pretty sure" emergency preparedness had been discussed during his/her admission. The patient's spouse looked in the admission booklet while the surveyor was watching and pulled out a leaflet on preventing accidents in the home. When asked if there was a plan in the booklet specifically saying what would happen in the event of an emergency or disaster, the spouse stated in part, "No. There's nothing there." 8. An interview was conducted with the Executive Director (ED) on 6/23/21 at 2:30 p.m. The ED concurred emergency preparedness plans are not detailed in the POC, but stated the patient could tell whoever came to get them what they needed.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and patient and staff interview it was determined the agency failed to document an individualized Emergency Preparedness Plan (EPP) during the admission process in eight (8) out of nine (9) records reviewed (Patients #1, 2, 3, 5, 6, 7, 8 and 9). This failure to include patients' individualized EPP in the admission assessment creates the potential for confusion resulting in harm during an emergency to all patients. Findings include: 1. Review of the clinical record for Patient #1 revealed the start of care (SOC) date was 6/15/21. The patient's plan of care (POC) did not include a triage level or an individualized Emergency Preparedness Plan (EPP). 2. Review of the clinical record for Patient #2 revealed the SOC date was 6/7/21. The patient's POC did not include a triage level or an individualized EPP. 3. Review of the clinical record for Patient #3 revealed the SOC date was 6/12/21. The patient's POC did not include a triage level or an individualized EPP. 4. Review of the clinical record for Patient #5 revealed the SOC date was 4/22/21. The patient's POC did not include an individualized EPP. 5. Review of the clinical record for Patient #6 revealed the SOC date was 5/15/21. The patient's POC did not include an individualized EPP. 6. Review of the clinical record for Patient #7 revealed the SOC date was 5/11/21. The patient's POC did not include a triage level or an individualized EPP. 7. Review of the clinical record for Patient #8 revealed the SOC date was 1/15/20 with a discharge date of 3/12/20. The patient's POC did not include a triage level or an individualized EPP. 8. Review of the clinical record for Patient #9 revealed the SOC date was 1/27/21 with a discharge date of 2/4/21. The patient's POC did not include a triage level or an individualized EPP. 9. An interview was conducted with Patient #6 and the patient's spouse on 6/22/21 at 1:15 p.m. during a home visit. Patient #6 stated he/she was "pretty sure" emergency preparedness had been discussed during his/her admission. The patient's spouse looked in the admission booklet while the surveyor was watching and pulled out a leaflet on preventing accidents in the home. When asked if there was a plan in the booklet specifically saying what would happen in the event of an emergency or disaster, the spouse stated in part, "No. There's nothing there." 10. An interview was conducted with the Executive Director (ED) on 6/23/21 at 2:30 p.m. The ED concurred emergency preparedness plans are not detailed in the POC, but stated the patient could tell whoever came to get them what they needed.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the agency failed to provide a means of informing emergency personnel or receiving facilities of patients' individual needs during evacuation and transportation during an emergency for twelve (12) out of twelve (12) patients (Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13 and 14). This failure creates the potential for harm to all patients. Findings include: 1. An interview was conducted with the Executive Director (ED) on 6/22/21 at 1:20 p.m. The ED stated Emergency Preparedness (EP) information individualized for each patient is kept in a fireproof safe in the East Liverpool City Hospital (ELCH) in Ohio (OH). After going to ELCH, the ED provided a document and stated they would give the information to any provider on patients in the event of an emergency. 2. Review of the agency's census revealed there were twelve (12) active patients (Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13 and 14). The document revealed there were no individualized plans indicating whether or not each patient is mobile, the type of life-sustaining equipment he/she would require, if the equipment would need to be transported, if the patient had special needs or what the patient's COVID (Coronavirus-19) status is. 3. An interview was conducted with the ED on 6/23/21 at 2:30 p.m. The ED concurred emergency preparedness plans are not detailed in the patients' plan of care, but stated the patient could tell whoever came to get them what they needed. The ED concurred keeping the information in a safe in OH was not appropriate and stated they are getting a fire-proof safe for the West Virginia agency.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the agency failed to ensure information critical to a safe evacuation in an emergency would be readily available for twelve (12) out of twelve (12) patients (Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13 and 14). This failure creates the potential for harm to all patients. Findings include: 1. An interview was conducted with the Executive Director (ED) on 6/22/21 at 1:20 p.m. The ED stated Emergency Preparedness (EP) information individualized for each patient is kept in a fireproof safe in the East Liverpool City Hospital (ELCH) in Ohio (OH). The ED agreed there was the potential the safe would not be accessible during an emergency and stated maybe staff could transmit patient information from their I-pad, and if the Internet was down they would have to come to the office or go to ELCH to print the information to give to emergency officials. After going to ELCH, the ED provided a document and stated they would give the information to any provider on patients in the event of an emergency. 2. Review of the agency's census revealed there were twelve (12) active patients (Patients #1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13 and 14). The document revealed there were no individualized plans indicating whether or not each patient is mobile, the type of life-sustaining equipment he/she would require, if the equipment would need to be transported, if the patient had special needs or what the patient's COVID (Coronavirus-19) status is. 3. An interview was conducted with the ED on 6/23/21 at 2:30 p.m. The ED concurred emergency preparedness plans are not detailed in the patients' plan of care, but stated the patient could tell whoever came to get them what they needed. The ED concurred keeping the information in a safe in OH was not appropriate and stated they are getting a fire-proof safe for the West Virginia agency.

