Every finding on record at Optimum Home Health Care, Inc

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: PM = Afternoon Pt./Pts. = Patient/Patients POC = Plan of Care

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined that for 3 of 7 (Pts. #4, 5 and 7) clinical records reviewed, the Agency failed to ensure staff obtained physician orders for all services. 2. Pt. #5 was admitted to Home Health Services on 9/7/23 with primary diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 1/3/24. The record included Skilled Nursing visit notes for services provided on 11/9/23 and 11/17/23. The POC effective 11/6/23 was signed by the physician on 11/22/23. The record lacked documentation of a physician order for the above-mentioned Skilled Nursing visits. 3. Pt. #7 was admitted to Home Health Services on 12/23/22 with the Primary Diagnosis of Parkinson’s Disease. The closed clinical record was reviewed on 1/3/24. The record included Skilled Nursing visit notes for the services provided on 2/24/23, 3/3/23 and 3/10/23. The POC for the certification period of 2/21/23 to 4/21/23 was signed by the physician on 3/15/23. The record lacked documentation of a physician order for the above-mentioned Skilled Nursing visits. 4. On 1/3/24 between 3:00 PM to 4:30 PM, interviews were conducted with the Administrator and Alternate Administrator. During these interviews, the Administrator stated that after the initial certification, a verbal order is not obtained if services are continued past the initial 60-day certification period. An updated POC is completed and sent to the physician for review and signature. Meanwhile, services continue without physician approval until the POC is signed by the physician. During the same interviews, the above findings were confirmed. 1. Pt. #4 was admitted to Home Health Services on 9/21/23 with the primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 / Unspecified Chronic Kidney. The clinical record was reviewed on 1/3/24. The record included the PT visit notes for services provided weekly from 11/22/23 to 12/28/23. The POC effective 11/20/23 was signed by the physician on 12/11/23. The record lacked documentation of a physician order for the above-mentioned PT visits.

EP Program Patient Population CFR(s): 484.102(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)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (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: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to identify the population it serves. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan last updated 3/1/20 to 3/31/20 was reviewed on 1/12/21 at 9:45 AM. The plan lacked documentation relative to population being served. 2. During an interview on 1/13/21 at 1:45 PM with Administrator, Assistant Administrator/ Quality Assurance Supervisor, Nurse Supervisor, Therapy Coordinator and Intake Coordinator; the Administrator confirmed the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(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).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to establish a policy and plan, relative to the use of volunteers during an emergency. This has potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan last updated 3/1/20 to 3/31/20 was reviewed on 1/12/21 at 9:45 AM. The Plan lacked a policy and documentation relative to the use of volunteers. 2. During an interview on 1/13/21 at 1:45 PM with Administrator, Assistant Administrator/ Quality Assurance Supervisor, Nurse Supervisor, Therapy Coordinator and Intake Coordinator; the Administrator confirmed the Agency failed to incorporate volunteers into Agency's Emergency Preparedness Plan.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, clinical record review and staff interview, it was determined that the Agency failed to ensure the communication plan was complete. This has potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan last updated 3/1/20 to 3/31/20 was reviewed on 1/12/21 at 9:45 AM. The Plan contained a "Staff Phone Tree" which lacked the names and contact information for the Medical Social Worker and Occupational Therapist. 2. Pt. #4. SOC 12/21/20. Primary Diagnosis: Alzheimer's Disease, unspecified. The clinical record was reviewed on 1/12/21 at 11:00 AM. The record contained documentation that an Occupational Therapist provided service. 3. Pt. #5. SOC 11/6/20. Primary Diagnosis: Peripheral Vascular Disease, Unspecified. The clinical record was reviewed on 1/11/21 at 12:00 PM. The record contained documentation that a Medical Social Worker provided service. 4. During an interview on 1/13/21 at 1:45 PM with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Nurse Supervisor, Therapy Coordinator and Intake Coordinator; the Administrator confirmed the Agency's Emergency Preparedness Plan was incomplete.

