Every finding on record at Primary Home Health

A recertification survey was conducted at Lifetouch Home Health from 5/2/2023 through 5/4/2023 to assess compliance with Emergency Preparedness. Deficiencies were identified and cited.

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 interview and record review, it was determined the home health agency (HHA) did not develop, establish or maintain a comprehensive emergency preparedness plan. Specifically, the emergency plan submitted had agency specific information that was missing and the plan submitted did not include the following: natural disasters; man-made disasters; and facility-based disasters. Findings Include: On 5/2/2023, at the entrance conference, the emergency preparedness policy and procedures were as for. On 5/2/2023 at 2:48 PM, the emergency preparedness policy and procedures were received and reviewed. The policy named "EMERGENCY PREPAREDNESS PLAN" had the following areas that were not agency specific: "...[3.2.3.x (Identify location: describe circumstances.)] 3.2.4...[Describe process.] 3.3.2.x (Identify process) 3.3.2.x (identify others.) 3.3.3.x (Identify others.) 3.6.1 The [identify title] 3.6.2 [identify title] notifies [list all names, titles of management staff.] 3.6.3 [identify title] 3.6.4 [identify title]. 3.6.5... [identify title] 3.6.6...[identify title] 3.6.7...[identify title] 3.6.8... [identify title]... [List telephone numbers] 3.6.9.1...[when] 3.6.9.2... [list station number] 3.6.9.3... [when staff may use their own cellular phones OR where staff may obtain cellular telephones.] 3.6.9.4,,,[list number]... [list number].,..[identify other points.] 3.6.11 [identify titles(s)]." On 5/2/2023 at 2:48 PM, the administrator stated, "The Emergency Preparedness Plan and Risk Assessments are part of the admit packet.." The admit packet was reviewed and did not include an emergency preparedness plan or risk assessment.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not maintain an emergency plan that was based on and included a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: On 5/2/2023 at 10:30 am, surveyors requested the agency's emergency preparedness plan and risk assessments to review. A second request was made on 5/3/2023 at 12:41 PM, requesting a risk assessment that included potential hazards such as flooding, earthquakes etc, that had been rated high, medium and low. The agency provided their emergency preparedness plan on 5/3/2023 at 7:12 PM. The plan did not contain a facility-based and community-based risk assessment. No documented evidence was provided to indicate they had developed and maintained a facility and community-based assessment, utilizing an all-hazards approach.

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 interview and record review it was determined that the home health agency (HHA) did not develop and implement emergency policies and procedures, based on their emergency plan set forth from the risk assessment. The policies and procedures must be revised and updated at least every 2 years. Findings include: On 5/2/2023 at 10:30 am, surveyors requested the agency's emergency preparedness policies and procedures to review. On 5/3/2023 at 12:31 PM, a document was received titled, Emergency Preparedness Plan. The document included a section titled, Policy and Procedure. The section on policy and procedure, did not meet the requirements and had not been approved by the governing board and signed by the physician. On 5/3/2023 at 7:12 PM, an email was received from the administrator that stated “I did obtain an updated Emergency Preparedness Guide from the previous owner. I have made some adaptations to our new ownership. The approved documents are attached.” The board’s approval and physician review were dated 5/3/2023.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure individual emergency plan's (IEP) were developed for the HHA's patients during a natural or man-made disaster. Specifically, the HHA did not provide IEP's for each patient as part of the comprehensive assessment for 6 of 7 patients. (Patient identifiers: 2, 3, 4, 5, 6, and 7) Findings include: 1. During the certification survey from 5/2/2023 through 5/4/2023 the medical records of patients 1, 2, 3, 4, 5, 6, and 7 were reviewed. For 6 of 7 patients no evidence could be found to indicate an IEP in the event of an emergency had been developed for any of the sampled patients. 2. An email requesting IEPs was sent on 5/3/2023 at 1:01 PM and again on 5/4/2023 at 6:55 am. In an email response from the administrator on 5/4/2023 at 7:04 am he stated, “We are going to make IEPs part of our admit process going forward. This will make sure the IEPs are provided to the patients.”

