Every finding on record at Onecare Home Health Utah, LLC

A recertification survey was conducted at OneCare Home Health from 3/11/2024 through 3/13/2024 to assess compliance with Emergency Preparedness. Deficiencies were identified and cited in the area of Establishment of the Emergency 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 interview and record review, it was determined the agency failed to develop, implement, maintain and document an emergency preparedness (EP) program. Specifically, the agency did not establish and maintain an EP program that included all the required elements. Findings include: 1. On 3/11/2024 at 9:30 AM, surveyors requested the following: a. Emergency preparedness plan and risk assessments b. Emergency preparedness policies and procedures c. Emergency preparedness communication plan d. Documentation of emergency preparedness training for staff e. Documentation of annual emergency preparedness exercises conducted 2. On 3/11/2024 at 5:17 PM, a 23-page document titled "Emergency Management Plan" was provided. Upon review, the document contained an emergency preparedness plan for a company with a different name than the home health agency. It contained documents pertinent for an EP plan; however, they were not for OneCare Home Health and did not fully establish an effective EP program. 3. When asked for clarification regarding company ownership, the agency administrator emailed surveyors on 03/11/2024 at 3:05 PM, stating: "OneCare is owned by (name of another company). The policies and/or job description cover all our entities. We do not use a separate header as OneCare is owned by (name of another company)." 4. Through email correspondence on 03/12/2024 at 3:09 PM, surveyors requested documentation regarding change of ownership documentation. On 03/12/2024 at 3:59 PM, the administrator sent an email response with a copy of a letter from Centers for Medicare and Medicaid Services which stated approval of a "Change of Information (COI) application." 5. On 3/13/2024 at 9:43 AM, the administrator provided a Hazard and Vulnerability risk assessment. Note: the Hazard and Vulnerability risk assessment was labeled for the home health agency being surveyed; however, the Emergency Preparedness Plan was not specific to the agency. 6. During the exit interview on 3/13/2024 at 3:00 PM, the administrator stated that paperwork for a change of ownership had been completed for the agency; however, paperwork provided to surveyors by the agency was for a change of information through Centers for Medicare and Medicaid Services, and not for a change of ownership through the state. The agency failed to provide evidence, by interview or documentation, that they had established and maintained an EP program meeting regulatory requirements for tags: E-0004, E-0006, E-0007, E-0009, E-0013, E-0015, E-0016, E-0018, E-0019, E-0020, E-0022, E-0023, E-0025, E-0026, E-0029, E-0030, E-0031, E-0032, E-0033, E-0034, E-0036, E-0037, E-0039, and E-0042.

A recertification survey was conducted at OneCare Home Health from 3/11/2024 through 3/13/2024 to assess compliance with the 42 Code of Federal Regulations for Home Health agencies. Noncompliance was identified and deficiencies were cited in the following areas: §484.60 Care planning, coordination of services, and quality of care; §484.70 Infection prevention and control; §484.75 Skilled professional services; §484.80 Home health aide services; §484.100 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients; and, §484.105 Organization and administration of services.