Recertification survey completed. Standard Level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 1/14/21. Standard level deficiencies written. Abbreviations: x = times wk = week # = number E = Employee F = Fahrenheit AM = morning tab(s) = tablets ACT = actuation MG = milligrams SN = Skilled Nurse POC = Plan of care SOC = Start of care MCG = micrograms PsOC = Plans of Care MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist FIC = Focused Infection Control VA = Department of Veterans affairs COVID-19 = Coronavirus disease 2019 PPV = Pneumococcal Polysaccharide Vaccine

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician- ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined that the Agency failed to ensure the SOC assessment was conducted within 48 hours of the referral date. This was found in 3 of 7 (Pts. #3, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #3. SOC 11/23/20. Primary Diagnosis: Malignant Neoplasm of Colon. The clinical record was reviewed on 1/11/21 at 12:00 PM. The record contained the SOC comprehensive assessment completed by the RN and dated 11/23/20. The assessment did not include date of referral. The record included the "Intake Form date: 11/20/20 time 4:00 PM and SOC date 11/23/20." The Agency failed to conduct the initial assessment within 48 hours. 2. Pt. #6. SOC 9/11/20. Diagnoses: Unspecified Alzheimer's Disease and Dementia in Other Disease Classified Elsewhere without Behavioral Disturbance. The closed clinical record was reviewed on 1/11/21 at 2:15 PM. The record contained the SOC comprehensive assessment completed by the RN and dated 9/11/20. The referral for service included documentation the Physician's office had faxed the referral to the Agency on 8/26/20. The record lacked a Physician order indicating a specific SOC date or that the Pt. was discharged from an inpatient facility. The SOC was conducted 15 days after receiving the referral. The Agency failed to initiate service within 48 hours of receipt of the referral. 3. Pt. #7. SOC 9/11/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The closed clinical record was reviewed on 1/12/21 at 10:00 AM. The record contained the SOC comprehensive assessment completed by the RN and dated 9/11/20. The referral for service included documentation the Physician's office had faxed the referral to the Agency on 8/26/20. The record lacked a Physician order indicating a specific SOC date or that the Pt. was discharged from an inpatient facility. The SOC was conducted 15 days after receipt of the referral. The Agency failed to initiate service within 48 hours of receiving the referral. 4. During an interview with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Therapy Coordinator and the Intake Coordinator on 1/13/21 at 1:05 PM; the Administrator and Assistant Administrator/ Quality Assurance Supervisor confirmed the SOC was conducted after 48 hours of receiving the referral.

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 may choose to include. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, interview during a home visit, interview with Power of Attorney and staff interview, it was determined that the Agency failed to ensure that the POC included current medications. This was found in 2 of 3 (Pt. #3 and 2) home visits conducted. Findings include: 1. Pt. #3. SOC 11/23/20. Primary Diagnosis: Malignant Neoplasm of Colon. The clinical record was reviewed on 1/11/21 at 12:00 PM. The record contained the POC with the certification period effective 11/23/20 with these medications listed: Budesonide-Formoterol Fumarate Inhalation 160-4.5 MCG/ACT 2 puffs twice daily and Melatonin Oral 3 MG 1 tab daily at bedtime." A home visit was conducted on 1/13/21 at 9:00 AM, along with E #1. An interview was conducted with patient's neighbor/caregiver that stated medications are prepared by the Power of Attorney who will leave them in a medicine cup for him to administer. The patient's neighbor/caregiver stated that the Power of Attorney did come today, but no medications were left and thought that maybe the medications were discontinued. An interview was conducted on 1/13/21 at 10:45 AM with the patient's Power of Attorney that stated, the Budesonide and Melatonin were discontinued in November 2020 since Pt. #3's inpatient discharge on 11/19/20. The POC effective 11/23/20 was inaccurate. 