Every finding on record at Paragon Home Health Care Corporation

Based on the findings of an unannounced onsite Home Health Agency Medicare recertification and state re-licensure survey conducted May 6, 2024 through May 7, 2024, Caring Hand Home Health Care, was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

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 agency policy and interview with agency Director (EMP # 1), agency failed to maintain, and review an emergency preparedness plan to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings included: Policy, '1.1 Annual Review: Emergency Preparedness Plan' was reviewed on May 7, 2024 at approximately 1:15 p.m. Section, 'PROCEDURE' states, "The following aspects of our Emergency Preparedness Plan will be reviewed/updated at least every 12 months by the Emergency Preparedness team:...Hazard Risk Analysis; Hazard Risk Assessment...." Interview with EMP# 1 on May 7, 2024, between 1:00 p.m. and 2:00 p.m. concerning emergency preparedness. EMP# 1 confirmed agency failed to maintain, and review an emergency preparedness plan to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Interview with agency Director on May 7, 2024 at approximately 2:30 p.m. confirmed the above findings.

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 review of agency policy and interview with agency Director (EMP # 1), agency failed to participate in a full-scale exercise that is community-based exercise is not accessible, an individual, facility-based. The agency also failed to conduct an additional exercise that included, but was not limited to the following: (A) A second-full scale exercise that is community-based or individual, facility-based. (B) A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinical-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. The agency failed to analyze the agency's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the agency's emergency plan, as needed. Findings included: Policy, '1.13 Event/Drill Analysis: After-Action Review' was reviewed on May 7, 2024 at approximately 1:15 p.m. Section, 'POLICY' states, "It is the policy of our Agency to be in compliance with state & federal regulation regarding the annual testing and Plan analysis of our Emergency Preparedness Plan. Each time the Agency's Emergency Preparedness Plan is activated for a live event or Agency drill, our team will analyze the event, and the Agency's responses, making changes to the plan as appropriate." Interview with EMP# 1 on May 7, 2024, between 1:00 p.m. and 2:00 p.m. concerning emergency preparedness. EMP# 1 confirmed agency failed in participating in a full-scale exercise that is community based, drills, or a tablet top exercise. EMP# 1 confirmed agency failed analyze the agency's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the agency's emergency plan, as needed. Interview with agency Director on May 7, 2024 at approximately 2:30 p.m. confirmed no staff drills have been conducted or reviewed and the above findings.

Based on the findings of an unannounced onsite Home Health Agency Medicare recertification and state re-licensure survey conducted May 6, 2024 through May 7, 2024, Caring Hand Home Health Care, was found to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on May 13, 2021, Paragon Home Health Care Corporation was found not to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

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), §485.625(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 agency policies/procedures and documentation, and based on interview with the director of professional services (clinical director) and the administrator, the agency failed to ensure the emergency preparedness plan included a completed risk assessment/hazard vulnerability analysis (HVA). Findings included: On May 13, 2021 at approximately 3:15 PM, review of "Emergency Operations Plan" revealed the following under "Risk Assessment": A. This agency does an annual all hazard vulnerability assessment (HVA worksheet). Review of the "Hazard Vulnerability Assessment" form, which was included in the "Emergency Preparedness Packet for Home Health Agencies", revealed the HVA form was blank. During interview on May 13, 2021 at approximately 4:08 PM, the clinical director and the administrator reported that the HVA worksheet/form may have been previously completed but confirmed a completed HVA worksheet/form had not been maintained in the emergency preparedness manual.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted on May 13, 2021, Paragon Home Health Care Corporation was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the director of clinical services (clinical director) and the administrator, the agency failed to ensure written notice of the agency's transfer and discharge policies were provided to eight (8) of eight (8) patients who were admitted and discharged from home health services in 2020. (Patients #1, #2, #3, #4, #5, #6, #7 and #8) Finding include: On May 13, 2021 at approximately 3:06 PM, review of the agency policy titled "Patient Bill of Rights" revealed the following: On admission the Bill of Rights is explained to the patient....and is signed by the appropriate parties. The original is retained for the medical record and the patient retains a copy. On May 13, 2021 at approximately 3:07 PM, review of the agency policy titled "Discharge" revealed the following: The legal aspects of termination must be clear to the Agency. Services provided may be terminated by the patient's physician, by the patient or other person, or by Paragon Home Health Care Corporation...Discharge from Paragon Home Health Care Corporation is initiated once the verbal order for discharge is received from the physician. On May 13, 2021 at approximately 10:20 AM, review of the admission folder failed to reveal that the agency discharge and transfer policies/procedures had been included on the patient rights notification forms. Patient #1: On May 13, 2021 at approximately 11:17 AM, review of the clinical record revealed the start of care date was January 21, 2020, the primary diagnosis was malignant neoplasm (cancer) of the lung, and that skilled nursing (SN) and home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/21/2020 through 03/20/2020. Review of "Verbal Change of Order" documentation dated 01/03/2020 revealed the patient elected a transfer to hospice services. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #2: On May 13, 2021 at approximately 11:31 AM, review of the clinical record revealed the start of care date was January 24, 2020, the primary diagnosis was venous insufficiency (poor circulation), and that SN were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/24/2020 through 03/23/2020. Review of "Verbal Change of Order" documentation dated 02/11/2020 revealed the patient was discharged from services because a family member assumed responsibility for wound care. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #3: On May 13, 2021 at approximately 11:50 AM, review of the clinical record revealed the start of care date was January 30, 2020, the primary diagnosis was atherosclerotic heart disease (narrowing/hardening of the arteries), and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/30/2020 through 03/29/2020. Review of "Verbal Change of Order" documentation dated 02/19/2020 revealed the patient was to be discharged from the agency because the patient's condition was stable. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #4: On May 13, 2021 at approximately 12:12 PM, review of the clinical record revealed the start of care date was January 28, 2020, the primary diagnosis was wedge compression fracture (break) of the first lumbar (lower spine) vertebrae, and that SN, HHA and physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/28/2020 through 03/27/2020. Review of "Verbal Change of Order" documentation dated 02/26/2020 revealed the patient was to be discharged from the agency because the patient was to attend outpatient physical therapy. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #5: On May 13, 2021 at approximately 12:30 PM, review of the clinical record revealed the start of care date was January 17, 2020, the primary diagnosis was lobar (portion of the lung) pneumonia, and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/17/2020 through 03/16/2020. Review of "Verbal Change of Order" documentation dated 02/20/2020 revealed the patient was to be discharged from the agency because the patient was refusing SN and HHA services and because a family member of the patient had failed to return telephone calls. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #6: On May 13, 2021 at approximately 12:49 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was acute respiratory (breathing) failure with hypoxia (low oxygen levels), and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. Review of "Verbal Change of Order" documentation dated 02/12/2020 revealed the patient was to be discharged from the agency with the next SN visit because patient goals had been met. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #7: On May 13, 2021 at approximately 1:06 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was fracture of the shaft (length) of the left tibia, and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. Clinical record documentation dated 02/21/2020 revealed the patient was to be discharged from the agency at the patient's request. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. Patient #8: On May 13, 2021 at approximately 1:51 PM, review of the clinical record revealed the start of care date was January 13, 2020, the primary diagnosis was unspecified atrial fibrillation (irregular heart rate) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/13/2020 through 03/12/2020. Clinical record documentation revealed the patient requested discharge from the agency on 03/09/2020. There was no documentation in the clinical record which provided evidence that written notice of the agency's transfer and discharge policies had been provided to the patient. During interview on May 13, 2021 at approximately 4:08 PM, the clinical director and the administrator confirmed there was no documentation in the clinical record which provided evidence that the above identified patients received written notice of the agency's transfer and discharge policies.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the director of clinical services (clinical director) and the administrator, the agency failed to ensure written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property was provided to eight (8) of eight (8) patients who were admitted and discharged from home health services in 2020. (Patients #1, #2, #3, #4, #5, #6, #7 and #8) Finding include: On May 13, 2021 at approximately 3:06 PM, review of the agency policy titled "Patient Bill of Rights" revealed the following: On admission the Bill of Rights is explained to the patient....and is signed by the appropriate parties. The original is retained for the medical record and the patient retains a copy. On May 13, 2021 at approximately 10:20 AM, review of the admission folder failed to reveal that the rights forms included written notification regarding a patient's right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #1: On May 13, 2021 at approximately 11:17 AM, review of the clinical record revealed the start of care date was January 21, 2020, the primary diagnosis was malignant neoplasm (cancer) of the lung, and that skilled nursing (SN) and home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/21/2020 through 03/20/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #2: On May 13, 2021 at approximately 11:31 AM, review of the clinical record revealed the start of care date was January 24, 2020, the primary diagnosis was venous insufficiency (poor circulation), and that SN were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/24/2020 through 03/23/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #3: On May 13, 2021 at approximately 11:50 AM, review of the clinical record revealed the start of care date was January 30, 2020, the primary diagnosis was atherosclerotic heart disease (narrowing/hardening of the arteries), and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/30/2020 through 03/29/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #4: On May 13, 2021 at approximately 12:12 PM, review of the clinical record revealed the start of care date was January 28, 2020, the primary diagnosis was wedge compression fracture (break) of the first lumbar (lower spine) vertebrae, and that SN, HHA and physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/28/2020 through 03/27/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #5: On May 13, 2021 at approximately 12:30 PM, review of the clinical record revealed the start of care date was January 17, 2020, the primary diagnosis was lobar (portion of the lung) pneumonia, and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/17/2020 through 03/16/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #6: On May 13, 2021 at approximately 12:49 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was acute respiratory (breathing) failure with hypoxia (low oxygen levels), and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #7: On May 13, 2021 at approximately 1:06 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was fracture of the shaft (length) of the left tibia, and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. Patient #8: On May 13, 2021 at approximately 1:51 PM, review of the clinical record revealed the start of care date was January 13, 2020, the primary diagnosis was unspecified atrial fibrillation (irregular heart rate) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/13/2020 through 03/12/2020. There was no documentation in the clinical record which provided evidence that the patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property. During interview on May 13, 2021 at approximately 4:08 PM, the clinical director and the administrator confirmed there was no documentation in the clinical record which provided evidence that the above identified patients were provided written notification of the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property.

