Every finding on record at Premier Point Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 8/15/24. Standard level deficiencies cited. Pt./Pts.= Patient/Patients

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 8/12/24. The undated Emergency Preparedness plan lacked a date, indicating when the plan was last reviewed and updated. 2. During an interview with the Agency Supervisor on 8/15/24 at 11:30 AM, the Agency Supervisor confirmed the Agency failed to review and update the Emergency Preparedness plan biennially.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness policies and procedures, as required. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 8/12/24. The plan contained the Emergency Preparedness policies and procedures which lacked a date, indicating when the policies and procedures were last reviewed and updated. 2. The Emergency Preparedness plan contained the "Hazard Vulnerability Analysis 2021" indicating, the Agency last reviewed and updated the all-hazards risk assessment form in 2021. The plan lacked documentation that the Agency's all-hazards risk assessment was reviewed and updated every 2 years. 3. During an interview with the Agency Supervisor on 8/15/24 at 11:30 AM, the Agency Supervisor confirmed the Agency failed to review and update the Emergency Preparedness risk assessment, policies, and procedures biennially.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update the communication plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include 1. The Emergency Preparedness plan was reviewed on 8/12/24. The plan included a communication plan which included documentation the Agency last reviewed and updated on “4/2/2018”. The Agency failed to review and revise the communication plan every 2 years. 2. During an interview with the Agency Supervisor on 8/15/24 at 11:30 AM, the Agency Supervisor confirmed the Agency failed to review and update the communication plan biennially.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 8/12/24. The plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness plan since 2020. 2. During an interview with the Agency Supervisor on 8/15/24 at 11:30 AM, the Agency Supervisor confirmed the Agency failed to conduct the required testing of its Emergency Preparedness plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 8/15/24. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients. SOC = Start of Care AM = morning PM = afternoon % = Percent RN = Registered Nurse LPN = Licensed Practical Nurse

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 2356 of 5877 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 04/2023 to 03/2024, was reviewed on 8/14/24. The report included error # -3330 for 2356 of 5877 late submissions, which was 40.09% of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Agency Supervisor on 8/14/24 at 3:00 PM, the Agency Supervisor confirmed that the error occurred.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews it was determined that in 2 of 5 patients (Pts. # 7 and # 8) with Aide services, the RN failed to make onsite supervisory visits. Findings include: 1. Pt. # 7 was admitted for home health services on 1/6/24 with the diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 8/13/24. The clinical record contained a POC for certification period 5/5/24 to 7/3/24 that included Aide visits 2 times a week for 9 weeks, and SN visits 1 time a week for 9 weeks. The clinical record contained weekly SN visits completed by the LPN, and Aide visits 2 times week as ordered for the entire certification period. The clinical record lacked onsite RN supervisory visits for the Aide services. 2. Pt. # 8 was admitted for home health services on 11/28/23 with the diagnosis of Type 2 diabetes with diabetic peripheral angiopathy without gangrene. The clinical record was reviewed on 8/13/24. The clinical record contained a POC for certification period 5/26/24 to 7/24/24 that included Aide visits 2 times a week for 9 weeks, and SN visits 1 time a week for 9 weeks. The clinical record contained weekly SN visits completed by the LPN, and Aide visits 2 times week as ordered for the entire certification period. The clinical record lacked onsite RN supervisory visits for the Aide services. 3. Findings of the RN not completing onsite Aide supervisory visits was confirmed during an interview with the Agency Supervisor on 8/14/23 at 2 pm.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure the Physician was sent a copy of the discharge summary. This was found in 4 of 5 (Pts. #13, 17, 15, and 16) closed/discharged clinical records reviewed. Findings include: 1. Pt. #13 was admitted to home health services on 5/6/24 with diagnosis of Unspecified Dementia. The clinical record was reviewed on 8/13/24. The discharge summary was dated 6/26/24. The clinical record lacked evidence that the discharge summary was sent to the Physician. 2. Pt. #17 was admitted for home health services on 11/9/23 with the diagnosis of Dysarthria. The clinical record was reviewed on 8/13/24. The clinical record contained the discharge summary dated 1/5/24. The record lacked documentation that a copy of the discharge summary was forwarded to the Physician. 3. Pt. #15 was admitted for home health services on 6/10/23 with the diagnosis of Hemiplegia Following Cerebral Infarction Affecting Right Doninant Side. The clinical record was reviewed on 8/14/24. The clincal record contained the discharge summary dated 7/5/23. The record lacked documentation that a copy of the discharge summary was forwarded to the Physician. 