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 interview and record review, it was determined the agency did not ensure each patient received home health services that were written in an individualized plan of care (POC) that identified interventions and patient-specific measurable outcomes and goals. Specifically, 2 of 7 sampled patients did not receive home health services that were written in their POC. (Patient identifiers: 3 and 5) Findings include: A review of five active patients and two discharged patients was completed on 03/12/2024. For 2 of 7 sampled patients, care was not provided according to the written POC. 1. Patient 3 was admitted on 02/02/2024 with a diagnosis of Orthopedic aftercare following spinal fusion surgery. A review of the medical record for Patient 3 with a POC dated 02/02/2024 to 04/02/2024, was completed on 3/12/2024. a. The POC stated the occupational therapist had physician orders to visit Patient 3 once weekly for 4 weeks. b. An order, dated 2/13/2024, stated Patient 3 moved outside of the coverage area, “OT on hold effective 2/13/24”. c. Through email correspondence with the agency administrator on 3/12/24 at 10:21 AM, surveyors requested additional information regarding why OT was put on hold. d. The administrator responded via email on 3/12/2024 at 3:36 PM. The administrator stated: “Patient was accepted based on service location. Once she admitted to HH (home health) she moved to another location which was anticipated for a short time. OT was not able to cover this area and planned to resume care once she returned home. PT (physical therapy) and nursing were able to manage the extra travel.” No other information was provided. 2. Patient 5 was admitted on 12/04/2023 with a diagnosis of Acute respiratory failure with hypoxia. A review of the medical record for Patient 5 with a POC dated 12/04/2023 to 02/01/2024, was completed on 3/12/2024. a. The POC stated the home health aide had physician orders to visit Patient 5 once weekly for 4 weeks. The home health aide visited the patient on 12/08/2023, 12/19/2023, 12/29/2023, and 01/05/2024. b. Through email correspondence with the agency administrator on 03/11/24 at 4:49 PM, surveyors requested additional information regarding the late home health aide (HHA) visits. c. The administrator responded via email on 3/12/2024 at 3:29 PM. The administrator provided the plan of care dated 12/04/2023, and an order dated 12/15/23 with the following in the "order description" category: "HHA has COVID and unable to make visit. Visit to be moved so patient receives appropriate care.” No other information was provided.

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 record review and interview, it was determined the home health agency did not ensure infection control education for agency staff. Specifically, for 9 of 9 sampled personnel, the home health agency did not ensure infection control education was completed. (Personnel identifiers: 1, 2, 3, 4, 5, 6, 7, 8, and 9) Findings include: During the entrance conference on 3/11/2024 at 9:30 AM, surveyors requested a personnel list for the home health agency. On 3/12/2024 at 8:03 AM, a partial list of employees was provided to surveyors. On 3/12/2024 at 8:33 AM, surveyors requested a complete personnel list. The agency administrator emailed the personnel roster to surveyors on 3/12/2024 at 9:43 AM. On 3/12/2024 at 10:10 AM, surveyors requested personnel records (including in-service hours, skills and competencies, infection control training, background checks, and licenses or certificates) for a sample of 9 personnel (3 home health aides, 3 registered nurses, 1 physical therapist, 1 occupational therapist, and 1 social worker). On 3/12/2024 at 3:09 PM, surveyors had not received the personnel files and requested all information (personnel records as well as the other survey requests) be submitted for review. The administrator stated she would provide all information by 8:00 AM the next morning (3/13/2024). On 3/13/2024 at 7:48 AM, surveyors received the personnel files for the 9 requested personnel. For 9 of 9 personnel records, no documented evidence of infection control education was provided. No other personnel records or training for infection control were provided to surveyors by the end of the survey.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the home health agency did not ensure participation in-service training staff members. Specifically, for 3 of 9 sampled personnel, the home health agency did not ensure in-service training. (Personnel identifiers: 7, 8, and 9) Findings include: During the entrance conference on 3/11/2024 at 9:30 AM, surveyors requested a personnel list for the home health agency. On 3/12/2024 at 8:03 AM, a partial list of employees was provided to surveyors. On 3/12/2024 at 8:33 AM, surveyors requested a complete personnel list. The agency administrator emailed the personnel roster to surveyors on 3/12/2024 at 9:43 AM. On 3/12/2024 at 10:10 AM, surveyors requested personnel records (including in-service hours, skills and competencies, infection control training, background checks, and licenses or certificates) for a sample of 9 personnel (3 home health aides, 3 registered nurses, 1 physical therapist, 1 occupational therapist, and 1 social worker). On 3/12/2024 at 3:09 PM, surveyors had not received the personnel files and requested all information (personnel records as well as the other survey requests) be submitted for review. The administrator stated she would provide all information by 8:00 AM the next morning (3/13/2024). On 3/13/2024 at 7:48 AM, surveyors received the personnel files for the 9 requested personnel. For 3 of 9 personnel records (1 physical therapist, 1 occupational therapist, and 1 social worker), no documentation for in-service participation was provided. No other personnel records or documentation was provided to surveyors by the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the home health agency did not ensure competency evaluations were completed for all personnel. Specifically, for 8 of 9 sampled personnel, the home health agency did not ensure the completion of competency evaluations. (Personnel identifiers: 2, 3, 4, 5, 6, 7, 8, and 9) Findings include: During the entrance conference on 3/11/2024 at 9:30 AM, surveyors requested a personnel list for the home health agency. On 3/12/2024 at 8:03 AM, a partial list of employees was provided to surveyors. On 3/12/2024 at 8:33 AM, surveyors requested a complete personnel list. The agency administrator emailed the personnel roster to surveyors on 3/12/2024 at 9:43 AM. On 3/12/2024 at 10:10 AM, surveyors requested personnel records (including in-service hours, skills and competencies, infection control training, background checks, and licenses or certificates) for a sample of 9 personnel (3 home health aides, 3 registered nurses, 1 physical therapist, 1 occupational therapist, and 1 social worker). On 3/12/2024 at 3:09 PM, surveyors had not received the personnel files and requested all information (personnel records as well as the other survey requests) be submitted for review. The administrator stated she would provide all information by 8:00 AM the next morning (3/13/2024). On 3/13/2024 at 7:48 AM, surveyors received the personnel files for the 9 requested personnel. For 8 of 9 personnel records, documented evidence of competency evaluations was not provided. No other personnel records or competency evaluations were provided to surveyors by the end of the survey.