2. Pt. #2. SOC 12/2/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 1/12/21 at 12:00 PM. The record included a POC, effective 12/2/20, which included a Physician's order for "Metoprolol Tartrate 25 mg 1 tab(s) twice daily." There were no subsequent Physician's orders during this certification period for any new medications/medication changes. A home visit was conducted 1/12/21 at 10:30 AM, along with E #2. During this home visit, Pt. #2's Caregiver presented his/her medications, which did not include Metoprolol, and stated Pt. # 2 has not taken Metoprolol "since October, due to low blood pressure." The POC was inaccurate. 3. During a meeting with the Administrator, Assistant Administrator, Therapy Coordinator, Nursing Supervisor, and Intake Coordinator on 1/13/21 at 1:45 PM, and with the Administrator, Assistant Administrator, and Nursing Supervisor on 1/13/21 at 3:15 PM, the above findings were confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: 6. Pt. #7. SOC 9/11/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The closed clinical record was reviewed on 1/12/21 at 10:00 AM. The record contained the SOC comprehensive assessment completed by the RN and dated 9/11/20. The assessment included documentation the Pt. received the Flu vaccine last on 10/10/18. The record lacked an inquiry indicating whether the Agency had administered, arranged or the Pt. refused the vaccine, prior to the Agency's discharge on 11/5/20. 7. During a meeting with the Administrator, Assistant Administrator, and Nursing Supervisor on 1/13/21 at 3:15 PM, the Administrator stated when a Pt./Caregiver does not know the dates on which a Pt. received the flu/pneumonia vaccines. The RN should call the Physician to obtain this information, and enter this information in the clinical record. 8. During an interview with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Therapy Coordinator and the Intake Coordinator on 1/13/21 at 1:05 PM, 1:45 PM and 3:15 PM; the Administrator and Assistant Administrator/ Quality Assurance Supervisor confirmed the RN failed to assess, and maintain documentation of the patient's Pneumococcal Pneumonia and/or Influenza immunization status. 3. Pt. #1. SOC 11/10/20. Primary Diagnosis: Unspecified Fracture of Left Acetabulum. The clinical record was reviewed on 1/11/21 at 3:25 PM. The record included the SOC comprehensive assessment dated 11/10/20, in which Pt. #1/ Pt. #1's Caregiver answered "yes" to having received the Pneumonia and Flu vaccines; however, "Comments" included "Patient unable to recall dates of receiving the vaccines." The record lacked documentation that the RN did any further follow-up with the Physician to attempt to determine the dates these vaccines were administered to Pt. #1. 4. Pt. #2. SOC 12/2/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 1/12/21 at 12:00 PM. The record included the SOC comprehensive assessment dated 12/2/20, in which Pt. #2/ Pt. #2's Caregiver answered "yes" to having received the Pneumonia vaccine; however, "Comments" included "Per caregiver, he/she is uncertain when the Patient received the pneumonia vaccine." The record lacked documentation that the RN did any further follow-up with the Physician to attempt to determine the date this vaccine was administered to Pt. #2. 5. Pt. #5. SOC 11/6/20. Primary Diagnosis: Peripheral Vascular Disease, Unspecified. The clinical record was reviewed on 1/12/21 at 1:00 PM. The record included the SOC comprehensive assessment dated 11/6/20, in which Pt. #5/ Pt. #5's Caregiver answered "yes" to having received the Pneumonia and Flu vaccines. The "Comments" section was blank. The record lacked documentation that the RN did any further follow-up with the Physician to attempt to determine the dates these vaccines were administered to Pt. #5. 6. 3. During a meeting with the Administrator, Assistant Administrator, and Nursing Supervisor on 1/13/21 at 3:15 PM, the above findings were confirmed. The Administrator stated when a Pt./Caregiver does not know the dates on which a Pt. received the flu/pneumonia vaccines, the RN should call the Physician to try to determine this information, and subsequently enter the dates/attempt to determine the dates in the Patient's medical record. . A. Based on clinical record review and staff interview, it was determined that the Agency failed to ensure that the RN assess and maintain documentation of the patient's Pneumococcal Pneumonia and/or Influenza immunization status. This was found in 6 of 7 (Pts. #3, 4, 1, 2, 5 and 7) clinical records reviewed. Findings include: 1. Pt. #3. SOC 11/23/20. Primary Diagnosis: Malignant Neoplasm of Colon. The clinical record was reviewed on 1/11/21 at 12:00 PM. The record contained the SOC comprehensive assessment completed by the RN and dated 11/23/20. The assessment documented under "Most Recent Immunizations: Pneumonia and Flu" were marked "Yes", but no dates were indicated. The Comments section included: "PPV received at VA clinic, patient can't recall dates." The record pertaining to the patient's immunization status was incomplete. 