Every finding on record at Phillips County Hospital Home Health

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies, effective 11/15/17, a recertification EP survey was performed on 3/4/21. Deficiencies were cited for the Home Health Agencies EP Program. A COVID-19 Emergency Preparedness abbreviated survey was also conducted on 3/4/21 by the Montana Department of Public Health and Human Services. The facility was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6).

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a policy and procedure which ensured all patients of the home health agency have an individualized plan included as part of their comprehensive assessment for 6 (#s 1, 3, 4, 5, 6, and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients who received care by the home health agency. Findings Include: Review of patient #s 1, 3, 4, 5, 6, and 7, failed to show an individualized emergency plan was included as part of their comprehensive assessment. Review of the agency's Emergency Preparedness Policy and Procedures failed to provide a policy and procedure to develop an individualized emergency plan included as part of the comprehensive assessment. During an interview on 3/2/21 at 8:30 a.m., staff member Q stated the agency did not have a policy and procedure which outlined an individualized plan that was included as part of the comprehensive assessment for patients of the home health agency in the event of an emergency. During an interview on 3/2/21 at 8:30 a.m., staff member B stated she did not establish an individualized emergency plan for patients which was included as part of the comprehensive assessment.

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 interview and record review, the agency failed to develop a policy and procedure to follow up with patients to determine what services are needed during an emergency for 4 (#s 1, 2, 3, and 5) of 7 sampled patients. This deficient practice had the potential to affect all patients who received care from the agency. Findings include: Review of the agency's policy and procedures failed to include a policy which outlined the procedure and protocol for following up with active home health patients to determine what services are needed if there was an interruption in services due to an emergency. Review of the agency's document with the patient listings for patients on services who would require follow-up to determine what services were needed during an emergency did not include patient #s 1, 2, 3, and 5. During an interview on 3/2/21 at 8:30 a.m., staff member Q stated the hospital's emergency preparedness program did not have a policy and procedure which outlined the protocol for following up with active patients to determine what services would be needed during an emergency. During an interview on 3/2/21 at 8:30 a.m., staff member B stated the agency did not have their own policy and procedure to address this concern. She stated the agency did keep a list which they updated monthly that outlined the patients on home health services which identified their name, phone number, address, caregiver, diagnosis, and special needs. She said she tried to keep this up-to-date every time the agency admitted a new patient. She stated the agency would provide this list to the emergency command officer in the event services were interrupted due to an emergency.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement emergency preparedness (EP) communication plans, including a means of providing information about the condition, and location of patients under the clinic's care in case of an emergency. This deficient practice had the potential to affect all patients who received care from the agency. Findings include: Review of the agency's policy and procedures failed to include a written plan and interventions for communications, including a method for sharing patients' medical information during shelter in place, or during an evacuation to ensure continuum of care in event of a disaster. During an interview on 3/2/21 at 8:30 a.m., staff members B and Q stated the hospital's emergency preparedness program did not have a policy and procedure which outlined the communication protocol for sharing patients' medical information during shelter in place, or during an evacuation during an emergent event.

A Recertification survey was completed on 3/4/21. Condition and Standard level citations were cited for this survey. A COVID-19 Focused Infection Control (FIC) survey was conducted by the Montana Department of Public Health and Human Services on 3/4/21. The facility was found to not be in compliance with 42 CFR §484.70 infection control regulations and has not implemented the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. An Emergency Preparedness (EP) survey which included a review of 42 CFR §483.73; E-0024 (b)(6), was completed on 3/4/21. Standard level citations were cited for this survey; the agency was found to be in compliance with 42 CFR §483.73; E-0024 (b)(6). Facility Census: 3 Glossary: ADL Activities of Daily Living CMS Centers for Medicare and Medicaid Services DON Director of Nursing EP Emergency Preparedness EVS Environmental Services LOC Loss of Consciousness NP Nurse Practitioner OASIS Outcome and Assessment Information Set PT Physical Therapy PTA Physical Therapy Assistant SOC Start of Care

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Care Planning, Coordination, and Quality of Care; findings include: 1. The agency failed to provide physical therapy services as established by the agency's condition of need (see G572). 2. The agency failed to develop an individualized written plan of care to meet the patients' specified needs as identified in the comprehensive assessment, and periodically reviewed by the ordering provider (see G572). 3. The agency failed to establish a written plan of care which included all required elements of the patients' plan of care as identified in the comprehensive assessment (see G574). 4. The agency failed to ensure an individualized plan of care was reviewed and revised by the physician who was responsible for the patient's home health plan of care and the agency as indicated by the patient's condition, at the start of care, and at least once every 60-day certification period (see G588).