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the home health agency did not ensure change of ownership information was disclosed to the state survey agency at the time of change of ownership. Findings include: A review of agency documents and records during the survey revealed a different agency name on emergency preparedness and policies and procedures. When asked for clarification, the agency administrator emailed surveyors on 03/11/2024 at 3:05 PM, stating: "OneCare is owned by (name of another company). The policies and/or job description cover all our entities. We do not use a separate header as OneCare is owned by (name of another company)." Through email correspondence on 03/12/2024 at 3:09 PM, surveyors requested documentation regarding change of ownership documentation. On 03/12/2024 at 3:59 PM, the administrator sent an email response with a copy of a letter from the Centers for Medicare and Medicaid Services which stated approval of a "Change of Information (COI) application." During the exit interview on 3/13/2024 at 3:00 PM, the administrator stated that paperwork for a change of ownership had been completed for the agency; however, paperwork provided to surveyors by the agency was for a change of information through the Centers for Medicare and Medicaid Services, and not for a change of ownership through the state.

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 interview and record review, it was determined the home health agency (HHA) failed to organize, manage, and administer. Specifically, the agency was commingling with another entity and could not show separateness between the two agencies; did not provide evidence employees had training on infection control; did not provide evidence of employees competency evaluations and in-services; and did not provide evidence of an emergency preparedness program for the specific HHA. Findings include: 1. The home health agency failed to ensure each patient received home health services that were written in an individualized plan of care (POC) that identified interventions and patient-specific measurable outcomes and goals. (Refer to tag G572) 2. The home health agency failed to ensure infection control education for agency staff. (Refer to tag G686) 3. The home health agency failed to ensure participation of in-service training for staff members. (Refer to tag G722) 4. The home health agency failed to ensure competency evaluations were completed for all personnel. (Refer to tag G768) 5. The home health agency failed to ensure change of ownership information was disclosed to the state survey agency at the time of the change of ownership. (Refer to tag G852) 6. The home health agency failed to establish and maintain an Emergency Preparedness program meeting regulatory requirements. (Refer to tag E0001)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency did not have a governing body (GB) that had assumed responsibility for the overall operation of the agency. Findings include: The agency's governing body did not ensure compliance with the following: 1. The GB did not ensure each patient received home health services that were written in an individualized plan of care. 2. The GB did not ensure infection control education was completed for all personnel. 3. The GB did not ensure employees participated in in-service training. 4. The GB did not ensure competency evaluations were completed for all personnel. 5. The GB did not ensure change of ownership information was disclosed to the state survey agency at the time of the change of ownership. 6. The GB did not establish and maintain an Emergency Preparedness program meeting regulatory requirements.