Every finding on record at Premium Health at Home Rawlins LLC

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 7/17/24 to 7/23/24. The following common abbreviations are used throughout this document: DON: Director of Nursing EP: Emergency Preparedness HHA: Home Health Aide PT: Physical Therapist POC: Plan of Care QAPI: Quality Assurance/Process Improvement RN: Registered Nurse

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), §485.542(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, REHs at §485.542, "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 review of the facility’s emergency preparedness (EP) plan and staff interview, the facility failed to provide initial training to new staff and failed to provide training every two years to existing staff. The agency roster included the owner, RN #1, RN #2, PT #1, and homemaker #1 and the patient census was 4. The findings were: 1. Review of the agency EP plan showed the agency had a process for educating patients and caregivers in basic emergency preparedness. However, further review showed no evidence of staff training related to their role in the EP plan. 2. Interview with RN #2 on 7/22/24 at 4:53 PM revealed she was hired 1/26/24 and had not received any training related to EP and was unsure of her role within the agency in the event of an emergency.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the facility’s emergency preparedness (EP) plan and staff interview, the facility failed to conduct exercises to test the emergency plan. The patient census was 4. The findings were: 1. Review of the agency EP plan showed no evidence the plan had been tested. 2. Interview with the DON on 7/22/24 at 10:15 AM confirmed there had been no actual emergencies that required activation of the EP plan and she was unsure of the last time the EP plan had been drilled or tested.