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 or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide physical therapy services in the patients' place of residence; and failed to develop an individualized written plan of care to meet the patients' specified needs as identified in the comprehensive assessment, which was periodically reviewed by the ordering provider for 2 (#s 1 and 2) of 7 sampled patients. This deficient practice had the potential to affect all patients receiving care from the agency. Findings include: 1. PT Services Not Provided A review of the agency's policy and procedure titled, Compliance, showed, "... [Agency] will also meet necessary criteria for certification as a home health agency under the Social Security act to facilitate patient costs being met by Medicare and Medicaid. The [Agency] will be subject to any required modifications in order to maintain licensure and certification on federal, state, or local levels..." A review of the agency policy and procedure titled, Physical Therapy, showed, "Physical Therapy is incorporated into the Home Health Agency. It will function under all appropriate State and Federal guidelines. The therapy services will be given by or will be done under the supervision of a qualified therapist in accordance with the plan of treatment... ...Currently, the physical therapist has only accepted patients on an individual basis depending on the departments work schedule as they cannot always commit the time to see the patient in their home. Thus, a decision is made on which services would benefit the patient the most initially. Some patients have been receiving skilled and aide services and then been discharged to continue their recuperation with out-patient physical therapy services. Others, have received physical therapy services and hired home care privately." Review of patient #1's Home Health Certification/Recertification Face-to-Face, dated 9/11/20, showed: - "Home Health Skilled, one to two times a week for 30-days... - Home Health Aide, one to two times a week for 30-days... - Physical Therapy, not available due to staffing issues." A review of patient #1's Hospital Discharge Summary, dated 9/10/20, showed the patient was admitted to the hospital for a wedge compression fracture of the lumbar vertebrae. The discharge summary showed, "at this point, the plan is to continue physical therapy and get her strong enough and with adequate pain control..." Review of patient #1's SOC OASIS, dated 9/11/20, showed the primary reason for home health admission was for, "recovery and rehab post lumbar fracture." The SOC OASIS did not include recommended PT services to address the patient's need for rehab. During an interview on 3/2/21 at 3:07 p.m., staff member B stated patient #1 was admitted into home health services after being discharged from the hospital following a compression fracture of her back. She stated the patient would have benefited from continued PT services in the home due to her limited mobility, and need for strengthening, but this was not offered for the patient because her need for pain control was a higher priority. Staff member B stated pain management and medication reconciliation was a function of skilled nursing services. The decision was made that the patient's pain control was the top priority, so she was started on home health services for skilled nursing and aide services. PT services were not offered due to limited PT staffing. Review of patient #2's Face-to-Face showed, a "recent hospitalization after fall. Head surgical repair of wound... [sic]" - Mobility: "[patient] is unsteady of his feet, taxing effort for all transfers even with assistance." - Treatment Plan: "Home Health Skilled, one to two times a week for 30-days. Home Health Aide, one to two times a week for 30 days. Review of patient #2's SOC OASIS, with a SOC date of 7/30/20, showed services were initiated for wound care related to fall with head laceration, and aide services for ADL care related to: - A history of falls with injury, "out of shower, went backwards and scraped head. 5 inch cut with 1 liter of blood loss. No LOC... [sic]" - Strengths/Limitations: "How might the patient's limitation(s) affect their safety and/or progress: Function may decline unless rehab and strengthening occur." - Care Coordination: Other Services Involved: "none, PT not available at home due to staffing currently." Review of patient #2's Nurse Visit Note, dated 8/11/20, showed, "Head improved, needs 2 person give shower... Have contacted CGS [sic] as to how to handle the patient being taken to physical therapy out of the home. Will discharge as soon as pain is more controlled and aide help is established private pay. [sic]" Review of patient #2's Nurse Visit Note, dated 8/12/20, showed, "Talked with NP and talked with family about necessity to discharging patient from home health as he is getting outpatient PT. Assisted family with sign up for private pay aide assist with same aide to observe continuously.