Every finding on record at Preferred Certified, LLC

The following statement of deficiency represents the results of a re-certification survey of Preferred Certified Home Health Agency, ID# 337432 located at 280 N Bedford Road, Mount Kisco, NY, 10549. A Condition Level Survey was initiated on 5/23/22. On 5/24/22 a review of the agency's Emergency Preparedness Plan was conducted. The Governing Authority failed to ensure the agency develop and maintain a comprehensive emergency preparedness program that meets all applicable requirements. During the re-certification survey conducted on 5/24/22 a review of the agency's Emergency Preparedness Plan was conducted. The Governing Authority failed to ensure the agency develop and maintain a comprehensive emergency preparedness program that meets all applicable requirements. The following deficiencies were identified : E0036- Emergency Preparedness Training and Testing E0037- Emergency Preparedness Training Program

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and staff interview the agency failed to ensure that the agency develops and maintains an emergency preparedness training and testing program that is based on the emergency plan, their risk assessment, policies and procedures, and the communication plan at least every 2 years. Failure to ensure that the agency develops and maintains an emergency preparedness training and testing program at least every 2 years has the potential that the staff is unable to respond appropriately during emergency situation. The findings are: There is no documented evidence of the agency’s emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures, and communication at least every 2 years. On 05/24/2022 at 3:20pm, the Administrator was interviewed and did not provide an explanation for the survey findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and staff interview the agency failed ensure all staff receive an initial training in emergency preparedness policies and procedures and demonstrate knowledge of emergency procedures. Failure to ensure all staff receive initial training in emergency preparedness policies and procedures and demonstrate their knowledge of the emergency procedures has the potential for negative outcome. The findings: Employee #1, #2, #3, and #4 have a hire date of 1/23/2022. There is no documented evidence that agency provided initial training in emergency preparedness policies and procedures to the staff, and no documented evidence of staff demonstrating knowledge of emergency procedures. On 05/24/2022 at 3:20pm, the Administrator was interviewed and did not provide an explanation for the survey findings.

The following statement of deficiency represents the results of a re-certification survey and a focus COVID -19 infection control survey of Preferred Certified Home Health Agency, ID# 337432 located at 280 N Bedford Road, Mount Kisco, NY, 10549 initiated on 5/23/22. The survey exit date is 5/27/22. On 5/23/2022 at 11:45 AM the Administrator was interviewed and stated, "we (agency) do not have any patients on our census. They are no patients." During the pre-survey review on 05/20/22 ASPEN Central Office (ACO) documents: CHOW (Change In Ownership)/ Operator effective 8/25/2020. There is no documented evidence of the agency providing services to patients after the change in ownership. A Condition Level Survey was initiated. Deficient practices were identified within Level 1 standards 484.105 Condition : Organization and administration of services. Significant findings were identified within (CoP) Condition Of Participation: 484.45 Condition: Reporting OASIS information and 484.65 Condition: Quality assessment/performance improvement. The survey consisted of a review of five (5) personnel records identified as Employee #1, #2, #3, #4, and #5, review of the Quality Assurance and Performance (QAPI) Program – The Infection Control Policy: The Covid-19 Infection Control Policy, the COVID -19 vaccination policy : The Emergency Preparedness Plan : The Health Commerce System Policy: The Complaint Policy: Pre-survey activities consisted of a review on 5/13/22 and 5/20/2022 of the agency's Health Commerce System Account, the agency’s iQIES (Internet Quality Improvement and Evaluation System) Reports – OASIS Reports for the period 2020 to 2021, the agency’s iQIES Reports -OASIS Agency Final Validation Submission Reports, the compliance with the 2019 Statistical Report and the 2019 Emergency Drill. Findings were reviewed at the exit conference on 5/27/22 . The following deficiencies are identified as a result of the survey: E0036- EP Training and Testing E0037- EP Training Program G0370- Reporting OASIS information G0414-HHA administrator contact information G0640- Quality assessment/performance improvement G0646- Program Activities G0684- Infection Control G0687- COVID -19 Vaccination G0658- Performance improvement projects G0940- Organization and administration of services G 098- Skilled services furnished G 0984- In accordance with current clinical practice G 999-: Final Observations J1260-Governing authority J1460- Personnel L - 0000 - Initial Comments L- 0001 - Unacceptable Infection Control Procedures