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), §485.625(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 it was determined the agency failed to keep a current contact list for staff to be used in the event of an emergency. This failure creates the potential for harm to all patients from staff not being available to provide care during an emergency. Findings include: 1. An interview was conducted with the Executive Director (ED) on 6/22/21 at 1:20 p.m. The ED stated he/she probably had two (2) staff members' phone numbers stored in his/her cell phone. The ED stated he/she did not have a list of staffs' phone numbers or contact information immediately available to provide to the state surveyor.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on staff interview it was determined the agency failed to keep current, accurate information for emergency officials who may be able to assist during an emergency. This failure creates the potential for an inadequate response to an emergency placing all patients at risk for harm. Findings include: 1. An interview was conducted with the Executive Director (ED) on 6/22/21 at 1:20 p.m. The ED stated he/she was unaware the list he/she had in his/her emergency plan for emergency officials contained an incorrect phone number for the West Virginia Department of Health and Human Resources.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the agency failed to provide Emergency Preparedness (EP) training to two (2) out of two (2) home health aides. This failure places all patients at risk for harm. Findings include: 1. A review of personnel files for two (2) aides revealed there was no documentation of EP training. 2. An interview was conducted with the Executive Director (ED) on 6/23/21 at 10:05 a.m. The ED stated aides had the training, but it was not documented.

A recertification survey was conducted at East Liverpool Home Health from 6/21/21 to 6/23/21. The agency provides skilled nursing, physical therapy, occupational therapy, speech therapy and home health aide services to Brooke and Hancock counties. No services have been added or deleted since the last recertification survey. The active census at the time of the survey was twelve (12) patients. The twelve (12) month unduplicated census was one-hundred ninety-one (191). Nine (9) clinical records were reviewed, and three (3) home visits were made. A Focused COVID Infection Control Survey was also conducted. One (1) Condition level deficiency was cited at G 940. Three (3) standard level deficiencies were cited at G 574, G 954 and G 982. As a result of the cited Condition level deficiency, this agency will not be permitted to complete home health aide training or competency evaluations for two (2) years as per regulation 42 CFR 484.80(f)(3).

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 record review and staff interview it was determined the agency failed to provide comprehensive individualized plans of care in eight (8) out of nine (9) records reviewed (Patients #1, 2, 3, 5, 6, 7, 8 and 9). This failure creates the potential for harm to all patients due to inadequate care. Findings include: 1. Review of the clinical record for Patient #1 revealed the start of care (SOC) date was 6/15/21. The patient's plan of care (POC) did not include psychosocial status or an individualized emergency preparedness plan. 2. Review of the clinical record for Patient #2 revealed the SOC date was 6/7/21. The patient's POC only included medications and therapies. 3. Review of the clinical record for Patient #3 revealed the SOC date was 6/12/21. The patient's POC only included medications and therapies. 4. Review of the clinical record for Patient #5 revealed the SOC date was 4/22/21. The patient's POC did not include an individualized emergency preparedness plan. 5. Review of the clinical record for Patient #6 revealed the SOC date was 5/15/21. The patient's POC did not include an individualized emergency preparedness plan. 6. Review of the clinical record for Patient #7 revealed the SOC date was 5/11/21. The patient's POC did not include an individualized emergency preparedness plan. 7. Review of the clinical record for Patient #8 revealed the SOC date was 1/15/20 with a discharge date of 3/12/20. The patient's POC did not include an individualized emergency preparedness plan. 8. Review of the clinical record for Patient #9 revealed the SOC date was 1/27/21 with a discharge date of 2/4/21. The patient's POC did not include an individualized emergency preparedness plan. 9. An interview was conducted with the Executive Director (ED) on 6/23/21 at 10:05 a.m. The ED stated the agency does not have all the orders for Patients #2 and 3 because once a patient is admitted, the agency sends the information to someone at Matrix who reviews and codes it and then sends it back to them. Until it is sent back and approved the physician's orders for disciplines and medications are the only orders in the clinical record. The ED stated the other information needed to provide care is not in the orders but contained in the SOC assessment. The ED stated in the event of a disaster, the information needed to provide continuity of care is in a fire-proof safe located in Ohio. The ED stated if they were unable to get to the safe, and the Internet was down, the clinicians could come to the office and print patient information from their I-pads or go the East Liverpool City Hospital and print the information. 10. An interview was conducted with the ED on 6/23/21 at 2:30 p.m. The ED concurred the new computer system they are using (Matrix) does not include patients' psychosocial status and that it was somehow missed by the people who set the system up. The ED concurred emergency preparedness plans are not detailed in the patient's POC. The ED stated the patient could tell whoever came to get them what they needed. The ED stated they are getting a fire-proof safe for the West Virginia agency.