[sic]" A review of patient #2's Verbal Order, dated 8/12/20, showed, "discharge as patient has started outpatient PT services." A review of patient #2's Discharge OASIS, dated 8/12/20, showed the patient will start outpatient PT, and obtain private pay aide services. The reason for discharge showed, "Shoulder was injured during the fall and patient's head injury improved, the function and pain of the shoulder caused a problem." During an interview on 3/2/21 at 3:07 p.m., staff member B stated patient #2 was still considered homebound at the time of his discharge on 8/12/20. She stated he no longer needed skilled nursing for wound care of his laceration, but due to increased pain in his shoulder, unsteady gait, and history of falls, the patient needed PT services. He also needed continued aide services for ADLs and remained homebound. She said it was necessary to discharge the patient from home health services in order for him to get PT. PT was not able to see patient in his home. She said when she tried to schedule him for home PT, she was told by the PT department there was no availability for home PT visits. During an interview on 3/1/21 at 2:37 p.m., staff member B stated the home health agency has not been able to provide home health PT services for over a year. She said if a home health patient's condition changed during services which would require a PT evaluation and treatment plan, the patient would need to be discharged off home health in order to obtain outpatient PT. Staff member B stated decisions were made during the patient intake to determine if the agency could admit the patient onto services depending on their more urgent need. For example, if a patient needed skilled services more urgently they would be admitted into home health services, but if they needed the PT services, they would either be declined home health services, or be admitted for skilled nursing and/or aide services and then discharged later on to receive PT services. Staff member B said she worked very hard trying to find other community resources for the patient's if they needed to be discharged off home health for PT. During an interview on 3/2/21 at 2:20 p.m., staff member D stated the hospital's therapy department also provided PT services for the home health agency. She stated however, if the home health services "take us away for visits," they would not be able to see patients in their home. She stated the only way to offer therapy services for home health patients was for the patient to come into the outpatient therapy clinic. Staff member D said the therapy department now had two physical therapists, one full-time and one part-time, and two PTA's. For some time there was only one full-time physical therapist, and they could not cover all the outpatient clients, in-patient clients, and the home health clients. She said even after they hired the new part-time therapist, they were still very busy. Staff member D stated they would provide some home health services but would not go over 30 miles out of town. She said if PT was not able to see the patient in their home, they work to find another way to get them services, even if they need to be discharged from home health. During an interview on 3/2/21 at 3:20 p.m., staff member O stated they were told not to schedule the physical therapist for home health therapy. She said if a patient needed home health therapy services, the patient needed to make a decision if they wanted home health services or PT services, but they could not get both. Staff member O stated staff member B had provided them with names of home health patients who needed therapy services, but they were not able to schedule those patients for PT in their home. During an interview on 3/3/21 at 3:45 p.m., staff member P stated they were not able to determine what the hospital's reimbursement would be for home health therapy services versus outpatient therapy services because it had been so long since the hospital billed anyone for home health therapy services. She said the hospital charged $18.00 per unit for home health aide services, and $24.00 per unit for private pay aide services. During an interview on 3/4/21 at 10:15 a.m., staff member A stated he had just started working for the hospital. He said he was not aware PT was not able to provide home health services. He stated it was the expectation that the PT department provide those services. He said he did check with the hospital's HR department, and the hospital was not actively trying to recruit or hire for an additional physical therapist at this time. 2. Plan of Care A review of the agency's policy and procedure titled, Admission and Recertification, showed, "...Upon admission to [Agency] each patient will have a plan of care individualized to their specific needs. This treatment plan in the form of an electronic medical record or a patient summary note will be submitted and signed by the physician... An admission OASIS form and consent form will be completed at admission..." A review patient #s 1, 2, 3, 4, 5, 6, and 7's medical records failed to show an individualized written plan of care was developed for each patient. During an interview on 3/1/21 at 2:03 p.m., staff member B stated she did not develop a plan of care or also known as a (485) for the patients. She stated she used the comprehensive assessments to meet the requirements of the plan of care or (485). Staff member B said she attended a conference where they said CMS did not need a plan of care as long as the agency ensured they obtained the signed Face-to-Face and completed the comprehensive assessments. She said the she had the provider sign the Face-to-Face, since there was not a plan of care to sign.