4. Pt. #16 was admitted for home health services on 11/1/23 with the diagnosis of Spinal Stenosis. The clinical record was reviewed on 8/13/24. The clinical record contained the discharge summary dated 12/13/23. The record lacked documentation that a copy of the discharge summary was forwarded to the Physician. 5. During interviews with the Agency Supervisor on 8/13/24 at 2:00 PM, 8/14/24 at 11:30 AM, 12:15 PM and 3:00 PM; the Agency Supervisor confirmed the Agency failed to send a copy of the discharge summary to the Physician.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 7/22/21. Standard level deficiencies written. Abbreviations: # = number AM = morning PM = afternoon/evening SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist COVID-19 = Coronavirus disease 2019

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to fully assess Patients' Influenza and/or Pneumococcal vaccine status at the SOC, per Agency policy. This was found in 8 of 17 (Pts. #1, 5, 13, 15, 16, 2, 6 and 8) records reviewed. Findings include: 1. Pt. #1. SOC 5/22/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 7/20/21 at 1:10 PM. The record contained the SOC comprehensive assessment, dated 5/22/21. This assessment indicated "yes" to both the Pneumonia and flu vaccinations; however the dates for both of these vaccinations were left blank. 2. Pt. #5. SOC 5/1/21. Primary Diagnosis: Pleural Effusion. The clinical record was reviewed on 7/21/21 at 9:20 AM. The record contained the SOC comprehensive assessment, dated 5/1/21. This assessment indicated "yes" to both the Pneumonia and flu vaccinations; however the dates for both of these vaccinations were left blank. 3. Pt. #13. SOC 5/27/20. Primary Diagnosis: Peripheral Vascular Disease. The clinical record was reviewed on 7/21/21 at 10:00 AM. The record contained the SOC comprehensive assessment, dated 5/27/20. This assessment indicated "yes" to both the Pneumonia and flu vaccinations; however the dates for both of these vaccinations were left blank. 4. Pt. #15. SOC 11/7/20. Primary Diagnosis: Atherosclerosis of Left Leg. The clinical record was reviewed on 7/20/21 at 12:45 PM. The record contained the SOC comprehensive assessment, dated 11/7/20. This assessment indicated "yes" to the flu vaccination; however the date this vaccine was last received by the Pt. was noted as 2/2/16. The record lacked documentation the flu vaccine was offered to the Pt. at the SOC. 5. Pt. #16. SOC 1/18/21. Primary Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 7/21/21 at 10:45 AM. The record contained the SOC comprehensive assessment, dated 1/18/21. This assessment indicated "yes" to both the Pneumonia and flu vaccinations; however the dates for both of these vaccinations were left blank. 6. Pt. #2. SOC 5/25/21. Diagnoses: Hypertensive Urgency and Unspecified Bradycardia. The clinical record was reviewed on 7/20/21 at 12:20 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 5/25/21. The form included a section titled, "Most Recent Immunizations" which was checked "No," indicating the Pt. had not received the Influenza and Pneumococcal Pneumonia immunizations. The assessment form/record lacked documentation the SN offered the vaccines to the Pt., as required by the Agency. 7. Pt. #6. SOC 6/16/21. Diagnoses: Lumbar Region Spondylolsyis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 7/20/21 at 7:30 AM. The record contained the SOC comprehensive assessment form completed by the SN and dated 6/16/21. The section titled, "Most Recent Immunizations" was checked "Yes," indicating the Pt. had received the Influenza and Pneumococcal Pneumonia immunizations. The assessment form/record lacked the dates the Pt. received the vaccines, as required by the Agency. 8. Pt. #8. SOC 6/19/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Dominant Side. The clinical record was reviewed on 7/19/21 at 2:45 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 6/19/21. The section titled, "Most Recent Immunizations" was checked "Yes," indicating the Pt. had received the the Influenza and Pneumococcal Pneumonia immunizations. The assessment form/record lacked the dates the Pt. received the vaccines. 9. The Agency policy titled, "Administration and Documentation of Medications" was reviewed on 7/21/21 at 9:50 AM. The policy required: "11. Influenza and Pneumococcal vaccines... may be administered after an assessment of the patient to determine screening contraindications." 10. During an interview with the Director of Clinical Strategy/ Agency Supervisor on 7/21/21 at 9:47 AM, the Director of Clinical Strategy/Agency Supervisor stated: Staff are required to inquire regarding the need for Influenza and Pneumococcal Pneumonia vaccines during the SOC. If the Pt. had the vaccine, the staff are required to enter the date(s) the patient received the vaccines. The patient's response is entered into the SOC comprehensive assessment form. 11. During an interview with the President and the Director of Clinical Strategy/ Agency Supervisor (Administrative Staff) on 7/21/21 at 2:00 PM and 3:05 PM, the Administrative Staff confirmed the staff failed to assess and/or document the patient's Influenza and/or Pneumococcal Pneumonia vaccine status, as required by the Agency.