A recertification survey was conducted by Healthcare Licensing and Surveys from 7/17/24 to 7/23/24.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, patient interview, waiver case manager interview and staff interview the agency failed to promptly alert the physician to any changes in the patient's condition and/or that the plan of care should be altered for 2 of 7 sample patients (#2, #3). The findings were: 1. Review of the medical record for patient #2 showed admission to the agency on 7/10/24 and the patient had orders for skilled nursing, physical therapy and a home health aide (HHA) “2-3 x per week”. The following concerns were identified: a. RN #2 admitted the patient and developed a HHA plan of care dated 7/10/24 that included bathing "2 x weekly, as needed". b. Review of the patient's home visit notes showed the patient had not received a home health aide since admission. c. Interview with RN #2 on 7/22/24 at 4:35 PM revealed she had developed the HHA plan of care on the admission visit (7/10/24) then saw the patient again on 7/16/24 and the patient reported being able and willing to shower safely without a HHA and thus did not need assistance with bathing. However, the RN verified she had not notified the physician and/or received orders to revise the plan of care to discontinue the order for a home health aide. 2. Review of the medical record for patient #3 showed admission to the agency on 7/3/24 for a home health aide and a housekeeper as authorized by the Wyoming Medicaid Waiver program. The following concerns were identified: a. RN #2 admitted the patient and developed a HHA plan of care dated 7/3/24 and the plan of care (POC) included both personal care and housekeeping services "up to 3 x weekly". b. Review of the patient’s visit notes showed the patient had received housekeeping services 3 times a week from the agency but not a home health aide. c. Interview with the patient on 7/19/24 at 8:15 AM revealed the patient was satisfied with the housekeeper services and understood the agency did not have a home health aide available at that time to assist with a shower and that was okay for now as long as the agency would provide a housekeeper. d. Interview with the agency vice president on 7/22/24 at 12:30 PM revealed the patient's Medicaid waiver case manager called them when the patient had been abruptly discharged from another agency and they agreed to provide a HHA and housekeeper. She further revealed the agency had one HHA employed by the agency and the HHA was out unexpectedly on medical leave but the agency anticipated the eventual return of the HHA and had been attempting to recruit additional staff without success. e. Interview with the Medicaid waiver case manager on 7/22/24 at 12:42 PM verified the patient had been abruptly discharged from another agency and this agency was the only other provider in the service area so the patient was admitted to them for HHA and housekeeping services. f. Interview with RN #2 on 7/22/24 at 4:30 PM revealed the patient’s POC had authorization for a HHA and a housekeeper. The nurse confirmed the agency did not have a HHA available and the patient agreed to housekeeping services and had a family member that would be present and/or assist with showers as needed. The RN stated if the patient needed additional assistance she would provide shower assistance as needed. However, the RN verified she had not notified the physician and/or revised the plan of care to reflect the services the patient was actually receiving.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on review of the agency's quality assurance/process improvement (QAPI) plan and staff interview, the agency failed to identify indicators for their QAPI program and monitor and measure the indictors to improve health outcomes, patient safety, and quality of care for the patients. The findings were: 1. Review of the quality assurance/process improvement program (QAPI) showed the agency was collecting data related to quality improvement but had not identified indicators to monitor and measure to improve health outcomes, patient safety and quality of care for the patients. 2. Interview with the Director of Nursing on 7/7/22/24 at 10:30 AM confirmed the agency had collected data but the agency had not used that information to develop an effective, on-going, agency wide, written quality management program. 3. Interview with RN #2 on 7/22/24 at 4:55 PM revealed she was not aware of the QAPI program and what her role was within the program.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review, patient interview, Medicaid waiver case manager interview and staff interview the agency failed to ensure patients received all the services in the plan of care (POC) for 2 of 7 sample patients (#2, #3). The findings were: 1. Review of the medical record for patient #2 showed admission to the agency on 7/10/24 and the patient had orders for skilled nursing, physical therapy and a home health aide (HHA) “2-3 x per week”. The following concerns were identified: a. RN #2 admitted the patient and developed a HHA plan of care dated 7/10/24 that included bathing "2 x weekly, as needed". b. Review of the patient's home visit notes showed the patient had not received a home health aide since admission. c. Interview with RN #2 on 7/22/24 at 4:35 PM revealed she had developed the HHA plan of care on the admission visit (7/10/24) then saw the patient again on 7/16/24 and the patient reported being able and willing to shower safely without a HHA and thus did not need assistance with bathing. 2. Review of the medical record for patient #3 showed admission to the agency on 7/3/24 for a home health aide and a housekeeper as authorized by the Wyoming Medicaid Waiver program. The following concerns were identified: a. RN #2 admitted the patient and developed a HHA plan of care dated 7/3/24 and the plan of care (POC) included both personal care and housekeeping services "up to 3 x weekly". b. Review of the patient’s visit notes showed the patient had received housekeeping services 3 times a week from the agency but not a home health aide. c. Interview with the patient on 7/19/24 at 8:15 AM revealed the patient was satisfied with the housekeeper services and understood the agency did not have a home health aide available at that time to assist with a shower and that was okay for now as long as the agency would provide a housekeeper. d. Interview with the agency vice president on 7/22/24 at 12:30 PM revealed the patient's Medicaid waiver case manager called them when the patient had been abruptly discharged from another agency and they agreed to provide a HHA and housekeeper. She further revealed the agency had one HHA employed by the agency and the HHA was out unexpectedly on medical leave but the agency anticipated the eventual return of the HHA and had been attempting to recruit additional staff without success. e. Interview with the Medicaid waiver case manager on 7/22/24 at 12:42 PM verified the patient had been abruptly discharged from another agency and this agency was the only other provider in the service area so the patient was admitted to them for HHA and housekeeping services. f. Interview with RN #2 on 7/22/24 at 4:30 PM revealed the patient’s POC had authorization for a HHA and a housekeeper. The nurse confirmed the agency did not have a HHA available and the patient agreed to housekeeping services and had a family member that would be present and/or assist with showers as needed. The RN stated if the patient needed additional assistance she would provide shower assistance as needed.

A recertification survey and a COVID-19 focused infection control survey, which included a review of emergency preparedness requirement was conducted by Healthcare Licensing and Surveys from 7/12/21 to 7/15/21. The following common abbreviations are used throughout this document: OASIS: Outcome and Assessment Information set POC: Plan of Care RN: Registered Nurse