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 interview and record review, the agency failed to establish a written plan of care which included all required elements of the patients' plan of care as identified in the comprehensive assessment for 7 (#s 1, 2, 3, 4, 5, 6, and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients receiving care from the agency. Findings include: A review of the agency's policy and procedures showed the agency failed to establish a policy which outlined the required components of the plan of care. A review patient #s 1, 2, 3, 4, 5, 6, and 7's medical records failed to show an individualized written plan of care was developed which captured all required elements as identified in their comprehensive assessments. During an interview on 3/1/21 at 2:03 p.m., staff member B stated she did not develop a plan of care or also known as a (485) for the patients. She stated she used the comprehensive assessments and the Face-to-Face to meet the required elements for the plan of care.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure an individualized plan of care was reviewed and revised by the physician who was responsible for the patient's home health plan of care, and the agency, as indicated by the patient's condition, at the start of care, and at least once every 60-day certification period for 7 (#s 1, 2, 3, 4, 5, 6, and 7) of 7 sampled patients. This deficient practice had the potential to affect all patients receiving home health services. Findings include: A review of the agency's policy and procedures failed to show the agency developed a policy which outlined the need for physician review and revision, which included timelines for review, for the patients' individualized plan of care. A review patient #s 1, 2, 3, 4, 5, 6, and 7's medical records failed to show an individualized written plan of care was developed for each patient and/or reviewed and signed by the responsible provider. During an interview on 3/1/21 at 2:03 p.m., staff member B stated she had the provider sign the Face-to-Face.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on interview and record review, the agency failed to ensure it established an effective and ongoing infection control program which established and implemented policies and procedures to properly prevent the potential spread of COVID-19 and identify patients with undiagnosed upper respiratory symptoms. The agency failed to properly prevent the potential for the spread of COVID-19 prior to providing patient care which included the screening of staff and patients for signs of symptoms of COVID-19 prior to home visits, ensuring the proper disinfection of equipment between patient care, and ensuring the proper use of PPE was implemented by staff (see G682).