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on review of iQIES (Internet Quality Improvement and Evaluation System) Report -CASPER ( Certification And Survey Provider Enhanced Reports) and staff interview the agency failed to ensure that OASIS (Outcome and Assessment Information Set) information was submitted as required. Failure to ensure all OASIS data is collected and submitted has the potential for negative outcome. The findings are: On 5/12/22 and 5/20/22 during the pre-survey review the following iQIES Reports were requested: 1. The Agency Patient- Related Characteristics (Case Mix) Report. The report notification documents: “there is no results for this report criteria.” 2.The Potentially Avoidable Event Report. The report notification documents: “there is no results for this report criteria.” There is no documented evidence of the agency submitting all the required OASIS data. On 5/24/22 at 11:30 AM the Administrator/ DPS was interviewed and did not provide an explanation for the findings.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on admission packet review and staff interview, the agency failed to ensure that all contact information for the agency is accurate in order to receive patient complaints. Failure to ensure all required contact information is accurately included in the admission packet has the potential for negative patient outcomes. The finding is: The agency’s “Admission Booklet” documents: “Initiating a Complaint:” “1. Notify the Clinical Manager by phone at (718) 748-7447;” “2. Notify the Administrator, (name), by phone (718 748-7447;” and “3. If you are not satisfied with the initial outcome of the complaint, you may appeal the initial decision to our Board of Director/Other by calling (718) 748-7447.” On 05/24/2022 at 1:45PM, the surveyor called 718-748-7447 and the number is identified as belonging to another agency. The “Admission Booklet" lacks evidence that patients are provided with the direct telephone number of the agency in order to file complaints. On 05/24//2022 at 2:30PM, the Administrator /Director of Patient Services was interviewed and did not provide an explanation for the survey findings.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on review of the agency's policies and procedures and interviews with the Administrator/DPS the Governing Authority (GA) failed to ensure the development, implementation and maintenance of an agency-wide data driven QAPI (Quality Assessment Performance Improvement) program. Failure to ensure the development, implementation and maintenance of an agency wide data driven QAPI program has the potential for negative patient outcome. The findings are: On 5/23/22 at 11:30 am, the Administrator/DPS was interviewed and the Quality Management Program documentation was requested. On 5/24/22 at 11:30 am, the surveyor reviewed the Survey Documentation/ Information Required form with the Administrator/DPS who stated, “there is no Quality Management program information.” On 5/24/22 at 2:20pm the Preferred Certified, LLC Quality Assessment and Performance Improvement (QAPI) Plan Policy was received. The Policy documents: “The Governing Body is ultimately responsible for the QAPI Plan and for ensuring that the QAPI Plan is ongoing, implemented and maintained. A formal evaluation of all QAPI activities will occur annually.” There is no documented evidence of an annual Quality Management Plan. On 5/27/22 at 12:45pm the Administrator/DPS was interviewed and did not provide any additional explanation.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on staff interviews, the Governing Authority failed to ensure all the required Quality Improvement activities and functions were being conducted. Failure to ensure that the Quality Improvement committee conducts all the required functions and activities, has the potential for negative outcomes. The findings are: On 5/23/22 at 12:00PM, the agency’s Quality Management Program activities were requested. On 5/24/22 at 12:00 Noon the Information/ Document form was reviewed, and the Quality Management Program and Performance Improvement Project was requested. This was not received. There is no documented evidence of Quality Management Program activities being conducted. On 5/24/22 at 1:45 PM, the Director of Patient Services was interviewed and stated, "there is no documentation".