2. Pt. #4. SOC 12/21/20. Primary Diagnosis: Alzheimer's Disease, unspecified. The clinical record was reviewed on 1/12/21 at 11:00 AM. The record contained the SOC comprehensive assessment completed by the RN and dated 12/21/20. The assessment documented under "Most Recent Immunizations: Pneumonia" marked as "Unknown". The record pertaining to immunization status was incomplete.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians involved in the plan of care. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined that the Agency failed to ensure staff coordinate care with the Physician, prior to Agency's discharge. This was found in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/11/20. Diagnoses: Unspecified Alzheimer's Disease and Dementia in Other Disease Classified Elsewhere without Behavioral Disturbance. The clinical record was reviewed on 1/11/21 at 2:15 PM. The record contained the Physician order dated 10/22/20 indicating the Pt. had tested positive for COVID-19, and for the Agency to "Hold all visits..." The record also contained the discharge summary completed by a SN and dated 11/5/20 which included: "Condition at Discharge... Patient is still unstable...". As of 1/11/21, the record lacked any documentation the Agency collaborated with the Physician regarding discharge planning for Pt. #6. 2. Pt. #7. SOC 9/11/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The closed clinical record was reviewed on 1/12/21 at 10:00 AM. The record contained the Physician order dated 10/22/20 to "Hold all visits... patient tested possible for COVID 19". The record also contained the discharge summary completed by a SN and dated 11/5/20 which included: "Condition at Discharge... Patient is still unstable...". As of 1/12/21, the record lacked any documentation the Agency collaborated with the Physician regarding discharge planning for Pt. #7. 3. The Agency policy titled, "Patient Discharge Process" was reviewed on 1/12/21 at 2:00 PM. The policy required: "...Purpose... To assure collaboration with the physician... in planning for discharge from the agency... 3. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan" 4. During an interview with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Therapy Coordinator and the Intake Coordinator on 1/13/21 at 1:05 PM; the Administrator and Assistant Administrator/ Quality Assurance Supervisor confirmed, staff failed to coordinate care with the Physician prior to the Agency's discharge.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on observation, Agency policy review and staff interview, it was determined that the Agency failed to ensure that staff follow infection prevention standards. This was found in 1 of 3 (Pt. #3) home visits conducted. Findings include: 1. Pt. #3. SOC 11/23/20. Primary Diagnosis: Malignant Neoplasm of Colon. The clinical record was reviewed on 1/11/21 at 12:00 PM. A home visit was conducted with E#1 on 1/13/21 at 9:00 AM. E #1 was observed as he/she used an alcohol-based hand sanitizer then put on a pair of disposable gloves and removed a blood pressure cuff and stethoscope from the nursing bag. E #1 used the blood pressure cuff and stethoscope on the Pt. and returned the items into the nursing bag without cleaning them. Using the same gloved hand, E #1 went through items inside the bag and removed a smaller plastic bag containing a thermometer and alcohol wipes. E #1 cleaned the thermometer with an alcohol wipe, took the patient's temperature, cleaned the thermometer using another alcohol wipe, returned the thermometer into a smaller plastic bag, and then placed this bag inside the nursing bag with the same gloves on. E#1 failed to clean the blood pressure cuff and stethoscope before returning this equipment into the nursing bag. E#1 also failed to wash his/her hands before re-entering the nursing bag. 2. The Agency policy "Home Health bag technique" documented: " ....5. Equipment used is cleaned with alcohol-based wipes. Staff will wash hands again, prior to returning the equipment in the bag. 6. Clean and dirty supplies are maintained separately ...." 3. During an interview on 1/13/21 at 1:45 PM with Administrator, Assistant Administrator/ Quality Assurance Supervisor, Nurse Supervisor, Therapy Coordinator and Intake Coordinator; the Administrator stated that expectation for staff is based on the Agency's policy, to clean equipment before returning it into the bag and to perform hand hygiene before, in between and after Pt. care. During the same interview, the Administrator confirmed the above findings.