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 interview and record review, the agency failed to establish and implement policies and procedures to properly prevent the potential spread of COVID-19 which included screening staff for signs and symptoms of COVID-19 prior to providing patient care, screening of patients for signs or symptoms of COVID-19 prior to home visits, ensuring the proper disinfection of equipment between patient care, and the proper use of PPE. This deficient practice had the potential to affect all staff and patients of the agency. Findings include: 1. Policy and Procedures During an interview on 3/1/21 at 2:47 p.m., staff member B stated the agency had one patient on services who was positive for COVID-19, that patient was discharged from home health services in December 2020. She stated the agency currently did not have any patient's positive for COVID-19 or who were experiencing signs and symptoms of COVID-19. During an interview on 3/2/21 at 3:30 p.m., staff member C stated the hospital's infection control program did not include policies and procedures which outlined the agency's procedures for prevention, surveillance, monitoring, tracking, and reporting the spread of COVID-19 which included patients with undiagnosed upper respiratory symptoms. A review of the agency's infection control policy and procedures for COVID-19, showed the agency failed to establish protocols, which included written standards, policies, and procedures for undiagnosed respiratory illness and COVID-19. 2. Screening of Staff During an interview on 3/2/21 at 3:30 p.m., staff members B and C stated the agency was not completing screening of agency staff for signs and symptoms of COVID-19 prior to providing patient care. During an interview on 3/2/21 at 4:37 p.m., staff member B stated she was not screened by the agency for signs and symptoms of COVID-19 prior to providing patient care. During an interview on 3/3/21 at 11:48 a.m., staff member G stated she was not screened by the agency for signs and symptoms of COVID-19 prior to providing patient care. During an interview on 3/3/21 at 12:50 p.m., staff member F stated she had not been screened by the agency for signs or symptoms of COVID-19 prior to providing patient care. 2. Screening of Patients During an interview on 3/2/21 at 3:30 p.m., staff members B and C stated the agency was not completing screening of patients for signs and symptoms of COVID-19 prior to staff providing patient care. During an interview on 3/2/21 at 4:37 p.m., staff member B stated she did not screen the patients for signs and symptoms of COVID-19 prior to entering the patient's residence to provide care. During an interview on 3/3/21 at 11:48 a.m., staff member G stated she did not screen the patients for signs and symptoms of COVID-19 prior to entering the patient's residence to provide care. During an interview on 3/3/21 at 12:50 p.m., staff member F stated she did not screen the patients for signs and symptoms of COVID-19 prior to entering the patient's residence to provide care. She stated she would ask them if they were having any signs or symptoms after she entered their home and started providing patient care. 3. PPE During an interview on 3/2/21 at 3:30 p.m., staff members B and C stated it was the expectation staff wear the appropriate PPE while providing patient care. Staff member B stated a surgical mask should be worn at all times by all staff when providing patient care for patients who do not have any signs or symptoms of COVID-19. Staff member B stated any PPE worn in a patient's residence, should be disposed of prior to leaving the home. During an interview on 3/2/21 at 4:37 p.m., staff member B stated when she had cared, in the past, for a patient positive for COVID-19, she removed the contaminated PPE and put it into a plastic shopping bag and put the bag in the trunk of her car. She stated she later disposed of the bag with contaminated PPE in a grocery store garbage bin. During an interview on 3/3/21 at 12:50 p.m., staff member F stated she was not sure what the agency's policy and procedure was for donning and doffing of PPE when providing care in a patient's home. She stated she did not have any clean PPE in her car in the event a patient or family member report signs and symptoms of COVID-19 while she was out on home visits. She stated she did wear a cloth face mask, which she did not change between patients. She stated she just pulled the mask down to her neck. She said she did wash her cloth face mask at the end of the day with the rest of her laundry. A review of the agency's policy and procedures failed to show the agency developed policy and procedures on the proper use of PPE when providing care for patients on home health services. 4. Disinfection During an interview on 3/2/21 at 3:30 p.m., staff members B and C stated it was the expectation for staff to disinfect all patient care equipment and items brought into a patient's residence, and between patient appointments to prevent the spread of infection. During an interview on 3/2/21 at 4:37 p.m., staff member B stated she tried to disinfect all patient care equipment between patient appointments. She said when she was able to disinfect her equipment she used the yellow disinfectant in the spray bottles from the EVS. She said she was not sure what the "kill time" was on the that disinfectant. During an interview on 3/3/21 at 8:30 a.m., staff member B stated she checked with EVS and the "kill time" on the disinfectant spray was 10 minutes. She stated it would be difficult to maintain a wet service on the patient care equipment for 10 minutes. She said she would look into using something else to disinfect her equipment. During an interview on 3/3/21 at 12:50 p.m., staff member F stated she did not know what the agency's protocol was for disinfecting equipment between patient care. She said she made her own hand sanitizer and a bleach and water disinfectant which she used to disinfect her equipment. She stated she was not sure what the "kill time" was for the disinfectant she made at home. She said she could use the agency's disinfectant but was just using hers for now. A review of the agency's policy and procedures failed to show the agency developed policy and procedures on the proper use for disinfectant patient care equipment between patient care.