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) did not develop and implement emergency communication that complies with Federal, State and local laws. The communication plan must be reviewed and updated at least every 2 years and must include contact information for Federal, State, tribal, regional, and local emergency preparedness staff. Findings include: On 5/2/2023 at 10:30 AM, surveyors requested the agency's emergency preparedness policies and procedures to review. On 5/3/2023 at 12:31 PM, a document was received titled, Emergency Preparedness Plan. On 5/3/2023 at 12:45 PM, an email was received from the administrator that stated, “I believe that the emergency preparedness and communications Plan are covered under section 3.4.2” 3.4.2 Provides specific, individualized information to each patient about their special needs and plan in the event of emergency and includes that in the patient’s chart. 1. 3.4.2.1 Identification of types of disasters in the community (tornado, hurricane, earthquake, fire, explosion, riot, etc.) and needs for different emergencies. 2. 3.4.2.2 Emergency telephone numbers including police, ambulance, fire, gas, electric, water, etc. 3. 3.4.2.3 Emergency supplies including food, water, heat and other necessities. 4. 3.4.2.4 Disaster planning including access to radio stations, first aid supplies, blankets, smoke detectors, evacuation plans. 5. 3.4.2.5 Procedures to follow if care or services are disrupted due to a natural disaster or emergency. The documented evidence submitted for the communication plan was generalized and not agency specific and did not meet the requirements. On 5/3/2023 at 7:12 PM, an email was received from the administrator that stated, “I did obtain an updated Emergency Preparedness Guide from the previous owner. I have made some adaptations to our new ownership. The approved documents are attached.” The board’s approval and physician review were dated 5/3/2023. The new emergency preparedness plan referred to a calling list, but no list was included. The emergency preparedness plan also did not include contact information for Federal, State, tribal, regional, and local emergency preparedness staff.

A recertification survey was conducted at Lifetouch Home Health from 5/2/2023 through 5/4/2023 to assess federal regulations that govern home health agencies. Deficiencies were identified and cited.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) did not provide an Outcome and Assessment Information Set (OASIS) privacy notice to all patients, for whom the OASIS data was collected. Findings include: During the entrance conference on 5/2/2023, surveyors requested the information given to patients in their admission packet and/or given to patient's before care was provided by the HHA. A review of the information provided to surveyors revealed that the OASIS privacy notice was not included in the information provided to patient's upon admission or before care was provided by the HHA. On 5/2/2023 at 11:59 AM, an email requesting an electronic copy of the admission packet was sent. An email containing the admission packet was received and reviewed on 5/2/2023 at 12:53 PM. A review of the electronic admission packet revealed that it did not contain the OASIS privacy notice. On 5/3/2023 at 6:27 AM, an email was sent requesting documentation that the OASIS privacy notice had been provided to patients at admission or before providing care. No response was received. During the exit conference on 5/4/2023 at 9:00 AM, the director of clinical services stated “I had never heard of an OASIS privacy notice until this survey. No agencies that I have worked for in the past have ever used them.”

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) did not advise the patient of the charges the individual may have to pay before care was initiated. Specifically, 3 of 7 patient's cost per visit was left blank on the admission agreement. Patient identifiers: (1, 2, and 5) Findings include: A review of the home health consent and admission agreement for 7 sampled patients including 5 active patients and 2 discharge patients was conducted from 5/2/2023 to 5/4/2023. Documented evidence showed that for 3 of 7 sampled patients (1, 5, and 7), the section notice of services; financial agreement for service; and liability for services did not include the cost per visit. In an email on 5/3/2023 at 5:56 AM, the administrator stated, “This has been addressed with the specific therapists and with other admitting therapists.”

