Every finding on record at Oregon Continental Home Health Care, Inc

An unannounced Federal recertification survey was completed at this agency on 2/8/2023. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held with the CFO on 1/30/2023 at 9:51 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFO - Chief Financial Officer EP - Emergency Preparedness

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 interview and emergency preparedness program documentation review, it was determined the agency failed to conduct a full-scale and tabletop exercise annually. Findings: Review of the emergency preparedness documentation presented by the agency revealed it failed to include policies and procedures addressing the performance of annual drills and tabletop exercises. The emergency preparedness program lacked documentation of the performance of any annual drills and tabletop exercises. During an interview with Employee #1 and Employee #2 on 2/8/2023 beginning at 1:30 PM, the lack of documentation of drills and tabletop exercises was confirmed. Employee #2 stated "We expected to get a citation for Emergency Preparedness..." The agency provided a tabletop exercise that was dated 1/31/2023, which was the first day of this survey.

An unannounced Federal recertification survey was completed at this agency on 2/8/2023. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the CFO on 1/30/2023 at 9:51 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: ADLs - Activities of Daily Livings CFO - Chief Financial Officer CFR - Code of Federal Regulation CEO - Chief Executive Officer HHA - Home Health Agency HHA - Home Health Aide SOC - Start of Care 2w8 - Two visits for 8 weeks

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview, review of patient medical records and review of policies and procedures, it was determined that for 1 of 10 patients (Patient #3), the agency failed to ensure a physician was promptly notified of changes in the patient's condition that suggest a need to alter the plan of care. Findings: Review of Patient #3's medical record revealed a SOC date of 1/4/2023. The document titled "Home Health Certification and Plan of Care" under "Orders For Discipline and Treatment" revealed "HHA Frequency: 2w8 Home Health Aide to provide assistance with personal care and ADLs as indicated by limitations on functional and physical status impeding self-care. Aide to report all falls injuries, hospitalizations." Review of the document titled "HHA visit" indicated the Home Health Aide visits to Patient #3 occurred only on 1/11/2023 and 1/18/2023. Review of the document titled "HHA Care Plan" under "Comments/Additional Instructions" revealed "Home Health Aide to provide assistance with personal care and ADLs as indicated by limitations on functional and physical status impeding self-care. Aide to report all falls injuries, hospitalizations, ER visits suspected abuse, neglect or misappropriation to the agency immediately." During an interview with Employee #1 and Employee #2 on 2/8/2023 at 2:08 PM, when asked about documentation of the Home Health Aide visit to Patient #3 after 1/18/2023 as the physician order was for twice a week for eight weeks, Employee #1 stated that Patient #3 was showing "sexual [inappropriateness]" therefore the agency stopped the Home Health Aide visits. Employee #2 stated "There is no documentation by the Aide about the inappropriate conduct and physician was not notified." The agency also failed to provide any documentation to Patient #3 that care was being terminated. Employee #2 further stated "If there was no documentation then it was not done."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and review of documentation in 1 of 10 patient records (Patient #2), it was determined the agency failed to implement physician orders to provide Home Health Aide service. Findings: Review of Patient #2's medical record revealed a SOC date of 12/6/2022. The document titled "Home Health Certification and Plan of Care" under "Orders For Discipline and Treatment" revealed "HHA Frequency: 2w8 Bath aide." During an interview with Employee #1 and Employee #2 on 2/8/2023 at 1:55 PM, this surveyor asked to see the Home Health Aide visit notes and care plan. This agency was unable to provide the requested documents. When asked why there was no documentation, Employee #2 stated "What I can tell you is that the patient was never scheduled for a Home Health Aide... [RN name] was a new employee, it was missed. We are sorry. I will be educating everyone again."

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 agency failed to ensure the Administrator was available for the everyday operation of the agency. The agency also failed to have a clear written instructions for what was temporary delegation and for how long was the Administrator delegating duties to the alternate administrator. Findings: When this surveyor entered the agency office on the first day of the survey on 1/30/2023 at 9:51 AM, the CFO was the only person present in the office. When the CFO was asked about the Administrator, the CFO stated the Administrator was in Ohio for family reasons. The CFO further stated the Administrator travels to Ohio often because the Administrator has a family residing in Ohio. The CFO was not able to say when exactly the Administrator would be back to the office. Throughout this survey, the Administrator was in Ohio and was only available by phone or email. The review of documentation titled "DIRECTOR OF PROFESSIONAL SERVICES BACKUP" under "POLICY" revealed "In compliance with established policy, if the Director of Professional Services is not available, a designated, qualified alternate will assume his or her duties and responsibilities and be available to respond to emergencies. If the Director Professional Services leaves employment, the designated alternate will assume the Director of Professional Services responsibilities until a replacement is hired and oriented. The Director of Professional Services or alternate will be available during hours of operation." Under the "STATEMENT OF RESPONSIBILITY" revealed "In compliance with established policy and if the Administrator [name] is not available, the designated, qualified backup, [name] will assume the duties and responsibilities of the Administrator Designee for [Administrator's name]." The document was signed and dated 1/2/2023 by the Administrator and designee. During an interview on the first day of the survey on 1/30/2023 beginning at 9:51 AM, the CFO of stated that this Administrator was an Administrator for another Home Health Agency that was in the process of obtaining a state licensure. During the initial licensure survey of the new Home Health Agency on 1/17/2023, the same Administrator was in Ohio for family reasons. During a prior initial licensure survey of the new Home Health Agency on 1/13/2021 and follow-up survey conducted on 7/9/2021, the same Administrator was in Ohio. Based on the above document and interview with the Administrator, the agency failed indicate a clear written instructions what the Administrator was temporarily delegating and how long the Administrator was going to be on leave. Furthermore, the amount of absence makes it unclear how the Administrator was responsible for all daily operations of the agency as stipulated in this rule.