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 observation and interview, the agency failed to ensure the agency's governing body provided oversight and management regarding the following: 1. The agency failed to ensure the governing body reviewed and approved in writing the agency's administrator (G968). 2. The agency failed to ensure adequate staffing to ensure physical therapy services were provided by the agency (G986).

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the governing body reviewed and approved in writing the agency's administrator. This deficient practice had the potential to affect all patients receiving services from the agency. Findings include: The agency failed to provide the requested documentation for the governing body's written approval of the agency's administrator. During an interview on 3/2/21 at 2:37 p.m., staff member B stated she was not sure who would now be considered the administrator for the agency. She stated she held the position previously, but with recent administration changes, she was no longer the administrator. She stated she believed that role was now given to staff member C. During an interview on 3/2/21 at 3:30 p.m., staff member C stated she was recently assigned as staff member B's supervisor. Staff member C said she was not sure what that role currently entailed.

Outpatient therapy services CFR(s): 484.105(g) Standard: Outpatient physical therapy or speech-language pathology services. An HHA that furnishes outpatient physical therapy or speech-language pathology services must meet all of the applicable conditions of this part and the additional health and safety requirements set forth in §485.711, §485.713, §485.715, §485.719, §485.723, and §485.727 of this chapter to implement section 1861(p) of the Act. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure adequate staffing to ensure physical therapy services were provided by the agency. This deficient practice had the potential to affect all patients who received home health services and needed physical therapy. Findings include: A review of the agency's policy and procedure titled, Compliance, showed, "... [Agency] will also meet necessary criteria for certification as a home health agency under the Social Security act to facilitate patient costs being met by Medicare and Medicaid. The [Agency] will be subject to any required modifications in order to maintain licensure and certification on federal, state, or local levels..." A review of the agency policy and procedure titled, Physical Therapy, showed, "Physical Therapy is incorporated into the Home Health Agency. It will function under all appropriate State and Federal guidelines. The therapy services will be given by or will be done under the supervision of a qualified therapist in accordance with the plan of treatment... ...Currently, the physical therapist has only accepted patients on an individual basis depending on the departments work schedule as they cannot always commit the time to see the patient in their home. Thus, a decision is made on which services would benefit the patient the most initially. Some patients have been receiving skilled and aide services and then been discharged to continue their recuperation with out-patient physical therapy services. Others, have received physical therapy services and hired home care privately." During an interview on 3/1/21 at 2:37 p.m., staff member B stated the home health agency had not been able to provide home health PT services for over a year. She said if a home health patient's condition changed during services which would require a PT evaluation and treatment plan, the patient would need to be discharged off home health in order to obtain outpatient PT. Staff member B stated this was due to limited staffing in the PT department. She said when she tried to schedule patients for home PT services, she was told there were no available appointments for home PT. Staff member B stated she had brought this concern to the governing body and quality improvement meetings and had not had any response to the lack of PT availability. She said the hospital had been trying to hire an additional PT for some time, and just recently hired a part-time PT. However, the PT department was still not able to offer home PT services as outlined in the home health agencies condition of need, even after hiring the part-time therapist. A review of the Agency's Improvement Project Documentation, dated 7/22/20, showed, Problem: "Dr. orders for home physical therapy, but no openings available on the schedule and no skilled nursing needs. Two patients this week and possibly another one next week..." Improvement Action: "Explained to patient that Dr. may dictate [need], but Medicare won't pay unless patient qualifies. Problem solved with patient so they could see how they could make an appointment at the hospital...[sic]" Review of the agency's governing body meeting minutes failed to show the governing body addressed the concerns regarding the lack of adequate therapy staff to provide home health therapy services. During an interview on 3/2/21 at 2:20 p.m., staff member D stated the hospital's therapy department also provided PT services for the home health agency. She stated however, if the home health services "take us away for visits," they would not be able to see patients in their home. She stated the only way to offer therapy services for home health patients was for the patient to come into the outpatient therapy clinic. Staff member D said the therapy department now had two physical therapists, one full-time and one part-time, and two PTA's. For some time there was only one full-time physical therapist, and they could not cover all the outpatient clients, in-patient clients, and the home health clients. She said even after they hired the new part-time therapist, they were still very busy. Staff member D stated they would provide some home health services but would not go over 30 miles out of town. She said if PT was not able to see the patient in their home, they work to find another way to get them services, even if they needed to be discharged from home health. During an interview on 3/2/21 at 3:20 p.m., staff member O stated they were told not to schedule the physical therapist for home health therapy. She said if a patient needed home health therapy services, the patient needed to make a decision if they wanted home health services or PT services, but they could not get both. Staff member O stated staff member B had provided them with names of home health patients who needed therapy services, but they were not able to schedule those patients for PT in their home. During an interview on 3/4/21 at 10:15 a.m., staff member A stated he had just started working for the hospital. He said he was not aware PT was not able to provide home health services. He stated it was the expectation that the PT department provide those services. He said he did check with the hospital's HR department, and the hospital was not currently, actively, trying to recruit for hire an additional physical therapist.