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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the director of clinical services (clinical director) and the administrator, the agency failed to ensure the "Home Health Certification and Plan of Care" included a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors for eight (8) of eight (8) patients who were admitted and discharged from home health services in 2020. (Patients #1, #2, #3, #4, #5, #6, #7 and #8) Finding include: On May 13, 2021 at approximately 3:06 PM, review of the agency policy titled "Plan of Care" revealed the following under "Purpose": 1. To establish and periodically review, in consultation with the attending physician, a plan of care, which is consistent with the patient's medical, nursing and social needs. On May 13, 2021 at approximately 11:20 AM, review of the "Start of Care OASIS Only Assessment" (Outcome and Assessment Information Set) revealed the following hospitalization risk factors were included under item M1033: 1: History of falls in the past 12 months 2. Unintentional weight loss in the past 12 months 3. Multiple hospitalizations in the past 6 months 4. Multiple emergency department visits in the past 6 months 5. Decline in mental, emotional or behavioral status in the past 3 months 6. Reported or observed history of difficulty complying with any medical instructions in the past 3 months 7. Currently taking five (5) or more medications 8. Currently reports exhaustion 9. Other. Patient #1: On May 13, 2021 at approximately 11:17 AM, review of the clinical record revealed the start of care date was January 21, 2020, the primary diagnosis was malignant neoplasm (cancer) of the lung, and that skilled nursing (SN) and home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/21/2020 through 03/20/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/21/2020 revealed the hospitalization risk factors included under item M1033 were #3, #7 and #8. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #2: On May 13, 2021 at approximately 11:31 AM, review of the clinical record revealed the start of care date was January 24, 2020, the primary diagnosis was venous insufficiency (poor circulation), and that SN were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/24/2020 through 03/23/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/24/2020 revealed the hospitalization risk factors included under item M1033 were #1, #5, #6 and #9. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #3: On May 13, 2021 at approximately 11:50 AM, review of the clinical record revealed the start of care date was January 30, 2020, the primary diagnosis was atherosclerotic heart disease (narrowing/hardening of the arteries), and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/30/2020 through 03/29/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/30/2020 revealed the hospitalization risk factors included under item M1033 were #3, #4, #7, #8 and #9. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #4: On May 13, 2021 at approximately 12:12 PM, review of the clinical record revealed the start of care date was January 28, 2020, the primary diagnosis was wedge compression fracture (break) of the first lumbar (lower spine) vertebrae, and that SN, HHA and physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/28/2020 through 03/27/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/28/2020 revealed the hospitalization risk factors included under item M1033 were #1, #3, #7, #8 and #9. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #5: On May 13, 2021 at approximately 12:30 PM, review of the clinical record revealed the start of care date was January 17, 2020, the primary diagnosis was lobar (portion of the lung) pneumonia, and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/17/2020 through 03/16/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/17/2020 revealed the hospitalization risk factor included under item M1033 was #6. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #6: On May 13, 2021 at approximately 12:49 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was acute respiratory (breathing) failure with hypoxia (low oxygen levels), and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/18/2020 revealed the hospitalization risk factors included under item M1033 were #7, #8 and #9. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #7: On May 13, 2021 at approximately 1:06 PM, review of the clinical record revealed the start of care date was January 18, 2020, the primary diagnosis was fracture of the shaft (length) of the left tibia, and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/18/2020 through 03/17/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/18/2020 revealed the hospitalization risk factors included under item M1033 were #1, #7 and #8. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. Patient #8: On May 13, 2021 at approximately 1:51 PM, review of the clinical record revealed the start of care date was January 13, 2020, the primary diagnosis was unspecified atrial fibrillation (irregular heart rate) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/13/2020 through 03/12/2020. Review of the "Start of Care OASIS Only Assessment" dated 01/13/2020 revealed the hospitalization risk factors included under item M1033 were #7 and #8. The "Home Health Certification and Plan of Care" for the initial certification period failed to include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors. During interview on May 13, 2021 at approximately 4:08 PM, the clinical director and the administrator confirmed the "Home Health Certification and Plan of Care" for the above identified patients did not include a description of the patient's risk for emergency department visits/hospital re-admission and all necessary interventions to address the underlying risk factors.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures and clinical records, and CMS (Centers for Medicare/Medicaid Services) Interim Final Rule guidance, and based on interview with the director of clinical services (clinical director) and the administrator, the agency failed to ensure that the last qualified clinician to provide skilled home health services completed the discharge assessment for two (2) of three (3) patients for whom an unplanned discharge occurred in 2020. (Patients #2 and #5) Finding include: On May 13, 2021 at approximately 3:12 PM, review of the agency policy titled "Skilled Nursing Services" revealed the following under "Registered Nurse Procedures": 6. The registered nurse prepares and documents clinical and progress notes... On May 13, 2021 at 4:01 PM, review of CMS Final Rule guidance revealed the following: Based on the CMS Interim Final Rule [CMS-5531-IFC] announced on April 30, 2020, in the situation of an unplanned discharge, the last qualified clinician that performed the last in-person visit or Telehealth encounter could complete the discharge comprehensive assessment with OASIS (Outcome and Assessment Information Set) using information collected at the visit/encounter. Patient #2: On May 13, 2021 at approximately 11:31 AM, review of the clinical record revealed the start of care date was January 24, 2020, the primary diagnosis was venous insufficiency (poor circulation), and that skilled nursing (SN) were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/24/2020 through 03/23/2020. Review of the "Skilled Nursing Visit Report" form revealed a registered nurse (RN-employee #1) provided SN services on 02/07/2020 during which the RN provided wound care and performed a SN assessment which included, but was not limited to, an assessment of vital signs and wound status. The RN documentation that the patient had a physician appointment scheduled for 02/11/2020. Review of "Verbal Change of Order" documentation dated 02/11/2020 revealed the patient was discharged from services because a family member assumed responsibility for wound care. Review of comprehensive OASIS discharge assessment documentation dated 02/11/2020 revealed the clinical director/RN (employee #3) completed the discharge assessment utilizing assessment data from the 02/07/2020 SN visit which was performed by employee #1. There was no documentation in the clinical record which provided evidence that skilled services were provided after 02/07/2020 nor was documentation present which provided evidence that the last clinician to provide skilled services (RN-employee #1) had completed the comprehensive OASIS discharge assessment dated 02/11/2021. Patient #5: On May 13, 2021 at approximately 12:30 PM, review of the clinical record revealed the start of care date was January 17, 2020, the primary diagnosis was lobar (portion of the lung) pneumonia, and that SN, HHA and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/17/2020 through 03/16/2020. Review of the "Skilled Nursing Visit Report" form revealed a RN (employee #1) provided SN services on 01/31/2020 during which the RN performed a SN assessment which included, but was not limited to, assessment of vital signs and the respiratory (breathing) system. Review of "Verbal Change of Order" documentation dated 02/20/2020 revealed the patient was to be discharged from the agency because the patient was refusing SN and HHA services and because a family member of the patient had failed to return telephone calls. Review of comprehensive OASIS discharge assessment documentation dated 02/20/2020 revealed the administrator/RN (employee #2) completed the discharge assessment utilizing assessment data from the 01/31/2020 SN visit which was performed by employee #1. There was no documentation in the clinical record which provided evidence that skilled services were provided after 01/31/2020 nor was documentation present which provided evidence that the last clinician to provide skilled services (RN-employee #1) had completed the comprehensive OASIS discharge assessment dated 02/20/2021. During interview on May 13, 2021 at approximately 4:08 PM, the clinical director and the administrator confirmed the last RN to provide skilled home health services had not completed the discharge assessment for the above identified patients.