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: . A. Based on a review of clinical records, observation during a home visit, Agency policy, and staff interview, it was determined that the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. service; and ensure staff comply with the Agency's Bag Technique policy. This was found in 3 of 17 (Pts. #5, 13, and 6) records reviewed.. Findings include: 1. Pt. #5. SOC 5/1/21. Primary Diagnosis: Pleural Effusion. The clinical record was reviewed on 7/21/21 at 9:20 AM. The record contained documentation the SN provided service on 5/1/21, 5/4/21, 5/5/21, 5/11/21, 5/12/21, 5/18/21, 5/25/21, 6/3/21, and 6/14/21. The SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms prior to providing service on these dates 2. Pt. #13. SOC 5/27/20. Primary Diagnosis: Peripheral Vascular Disease. The clinical record was reviewed on 7/21/21 at 10:00 AM. The record contained documentation the SN provided service on 5/27/21, 5/29/21, 6/1/21, 6/5/21, 6/8/21, 6/10/21, and 7/1/21. The SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms prior to providing service on these dates. 3. Pt. #6. SOC 6/16/21. Diagnoses: Lumbar Region Spondylolsyis and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 7/20/21 at 7:30 AM. The record contained the PT visit notes dated 6/24/21, 6/29/21, 7/1/21 and 7/6/21 indicating service was provided. The PT visit notes lacked documentation the PT screened the Pt. before the visit for symptoms of COVID-19, as required by the Agency. A home visit was conducted with E #13 on 6/16/21 at 9:00 AM. During the home visit, observed E #13 remove a blood pressure machine (reusable equipment) from his bag and use it on the Pt. E #13 proceeded to clean the blood pressure machine with a hand sanitizer wipe and return to his bag. 4. The Agency policy titled, "Bag Technique" was reviewed on 7/21/22 at 9:20 AM. The policy required: "...5. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution... and supplies will be returned to the bag..." 5. During the entrance interview with the President and the Director of Clinical Strategy/ Agency Supervisor on 7/19/21 at 9:15 AM, the Director of Clinical Strategy/ Agency Supervisor stated: "Before the visit, staff call (the Pt.) and ask the Pt. or family member COVID screening questions. This is documented in their notes." 6. During an interview with the President and the Director of Clinical Strategy/ Agency Supervisor (Administrative Staff) on 7/21/21 at 3:05 PM, the Clinical Strategy/ Agency Supervisor stated: "Staff are required to clean reusable equipment with 75% alcohol wipes, which are provided by the Agency." 7. During an interview with the President and the Director of Clinical Strategy/ Agency Supervisor (Administrative Staff) on 7/21/21 at 2:00 PM and 3:05 PM, the Administrative Staff confirmed the staff failed to comply with Agency policy and procedures relative to Infection Control.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: A. Based on the Illinois Administrative Code, observation and staff interviews, it was determined the Governing Body failed to ensure the parent Agency reported its branch office to the State Agency. This has the potential to affect all services provided by the Agency. Findings include: 1. 77 Illinois Administrative Code Section 245.20 defines: "Branch Office - a location or site from which an agency provides services within a portion of the total geographic area served by the parent agency. The branch office is part of the agency and is located sufficiently close to share administration, supervision and services in a manner that renders it unnecessary for the branch to be independently licensed. " 2. An entrance interview was conducted on 7/19/21 at 9:15 AM. During the interview, the President stated the Agency had an office for "support staff across the street at 4700 N. Sheridan". 3. On 7/19/21 at 2:15 PM, a tour was conducted with the President at the "support staff" office at 4700 N. Sheridan Road, ground floor (across the street from the Agency). Multiple cubicles were observed with staff working. The President stated the office is used for: "Billing, claims, intake, social services and IT support". 4. During the tour of the 4700 N. Sheridan Road site on 7/19/21, an observation was made of E#5 (Social Worker/direct staff/date of hire 2/2/15) sitting at a desk with a telephone, cabinets, drawers and documents inside the drawers. E#5 stated, she work in this office Monday through Friday since hired in 2015. E#5 stated: "I have some documents here, I take notes and eventually load them into ...clinical record". 5. During the tour of the 4700 N. Sheridan Road site on 7/19/21, an observation was made of E#7 (Social Worker/direct staff/date of hire 4/15/12) sitting at a desk on the telephone. The cubicle had cabinets with drawers. E#7 stated: "I keep some documents in here that I use, so its nearby". E#7 opened a drawer and I observed multiple documents in hanging files. E#7 stated he has worked in this office for the past 5 years, Monday through Friday. 6. An interview was conducted with the Director of Clinical Strategy/Agency Supervisor on 7/20/21 in the 4701 N. Sheridan Road office at 12:20 PM. An inquiry was made for a shredder or shred box to dispose sensitive documents within the Agency. The Director of Clinical Strategy/Agency Supervisor stated the other office across the street at 4700 N. Sheridan has a shred box to dispose agency documents, that documents from the 4701 N. Sheridan office are carried across the street and disposed. The Agency maintains patient, staff and business documents in the 4700 N. Sheridan Road office, until they are destroyed. As of 7/20/21, the office at 4700 N. Sheridan Road, Chicago, IL. is a functional and operational site, maintained and used as a branch office as identified by 77 Illinois Administrative Code Section 245.20. 7. During an interview with the President and the Director of Clinical Strategy/Agency Supervisor on 7/21/21 at 3:05 PM, both confirmed the operation of the office location at the secondary site has not been reported to the State Agency for approval.