Every finding on record at Pace Plus Corp

Substantial Allegation Survey Substantial Allegation 100852 The following deficiency is based upon substantial allegation 100852 completed on 10/04/23, Arista Home Care Solutions, 368170, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agency. An entrance conference was conducted on 10/03/23 at 8:00 AM with Administrator and an exit conference was conducted on 10/04/23 at 5:00 PM with Administration.

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 medical record review and staff interview, the agency failed to report to the attending physician when the agency was unable to provide Home Health Aide (HHA) services as ordered for two out of the three medical records reviewed, Client #1 and Client #2. This had a potential to affect all patients that were receiving HHA services. Census at the time of survey was 77. 1. The medical record review for Client #1 revealed they started with the agency on 07/15/2022. The medical record review for certification period 03/12/23 to 04/16/23 and period 05/11/23 to 07/09/23 revealed the client was to receive HHA services for 20 to 28 hours per week. The medical record review for the week starting 05/07/23 revealed the client received 18 hours of HHA services. The week starting 05/07/23 revealed the client received 17.25 hours of HHA services. The week starting 05/14/23 revealed the client received 17.25 hours of Aides services. The week starting 05/21/23 revealed the client received 18 hours of HHA services. The week starting 06/04/23 revealed the client received 16 hours of HHA services. The medical record review confirmed the client was not receiving services as ordered. Review of the medical record failed to reveal the physician was notified the agency was not providing services as ordered Interview with Staff B on 10/04/23 at 3:00 PM confirmed the findings. Staff B revealed the agency had not notified the physician the services ordered had not been completed. 2. The medical record review for Client #2 revealed they started with the agency on 10/14/2022. The medical record review for certification period 04/12/23 to 06/10/23 revealed the client was to receive HHA services for 12 to 15 hours per week. The medical record review starting 04/30/23 revealed that the client received 10 hours of HHA services. The week starting 05/07/23 revealed that the client received 10 hours of HHA services. Review of the medical record failed to reveal that the physician was notified that the agency was not providing services as ordered. Interview with Staff B on 10/04/23 at 3:00 PM confirmed the findings. taff B revealed the agency had not notified the physician that the services ordered had not been completed.

AMENDED 03/06/23 EMERGENCY PREPAREDNESS SURVEY The following deficiencies are based on the emergency preparedness survey completed 02/21/23.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the emergency plan and staff interview. the agency failed to develop a completed emergency preparedness program that included an assessment utilizing a All-Hazards approach. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan on 02/15/23 failed to reveal no assessment utilizing an All-Hazard approach. Interview with Staff A on 02/16/23 at 2:00 PM verified the agency had not completed the an assessment using an All-Hazards approach.

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), §485.542(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 the emergency preparedness plan and staff interview, the agency failed to develop a completed emergency preparedness program that included patient population risks. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the Emergency Preparedness plan on 02/15/23 revealed the plan did not contain a patient population risk assessment. During interview with Staff A on 02/16/23 at 2:00 PM it was confirmed the agency had not completed a patient population individual risk assessment.

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 review of the emergency preparedness plan and staff interview, the agency failed to develop a completed emergency preparedness program that included policies and procedures for reporting homebound status to state and local emergency preparedness officials. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan revealed no policies and procedure for reporting homebound status to state and local emergency preparedness officials in case of the need for evacuation. Interview with Staff A on 02/16/23 at 2:00 PM verified the above findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and staff interview, the agency failed to develop a completed emergency preparedness program that included procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan contained no procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. Interview with Staff A on 02/16/23 at 2:00 PM verified the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(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 facilities]. 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: Based on review of the emergency preparedness plan and staff interview, the agency failed to develop a completed emergency preparedness program that included procedures for 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. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan revealed procedures for 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. Interview with Staff A on 02/16/23 at 2:00 PM verified the above findings.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on emergency preparedness plan review and staff interview, the agency failed to develop a communication plan. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan on 02/15/23 failed to reveal a communication plan had been developed as part of the plan. Interview with Staff A on 02/16/23 at 2:00 PM verified the above.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and staff interview, the agency failed to develop a training and testing plan in their emergency preparedness plan based on the emergency plan. This finding could affect all client and staff members. The census at the time of survey was 89. Review of the emergency preparedness plan revealed no training and testing plan was present. Interview on 02/16/23 at 2:00 PM Staff A verified no training and testing plan was present in the emergency preparedness plan.

