Every finding on record at Precious Care Home Health Inc

Purpose of visit: Recertification/Re-licensure Survey Entrance: 09/08/2021 The agency's census was: Hospice-16 Exit: 09/10/2021 An entrance conference was conducted on 09/08/2021 at 12:25 PM with the Administrator and Office Coordinator/PAS Supervisor. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 09/10/2021 at 2:51 PM with the Administrator and Office Coordinator/PAS Supervisor. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. The agency was not in compliance with deficiencies and violations cited. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI).

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), §485.625(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, 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 record review and interview, the agency failed to test the response phase of its emergency preparedness and response plan in a planned drill if not tested during an actual emergency response for two of three years reviewed (2019 and 2020). This failure placed agency operations and client lives at risk in the event of a disaster occurring as the agency would not know if the plan was effective or not. Findings include: Record review of the emergency preparedness plan: Review of the agency's emergency preparedness binder showed no documentation of agency's performance of drills for its emergency preparedness and response plan for years 2019 and 2020. In an interview on 09/10/2021 with the Alternate Administrator/ Director of Nursing (Employee A) at 1:40 p.m., the surveyor reviewed the findings regarding the lack of emergency preparedness drills. The surveyor asked why the agency did not have emergency preparedness drills for the years 2019 and 2020? The Alternate Administrator/ Director of Nursing (Employee A) stated, "I don't know."

Purpose of visit: Recertification/Re-licensure Survey Entrance: 09/08/2021 The agency's census was: Hospice-16 Exit: 09/10/2021 An entrance conference was conducted on 09/08/2021 at 12:25 PM with the Administrator and Office Coordinator/PAS Supervisor. The agency was informed that the purpose of the survey was to conduct a Recertification/Re-licensure Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 09/10/2021 at 2:51 PM with the Administrator and Office Coordinator/PAS Supervisor. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violation. The agency was not in compliance with deficiencies and violations cited. Abbreviations: Quality Assessment Performance Improvement Plan (QAPI).

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that written notification of discharge was delivered to 3 of 3 discharged clients (#6, #7, & #8) patient records reviewed whose reason for DC was goals met. The agency failed to provide the completed CMS form titled, "Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. Findings include: Client #6 Review of the agency's discharge record showed client #6 was discharged from the agency on 05/27/2019. The clinical record did not contain a CMS form titled, "Notice of Medicare Non-Coverage". Client #7 Review of the agency's discharge record showed client #7 was discharged from the agency on 05/06/2019. The clinical record did not contain a CMS form titled, "Notice of Medicare Non-Coverage". Client #8 Review of the agency's discharge record showed client #8 was discharged from the agency on 05/02/2019. The clinical record did not contain a CMS form titled, "Notice of Medicare Non-Coverage". During an interview session with Alternate Administrator (Employee A) on 09/10/2021 at 12:29 p.m., the surveyor asked why the agency had not provided CMS form titled, "Notice of Medicare Non-Coverage" for Clients 6, 7, and 8 discharged from the agency with goals met. The Alternate Administrator/Director of Nursing (Employee A) replied, "I don't know."

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 observation, record review and interview, the agency failed to enforce its written policies to control infection including the prevention of the spread of infectious disease in that: The agency failed to update its infection control policy to include measures on how to maintain surveillance and identification, reporting, prevention, and control of the spread of the Novel COVID-19 virus among agency's clients and staff. Failure to screen staff and patients for COVED-19 prior to making home visits or immediately arrival to the home placed those individuals at risk for exposure to COVID-19 which could lead to illness or death. Findings include: The agency policy titled, "INFECTION CONTROL PROGRAM IC.1" with a revision date of 09/25/07 read in part, "... POLICY bs infection control program will be based on the following criteria: ....Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections. CDC .... Current Federal/State/local laws and regulations ..." Review of agency's policies on infection control documentation contained no information about the Novel COVID-19 Pandemic that started threatening the health and safety of the global community in 2020. Review of the agency's infection control folder also contained no information about the COVID-19 virus. Observation upon entry into the agency's office on 09/08/2021 revealed that none of the agency's staff checked the surveyor's temperature or conducted any COVID-19 screening protocols. During interview with the administrator on 09/08/2021 at 1:13 p. m. she was presented with the above findings of the agency's infection control policy not being updated to include the novel COVID-19 virus she stated that all the agency had done about the COVID-19 pandemic was produce a binder with COVID-19 educational information which she presented to the surveyor. The administrator did not respond to the surveyor's inquiry as to the reason agency did not update their infection control policy to include the COVID-19 Pandemic... During interview with the Office Manager/PAS Supervisor on 09/08/2021 at 1:15p.m. on whether the agency's staff self-screened daily, she stated that the agency sent an email to all agency's field staff to conduct daily COVID-19 self-screenings and to screen paients/clients and household members, but the agency did not have documentation of the staff screenings and no documentation of the office staff screenings to show the surveyor. During interview with the Supervising Nurse on 08/05/2021 on whether the agency's staff self-screened daily, she stated that the agency sent an email to all agency's field staff to conduct daily COVID-19 self-screening, but the agency did not have documentation of the staff screenings and no documentation of the office staff daily screenings to show the surveyor. The agency policy titled, "INFECTION CONTROL PROGRAM IC.1" with a revision date of 09/25/07 read in part, "... POLICY bs infection control program will be based on the following criteria: ....Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections. CDC .... Current Federal/State/local laws and regulations ..."