Every finding on record at Orient Home Care Services Inc

A Recertification inspection survey was conducted on 10/05/2022. Licensed and certified census was 2. No deficiencies were cited.

A Recertification inspection survey was conducted on 10/05/2022. Licensed and certified census was 2. Deficiencies and a continuing deficiency were/was cited. Acronyms/Abbreviations: Adm-Administrator Alt Adm-Alternate Administrator ADON-Alternate Director of Nurses (Alternate Supervising Nurse) EHR- Electronic Health Record RN-Registered Nurse LVN-Licensed Vocational Nurse PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement COVID- Novel Coronavirus Disease 2019 CFR-Code of Federal Regulations CDC-Centers for Disease Control

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: This is a continuing deficiency cited at G 0658 during survey dated 10/10/2019. Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2019, 2020 and 2021 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and service delivery to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 09/29/2022 with the Alt Adm at approximately 10:00 a.m., the surveyor requested all agency QAPI documents/reports/manuals. At approximately 1:50 p.m. the records were provided. Record review of the agency’s QAPI records showed that it contained the agency's quarterly reports and annual agency evaluations. The binder did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2019, 2020 and 2021. During an interview on 09/29/2022 at approximately 3:30 p.m. with the Alt Adm, the surveyor asked if the agency had provided all QAPI information for review that was requested by the surveyor during the entrance conference. The Alt Adm replied, “Yes.” During an interview with the Adm/DON and Alt Adm on 10/05/2022 at 12:25 p.m., the surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2019, 2020 and 2021. The Adm/DON stated that the agency’s focus on was on correcting the deficiencies from survey dated 10/10/2019 and “then COVID came.” The surveyor also asked how not maintaining a QAPI Program per federal regulations could adversely affect agency patients. The Adm/DON replied, “It will lead to lack of improvement. It will cause poor care delivery.” Review of agency policies titled "Performance Improvement: Process: Data Collection[revised 070111;] Performance Improvement Process: Data Aggregation and Analysis[revised 103002; and] Performance Improvement Process: Improved Performance[revised 020102]" revealed that the policies did not include the CFR requirement that began on July 13, 2018, that “HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain a coordinated agency‐wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's quality assessment and performance improvement program for 2020, 2021 and 2022. The failure could place the agency's patients and the agency's staff at risk of contracting and spreading infectious and communicable diseases or cross infection. FINDINGS INCLUDED: Review of the agency’s infection control binder revealed the following: “Infection Surveillance Log” for the year 2022. The log documented for the first, second and third quarters of 2022: four “indwelling catheter” infections; four “wound infections;” four skin infections;” and one “reportable disease” infection. “Infection Surveillance Log” for the year 2021. The log documented two “wound infections” for the first quarter of 2021. “Infection Surveillance Log” for the year 2020. The log documented “01 + 2” other infections for the third quarter of 2020 and “01 + 01” other infections for the fourth quarter of 2020. The binder also included a “communication” note dated 07/13/2020 that revealed that Patient # 11 had tested positive for COVID. Further review of the infection control binder revealed that there was no documentation of the infections that included at a minimum: Date infection was detected, Patient's name, Primary diagnosis, Signs/symptoms, Sources of infection, Type of infection, Modes of transmission, Pathogen identified, and Treatment. Review of the agency’s QAPI records revealed that the agency failed to maintain an agency wide program for the surveillance and identification, and investigation of infectious and communicable diseases. Review of the agency’s QAPI records also did not show that the agency documented at a minimum according to agency policy. During an interview with the Adm/DON on 10/05/2022 at 12:15 p.m., the surveyor requested the agency’s COVID-19 exposure/infection documentation/surveillance. The Adm/DON stated that the agency documented in the patient records. The Adm/DON looked at the agency’s EHR and did not find and provide documentation of the infections. The surveyor asked how could not maintaining documentation and surveillance of patient infections adversely affect agency patients? The Adm/DON replied, “If we don’t do that it could cause cross infection.” Review of agency policy titled "INFECTION CONTROL PROGRAM IC.1" with a revision date of 090109, read in part: "…Policy...Agency’s infection control program will be based on the following criteria… Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections. CDC guidelines…Current federal, state and local laws and regulations…The Infection Control Program will include...3.1 Surveillance for the occurrence of an infection 3.2 Identification of the occurrence...Assignment of Responsibilities......Management will be responsible for coordinating all activities related to the Infection Control Program…Documentation will include at a minimum: Date infection was detected, Patient's name, Primary diagnosis, Signs/symptoms, Sources of infection, Type of infection, Modes of transmission, Pathogen identified, if any, [and] Treatment…” Review of the CDC website revealed that the CDC defines surveillance as "the ongoing, systematic collection, analysis, interpretation and evaluation of health data closely integrated with the timely dissemination of this data to those who need it." https://www.cdc.gov/