AMENDED 03/21/23 Partial Extended Recertification Survey An entrance conference was conducted on 02/15/23 at 10:00 AM with Administrator and Director of Nursing, an exit conference was conducted on 02/21/23 at 4:00 PM with Administration. The following deficiencies are based on the partial extended recertification survey completed 02/20/23. Arista Home Care Solutions is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agency.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on the admission packet and staff interview, the agency failed to provide the state home health hot line number, its contact information, its hours of operation, and that its purpose was to receive complaints or questions about local home health agencies. This could affect all clients. The census at the time of survey was 89. During review of the admission packet revealed the packet failed to contain the state home health hot line number, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies. Interview Ton 02/15/23 at 10:00 AM Staff A confirmed the findings.

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 review of a branch application form and staff interview, the agency did not provide failed to provide at least one of the services by agency employees. This had a potential to affect all clients receiving services. Census at the time of survey was 89. During an interview with Staff A and Staff D 0n 02/16/23 at 2:00 PM revealed the branch location was staffed with all contract staffing. Review of the application form revealed the agency did not have a single services line provide solely by the agency staff. Interview on 02/16/23 at 2:00 PM. with Staff D confirmed the findings.

Emergency Preparedness Substantial Allegation Survey OH00118291 The following deficiency is based on the Substantial Allegation Survey OH00118291 survey completed 1/20/2021.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and staff interview the facility failed to develop and maintain a comprehensive emergency preparedness plan. The agency census was 95 patients. Findings include: Record review on 1/13/21 noted the agency failed to complete three core elements of Emergency Preparedness. The agency had no comprehensive policy and procedures for emergency preparedness, no specific hazard vulnerability assessment identifying hazards for each branch location, or a communication plan and training plan which included a table top and/or a full-scale exercises. Interview with Staff A at time of this discovery verified the facility had an incomplete Emergency Preparedness plan in place.

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH00118291 COVID 19 FOCUSED INFECTION CONTROL SURVEY The following deficiencies are based on the COVID 19 Focused Infection Control Survey and Substantial Allegation Survey completed on 01/20/21.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and interview the agency failed to ensure patients had a written care plan signed by a physician. This affected two (Patients #2 and #3) of five sampled patients. The agency census was 95 patients. Findings include: 1. Review of Patient #2's medical record revealed the agency was providing personal care to the patient. The medical record lacked evidence of a written plan of care signed by a physician. 2. Review of Patient #3's medical record revealed the agency was providing personal care to the patient. The medical record lacked evidence of a written plan of care signed by a physician. During interview on 01/13/21 at 11:20 A.M., Staff A stated some patients do not have a plan a care. Staff A explained whether a patient gets a plan of care depends on the payor source and whether the care is skilled.

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: Based on observations, policy review and staff interview it was determined the agency failed to follow agency infection control policy. The agency census at the time of survey was 95. Findings include: Review of the agency policy COVID-19 7.00.1.3 revealed all staff when entering home office should wear a mask. The policy also stated when working with patients staff members were required to wear a mask during entire home health visit. On entrance to agency office three staff members in the lobby area were observed not wearing face masks. Interview with Staff A on 01/13/21 at 11:20 AM confirmed the finding in the lobby. During the interview, Staff A was asked about staff's use of face masks when working with patients. Staff A stated that Staff D had said that the mask caused his/her glasses to fog and would not wear a mask until he/she received contacts. This deficiency substantiates Substantial Allegation OH00118291.