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) did not provide to the patients, the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that serve the area where the patient resides: The Agency on Aging, The Center for Independent Living, The Protection and Advocacy Agency, The Aging and Disability Resource Center, and The Quality Improvement Organization. Findings include: On 5/2/2023, surveyors requested the information given to patients in their admission packets and/or given to patients before care was provided by the HHA. A review of the information provided to surveyors revealed that the names, addresses and telephone numbers for the following Federally and state funded entities were not included in the information provided to patients upon admission or before care was provided by the HHA. 1. The Agency on Aging 2. The Center for Independent Living 3. The Protection and Advocacy Agency 4. The Aging and Disability Resource Center 5. The Quality Improvement Organization On 5/2/2023 at 11:59 AM, an email requesting an electronic copy of the admission packet was sent. An email containing the admission packet was received and reviewed on 5/2/2023 at 12:53 PM. A review of the electronic admission packet revealed that it did not contain a list of Federally and state funded entities. On 5/3/2023 at 6:27 AM, an email was sent requesting documentation that the list of Federally funded and state funded entities had been provided to patients at admission or before providing care. No response was received.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and medical record review, it was determined that the agency did not ensure that all patient medications had been reviewed by a nurse no later than 5 calendar days from their start of care for 7 of 7 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, and 7) Findings include: A review of 5 active patient's and 2 discharged patient's medical records was completed on 5/4/2023. The agency could not provide documented evidence that a review of medications by a nurse was completed within five days from the date of admission to the agency for 7 of 7 sample patients. In an email on 5/3/2023 at 12:48 PM, the administrator stated “The registered nurse (RN) was not able to login to the previous electronic health record (EHR) and was just recently able to get into our current EHR. She felt it would have been inappropriate to backdate her medication review and completed them last night as a result of our audit of the charts.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure each patient's plan of care (POC) contained all the required elements for 7 of 7 sampled patients. Specifically, for 7 of 7 patients physical therapy (PT) and/or occupation therapy (OT) interventions were not individualized. Patient identifiers: (1, 2, 3, 4, 5, 6 and 7) Additionally, 3 of 7 sampled patients POC did not contain timeframe's for how often assessments were to be completed. (Patient identifiers: 1, 5 and 7); 2 of 7 sampled patients individualized POC did not include the frequency and duration of the visits to be made. Patient identifiers: (1 and 5); and 1 of 7 sampled patients individualized POC did not contain occupational therapy (OT) goals or interventions. Patient identifier: (4). Findings include: A review of the most current individualized POC for 7 sampled patients including 5 active patients and 2 discharge patients was conducted from 5/2/2023 to 5/4/2023. 1. For 7 of 7 sampled patients (1, 2, 3, 4, 5, 6 and 7), PT interventions for each patient stated: education, neuromuscular invention, gait training, therapeutic exercises, and manual therapy. In an email received on 5/3/2023 at 5:56 am, the administrator stated: “It appears that the intervention, although generic, are still applicable to each patient, as they are based on standardized tests that Medicare uses to deem a patient as being homebound or not. However, this will be addressed in future interventions to make sure they are patient specific.” 2. For 3 of 7 sampled patients (1, 5, and 7), the plan of care (POC) did not contain timeframes for how often assessments were to be completed Patients 1, 5, and 7’s POC stated: Notify physician of: temperature greater than 101 or less than 96; pulse greater than 100 or less than 50; respirations greater than 24 or less than 12; systolic blood pressure (BP) greater than 180 or less than 90; diastolic BP greater than 90 or less than 60; O2 Sat less than 90%; fasting blood sugar greater than 250 or less than 60; random blood sugar greater than 300 or less than 60; weight greater than 3 pounds (lbs) or less than 5 lbs. However, there was no documented evidence for frequency of vital sign or physical assessment interventions on the POC. 3. For 2 of 7 sampled patients (1 and 5), individualized POC did not include the frequency and duration of the visits to be made. a. Patient 1 was admitted to the agency on 3/5/2023 with a diagnosis of Spinal stenosis of lumbar region with neurogenic claudication. A review of patient 1’s medical records was completed on 5/4/2023. Documented evidence showed physician's orders for occupational therapy (OT) 1 time per week for 8 weeks to evaluate and treat for activities of daily living (ADLs), gait, and coordination, dated 3/20/2023. The orders for OT was not on the POC. In an email on 5/3/2023 at 6:00 AM, from the administrator a revised 485 was received with OT added. In the email the administrator stated, "The initial 485 was created prior to OT eval being completed. The 485 has been corrected and signed by the physician. See attached 485." b. Patient 5 was admitted to the agency on 2/27/2023 with diagnoses which included spinal stenosis, radiculopathy, bilateral osteoarthritis of knees and hip. Patient 5's medical record was reviewed on 5/4/2023. On 3/1/2023 a physician's order was received to start OT 1 times a week for 8 weeks. The initial POC did not include the OT frequency. The recertification survey, beginning 4/28/2023 was reviewed. There was no an order to continue OT and the POC did not include OT orders. In an e-mail, dated 5/3/2023 at 5:56 AM, the administrator stated, "..They are not signed and included [in the POC." 4. For 1 of 7 patients sampled individualized POC did not include occupational therapy (OT) goals or interventions. Patient identifier: (4). Patient 4 was admitted to the agency on 2/10/2023 with diagnoses which included hereditary and idiopathic neuropathy and intervertebral disc disorders. Patient 4's medical record was reviewed on 5/4/2023. The April 2023 recertification period was reviewed. The PT goals and interventions were not included on the plan of care. In an e-mail dated 5/3/2023 at 5:56 AM, the administrator stated, "...Final QA (quality assurance) of the 485 has not been performed so I didn't see this..."