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 and observation it was determined the agency failed to organize, manage and administer its resources independent of other providers. The providers maintaining and controlling files integral to the running of the agency are located in Ohio (OH). There are no contracts with those providers to provide administrative services. This failure creates the potential for harm to all patients. Findings include: 1. On 6/22/21 at 8:30 a.m. documentation was requested for the employee files of two (2) home health aides and a physical therapist. The Executive Director (ED) stated they would have to get the files from Human Resources (HR) who maintain and control the files from East Liverpool City Hospital (ELCH) located in OH. The ED stated they used to keep employees' files at East Liverpool Home Health (ELHH). The ED stated they told the company, which owns both ELCH and ELHH, that the files should be kept by ELHH in West Virginia. The ED stated they were following the owner's instructions to leave the files in OH and left the agency to go to OH to retrieve the files. 2. On 6/22/21 at 9:30 a.m. the ED provided the employee files for the two (2) home health aides. The ED stated ELCH HR would not give him the physical therapist's employee file because all of the therapists used by ELHH are under contract with ELCH, not ELHH. The ED stated ELCH would only give them parts of the physical therapist's employee file, which documented education. The ED stated ELHH does not have a contract with ELCH for management of HR nor a contract with the ELCH therapists. 3. On 6/23/21 at 10:30 a.m. documentation was requested to determine whether all staff had emergency preparedness training. The ED stated that information was also kept in employee files in the HR at ELCH and left to retrieve the files. Documentation was requested of patient information, which would be used in the event of a disaster, and the ED stated the information was located in a fire-proof safe in the office in OH. 4. An interview was conducted with the ED on 6/23/21 at 2:30 p.m. The ED concurred keeping essential patient information in a safe in OH was not appropriate and stated they were getting a fire-proof safe for ELHH in West Virginia.

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 it was determined the agency's Governing Body (GB) failed to appoint a back-up Administrator to run the organization in the event the appointed Administrator was absent. This failure creates the potential for disruption in services placing all patients at risk for harm. Findings include: 1. An interview was conducted with the Executive Director on 6/23/21 at 11:00 a.m. In response to a request for documentation the GB appointed a qualified clinician to serve as back-up Administrator, the ED stated the GB did not appoint one and did not think it was a federal regulation. When the state surveyor informed the ED it was a regulation, the ED concurred the regulation had not been followed.

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 staff interview it was determined the home health agency failed to have a contract/arrangement with the physical therapist who provides physical therapy for the home health agency. This failure has the potential for all patients who are ordered physical therapy to be denied the service ordered. Findings include: 1. On 6/22/21 at 8:30 a.m. documentation was requested for the employee files of two (2) home health aides and a physical therapist. The Executive Director (ED) stated they would have to get the files from Human Resources (HR) who maintain and control the files from East Liverpool City Hospital (ELCH) located in OH. The ED stated they used to keep employees' files at East Liverpool Home Health (ELHH). The ED stated they told the company, which owns both ELCH and ELHH, that the files should be kept by ELHH in West Virginia. The ED stated they were following the owner's instructions to leave the files in OH and left the agency to go to OH to retrieve the files. 2. On 6/22/21 at 9:30 a.m. the ED provided the employee files for the two (2) home health aides and the physical therapist. The ED stated ELCH HR would not give the physical therapist's employee file because all of the therapists used by ELHH are under contract with ELCH, not ELHH. The ED stated ELCH would only give them parts of the physical therapist's employee file, which documented education. The ED stated ELHH does not have a contract with ELCH for management of HR nor a contract with the ELCH therapists.