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patient consent for care forms were completed for 5 of 7 sample patients (patient #1, #2, #3, #4, #7). The findings were: 1. Review of medical records for patient #1 showed the patient was admitted to the agency on 7/31/2021. Further review showed the patient was to receive skilled nursing services weekly. However, the admission consent for services form was unsigned by the patient or patient representative. 2. Review of medical records for patient #2 showed the patient was admitted to the agency on 6/23/2021. Further review showed the patient was to receive skilled nursing services and physical therapy 2 times a week for 60 days. However, the admission consent for services form was unsigned by the patient or patient representative. 3. Review of medical records for patient #3 showed the patient was admitted to the agency on 6/7/21. Further review showed the patient was to receive skilled nursing services 3 times a week. However, the admission consent for services form was unsigned by the patient or patient representative. 4. Review of medical records for patient #4 showed the patient was admitted to the agency on 6/23/2021. Further review showed the patient was to receive skilled nursing services and physical therapy 2 times a week for 60 days. However, the admission consent for services form was unsigned by the patient or patient representative. 5. Review of medical records for patient #7 showed the patient was admitted to the agency on 11/24/21. Further review showed the patient was to receive physical therapy 1 to 2 times a week. However, the admission consent for services form was not started. 6. Interview with owner on 7/15/21 at 9 AM confirmed the patients' consents were not signed by the patient or patient representative or not started.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview, and policy and procedure review the agency failed to ensure the initial assessment visit was completed within the required timeframe for 2 of 7 sample patients (#4, #7). The findings were: 1. Review of the physician's order dated 6/15/2021 showed patient #4 was referred for home health services, including skilled nursing services and physical therapy. Review of the start of care OASIS assessment showed the initial assessment visit was dated 6/23/2021, 8 days after the physician order for home health services. Further review showed the patient's diagnosis included hemiplegia following a cerebral infarct affecting the right, dominant side. Interview with the agency owner on 7/14/2021 at 3 PM confirmed there was no evidence the physician was aware of or approved the delay in start of care. 2. Review of the physician's written order dated 11/13/20 showed patient #7 was referred for home health services, including physical therapy. Review of the start of care OASIS assessment showed the initial assessment visit was dated 11/24/20, 11 days after the physician's order for home health services. Further review showed the patient's diagnoses included right hip fracture from fall followed by open reduction and internal fixation (ORIF). Interview with the owner on 7/14/21 at 9:20 AM confirmed there was no evidence the physician was aware of or approved the delayed start of care. 3. Review of the policy "Processing Referrals", updated, showed "... Procedure: ... If the patient is not opened on the ordering/referring date or within 48 hours per patient request or due to other circumstances, the physician will be notified ..."

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on staff interview and policy review the agency failed to ensure measurable quality improvements were implemented, measured, analyzed, tracked and monitored. The findings were: Interview with the agency owner on 7/14/21 at 11:57 AM revealed the agency had Quality Assurance meetings every 3 months. However, the owner revealed the agency failed to maintain documentation of the meetings. Review of policy "Quality Assessment & Performance Improvement" undated showed "...d. QI meetings will be held as often as necessary, by no less than once every six (6) months, to address monitoring results and issue identified through the QI process..."

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, staff interview, and policy review the agency failed to ensure proper infection control practices were observed in the home during 1 of 3 home visits (patient #7) observed. Observation on 7/13/21 at 10 AM showed RN #1 was providing wound care to patient #3. The RN removed the old dressing, then cleaned and measured the wound. The RN then redressed the wound. The RN failed to change gloves and perform hand hygiene between removing the soiled dressing and applying the clean dressing. Interview at that time with the RN confirmed the gloves were not changed and no hand hygiene was performed. Interview on 7/13/21 at 11:30 AM with the agency owner revealed it was the agency's expectation for staff to change gloves and do hand hygiene between dirty and clean wound dressing change.

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 observation, staff interview and policy review, the agency failed to ensure supplies available for use were not expired in 1 of 1 supply storage area. The findings were: 1. Observation of the agency's supply storage on 7/12/21 at 3:48 PM identified the following concerns. a. Sixteen 10 milliliter (ml) syringes of 0.9% sodium chloride injection solution expired 7/1/21. b. Fifteen 300 unit per 3 ml syringes of heparin lock flush solution expired 2021/03. c. One hundred sterile cotton tipped applicators expired 2021/02. d. Six blood collection set 25 gauge by 3/4 inch by 12 inch vacutainers expired 6/30/2020. e Six bottles plain packing strip 1/4 inches by 5 yards expired 10/2020. 2. Interview with the owner on 7/12/21 at 3:48 PM confirmed the supplies were available for patient use, and the supplies were past the expiration date. 3. Review of the policy "Management of Expired Supplies", updated, showed ..."2. Expired products are removed and disposed of at the agency level..."