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 interview and record review, it was determined that the home health agency (HHA) did not provide services that were ordered by the physician for 3 of 7 sample patients. Specifically, 3 of 7 sampled patients’ vital signs were not being taken. Patient identifiers: (1, 5, and 7) Additionally, 3 of 7 sampled patients therapist visits were not authenticated by the therapist. Patient identifiers: (1, 5 and 7) Findings include: A review of the medical records for 7 sampled patients including 5 active patients and 2 discharge patients was conducted from 5/2/2023 to 5/4/2023. 1. For 3 of 7 sampled patients (1, 5, and 7), the plan of care (POC) contained orders to notify physician if temperature greater than 101 or less than 96; pulse greater than 100 or less than 50; respirations greater than 24 or less than 12; systolic blood pressure (BP) greater than 180 or less than 90; diastolic BP greater than 90 or less than 60; O2 Sat less than 90%; fasting blood sugar greater than 250 or less than 60; random blood sugar greater than 300 or less than 60; weight greater than 3 pounds (lbs) or less than 5 lbs. 2. For 3 of 7 sampled patients (1, 4 and 7) therapist visits were not authenticated by the therapist. a. Patient 1 was admitted to the agency on 3/5/2023 with a diagnosis of Spinal stenosis of lumbar region with neurogenic claudication. A review of patient 1’s medical records was completed on 5/4/2023. Documented evidence showed BP was not recorded by the physical therapist (PT) on 3/22/2023, 3/30/2023, 4/5/2023, 4/12/2023, 4/19/2023, and 4/28/2023. BP was not recorded by the Occupational therapist (OT) on 3/20/2023, 3/27/2023 and 4/17/2023. No vital signs were recorded by OT on 3/27/2023. Additionally, patient 1’s visit with the OT on 3/27/2023 was not authenticated by the therapist. b. Patient 4 was admitted to the agency on 2/10/2023 with diagnoses which included hereditary and idiopathic neuropathy and intervertebral disc disorders. Patient 4's medical record was reviewed on 5/4/2023. The PTA did not authenticate visit notes on 4/19/2023, 4/25/2023 and 5/1/2023. c. Patient 7 was admitted to the agency on 2/3/2023 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy. A review of patient 7’s medical record was completed on 5/4/2023. Documented evidence showed BP was not recorded by the (PT) on 2/9/2023. No vital signs were recorded by PT on 2/21/2023 and 2/22/2023. Additionally, patient 7’s visits with the PT on 2/9/2023, 2/21/2023 and 2/22/2023, were not authenticated by the therapist. In an email received on 5/3/2023 at 12:49 PM, the administrator stated, vitals not being taken has been addressed and is now a requirement for all visits and will be followed up closely moving forward. In an email received on 5/3/2023 at 5:56 am, the administrator stated, “When we added users, some of the therapists were not given access to use a signature. I have since gone through and added those permissions so all therapists can now sign electronically. I will go through and reopen and send all notes back for those clinicians to obtain signatures.”