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: . A. Based on review of a clinical record, Infection Surveillance Log, Agency policy and staff interview, it was determined that the Agency failed to ensure the Infection Surveillance program related to COVID-19 was complete and/or accurate. This was found in 1 of 2 (Pts. #6) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/11/20. Diagnoses: Unspecified Alzheimer's Disease and Dementia in Other Disease Classified Elsewhere without Behavioral Disturbance. The closed clinical record was reviewed on 1/11/21 at 2:15 PM. The record contained the "Interdisciplinary Communication" form completed by the Intake Coordinator and dated 10/16/20 which included: "RN reported today that patient is requesting for COVID 19 Test because he has flu-like symptoms..." The form contained documentation that the nurse and Physician were contacted. The Home Health Aide visit note dated 10/20/20 included documentation that when the Aide arrived at the patient's home, "...patient had fever...it was 101 F and the technician arrived to do COVID test." The Agency failed to notify the Home Health Aide that the Pt. was exhibiting COVID-19 symptoms. The record also lacked documentation that the Home Health Aide screened the Pt. for symptoms of COVID-19, prior to the visit conducted on 10/20/20, as required by the Agency. 2. The Agency's Infection Surveillance Log was reviewed on 1/11/21 at 11:00 AM. The Log lacked any documentation of surveillance of the Home Health Aide (E#3) for symptoms of COVID-19. 3. The Agency policy titled, "Infection Control Surveillance" was reviewed on 1/13/21 at 11:45 AM. The policy required: "...5. The agency will closely monitor and investigate employee's occupational exposure... 6. An infection control log will be maintained..." 4. During an interview with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Therapy Coordinator and the Intake Coordinator on 1/13/21 at 1:05 PM; the Administrator stated staff are required to call the Pt./caregiver prior to their visit to assess for COVID-19 symptoms, as part of the Agency's Surveillance Program. During the same interview, the Administrator and Assistant Administrator/ Quality Assurance Supervisor confirmed, the Agency failed to ensure the Infection Surveillance program related to COVID-19 was complete and/or accurate.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined that the Agency failed to ensure the discharge summary was complete and/or a copy was forward to the Physician. This was found in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/11/20. Diagnoses: Unspecified Alzheimer's Disease and Dementia in Other Disease Classified Elsewhere without Behavioral Disturbance. The clinical record was reviewed on 1/11/21 at 2:15 PM. The record contained the "Interdisciplinary Communication" form completed by the Intake Coordinator and dated 10/26/20 which included: "MD office called today to notify us that patient has stage 2 pressure ulcer on left buttock... services on hold...MD sent us order to send Mepilex, donut ring for pressure ulcer and still hold SN visits due to patient... COVID 19 positive..." The record contained the Agency's discharge summary form completed by the RN, and dated 11/5/20 which lacked the supply company's name and contact information for the caregiver to order wound care supplies after agency discharge, and instructions regarding ongoing care needs. The record contained documentation the SN, PT and/or Home Health Aide provided services from 9/11/20 to 10/20/20. As of 1/11/21, the record lacked documentation a copy of the discharge summary was sent to the Physician. 2. Pt. #7. SOC 9/11/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The closed clinical record was reviewed on 1/12/21 at 10:00 AM. The record contained documentation the SN and/or PT provided services from 9/11/20 to 10/22/20. As of 1/12/21, the record lacked documentation a copy of the discharge summary was sent to the Physician. 3. The Agency policy titled, "Patient Discharge Process" was reviewed on 1/12/21 at 2:00 PM. The policy required: "...Discharge Procedure... 2... A Discharge Plan shall be developed that is documented in writing and includes all written/verbal instruction regarding the client's ongoing care needs and available resources provided to the client and family..." 4. During an interview with the Administrator, Assistant Administrator/ Quality Assurance Supervisor, Therapy Coordinator and the Intake Coordinator on 1/13/21 at 1:05 PM; the Administrator and Assistant Administrator/ Quality Assurance Supervisor confirmed the Agency failed to ensure the discharge summary was complete, and that a copy was forwarded to the Physician.