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based staff interviews, the Governing Authority failed to develop, implement and conduct an ongoing Performance Improvement Projects. Failure to ensure a performance improvement project is developed and implemented has the potential for negative outcome. The findings are: On 5/24/22 at 12 Noon the Quality Management Program and Performance Improvement Project was requested. On 5/24/22 at 2:00PM the Director of Patient Services was interviewed and stated, “there is no Performance Improvement Project.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on staff interviews, the Governing Authority failed to ensure that the quality improvement program is established. Failure to ensure that the quality improvement program is defined and established has the potential risk for negative patient outcomes. The finding is: On 5/24/22 at 12:00 Noon the Quality Management Program and Performance Improvement Plan was requested. This was not received. The agency lacks documented evidence of an active ongoing quality management and performance improvement program. On 5/24/22 at 2:45 PM the Administrator was interviewed and stated, "there is no documentation for Quality Management Program and Performance Improvement".

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on staff interview, the Governing Authority failed to develop and policies for surveillance, identification, prevention, control, and investigation of all infectious and communicable diseases. Failure to develop and maintain policies and procedures for the surveillance, identification, prevention, control, and investigation of all infectious and communicable diseases has the potential for negative outcome. The findings are: On 5/23/22 at 11:50AM the Influenza Vaccination and Flu Mask Requirement Policy was requested. On 5/24/22 at 12:Noon, 1:17PM and 2:03PM the Influenza Vaccination and Flu Mask Requirement Policy was requested again. This information was not received. There is no documented evidence of a written Influenza Vaccination and Flu mask Policy. On 5/24/22 at 4:15PM the Administrator/DPS was interviewed and did not provide additional information regarding the request for the Influenza Vaccination and Flu mask Policy.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review and staff interview, the Governing Authority failed to develop a comprehensive written policy for COVID-19 vaccination to ensure that all staff are fully vaccinated. Failure to develop a comprehensive written policy for COVID-19 to ensure that all staff are fully vaccinated have the potential for negative patient outcomes. The findings are: On 5/23/22 at 11:00 AM the COVID-19 Infection and the COVID-19 Vaccination Policies were requested. On 5/24/22 at 12:00 Noon the COVID-19 Infection and the COVID-19 Vaccination Policies were requested. The Preferred Certified, Operations and Provision of Care LLC COVID-19 ETS Policy documents: “ The Organization shall require employees to be fully vaccinated unless – the vaccination is medically contraindicated, medical necessity requires a delay in vaccination, those entitled to reasonable accommodation under federal civil rights law. Organization shall maintain a record and roster of each employee’s vaccination status. On 5/24/22 at 1:45 PM the COVID-19 employee vaccination roster and agency’s tracking system for COVID Vaccination was requested. This information was not received. The agency lacks documented evidence of a process/system for tracking the required COVID-19 employees’ vaccination. On 5/24/22 at 4:30PM the Administrator was interviewed and did not provide an explanation for the finding.

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 staff interview the Governing Authority failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity. Failure to ensure the maintain the agency’s highest functional capacity has the potential for negative outcome. The finding is: On 5/24/22 at 1:437PM the agency's Home Health Agency Survey And Deficiencies Report (1572)(a) documents: Patient census since the last twelve (12): Admissions : No entry : Discharges: No entry ". There is no documented evidence for Preferred Certified, LLC in iQIES (Internet Quality Improvement and Evaluation System) and no documented evidence of OASIS (Outcome and Assessment Information Set) Reports. There is no documented evidence of the agency maintaining a functional capacity to provide services for the year 2020 and 2021. On 5/24/22 at 2:30 PM the Administrator was interviewed and did not provide an explanation for the finding.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on staff interview the Governing Authority failed to ensure visiting skilled nursing services were available for the patient's home. Failure to ensure visiting skilled nursing services are available has the potential for negative outcome. The finding is: On 5/24/22 at 1:30PM the agency’s employee list was reviewed. There is no documented evidence of visiting skilled field nursing staff on the employee roster. On 5/24/22 at 3:00PM the Administrator was interviewed and stated ,”we do not have field staff( Professional Disciplines to provide services in the home).”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on staff interview the Governing Authority failed to ensure HHA services for skilled nursing services were provided. Failure to ensure HHA skilled nursing services are available and are being provided has the potential for negative outcome. The finding is: The Home Health Agency Survey and Deficiency Report (Form CMS-1572 (a) lacks documented evidence of patient admissions and discharges for the past twelve months. On 5/24/22 at 1:37 PM the Administrator was interviewed and did not provide an explanation for the finding.