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the governing body had not appointed an administrator. Findings include: On 5/2/2023, at 10:30 AM, a request was made for a copy of the letter of appointment for the agency administrator. On 5/2/2023 at 2:43 PM, the administrator provided a document that indicated that he was the appointed administrator for the agency. The document titled Appointment of Administrators was dated 5/2/2023. On 5/2/2023 at 3:16 PM, an email was sent to the administrator asking for an explanation as to why the appointment was not completed prior to the survey date. The administrator replied in an email dated 5/2/2023 at 3:20 PM “I did not know that the agency needed letters of appointment prior to today. The letter is a formality (to me), since the director of clinical services and I are the owners of the business and are functioning in the roles listed. So, outlining it in an official capacity did not cross my mind.”

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the agency did not have a qualified pre-designated person to assume the same responsibilities and obligations as the administrator in the event of the administrators absence. Findings include: On 5/2/2023, at 10:30 AM, a request was made for a copy of the letter of appointment for the qualified person authorized to act in the absence of the administrator. On 5/2/2023 at 2:43 PM, the administrator provided a document that indicated that the director of clinical service was the qualified person authorized to act in the absence of the administrator. The document titled Appointment of Administrators was dated 5/2/2023. On 5/2/2023 at 3:16 PM, an email was sent to the administrator asking for an explanation on why the appointment was not completed prior to the survey date. The administrator replied in an email dated 5/2/2023 at 3:20 PM “I did not know that the agency needed letters of appointment prior to today. The letters are a formality (to me), since the director of clinical services and I are the owners of the business and are functioning in the roles listed. So, outlining it in an official capacity did not cross my mind.”

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 interview and record review, it was determined the home health agency (HHA) did not complete a discharge summary that was sent to the primary care practitioner within five business days of discharge or within two business days of a transfer occurring, for 2 of 2 sampled discharged patients. (Patient identifiers: 6 and 7). Findings include: A review of the medical records for 7 sampled patients including 5 active patients and 2 discharge patients was conducted from 5/2/2023 to 5/4/2023. 1. Patient 6 was admitted to the HHA on 2/14/2023 with diagnoses which included bilateral osteoarthritis and spinal stenosis. Patient 6's medical record was reviewed on 5/4/2023. Patient 6 was discharged from the agency on 3/7/2023 related to noncompliance. There was no documentation in patient 6's medical record that the discharge summary was submitted to patient 6's primary care physician within 5 days from the discharge date. On 5/3/2023 at 9:07 AM a clarification e-mail was submitted to the administrator asking if patient 6's primary care physician had been notified of his discharge. On 5/3/2023 at 12:10 PM the administrator responded by stating, "It was sent to the physician from the previous EHR (electronic health record) prior to transferring the data..." However documented evidence was not provided. 2. Patient 7 was admitted to the HHA on 2/3/2023 with a diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy. A review of patient 7’s medical record was completed on 5/4/2023. Discharge orders dated 3/6/2023 stated: Patient to discharge from services prematurely secondary to non-compliance. Documented evidence showed discharge Oasis as “not started”. In an email received from the administrator on 5/3/2023 at 12:48 PM, he stated, " nonbillable OASIS was completed today with the help of the physical therapy assistant (PTA), it has been added to the chart and faxed to the doctor."