Every finding on record at Prime Care Resource, Inc

Recertification survey completed. Standard Level deficiencies cited.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the Emergency plan was based on a facility and community-based risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 11/28/23. The plan lacked a facility and community-based risk assessment. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:45 am, the Administrator and the Director of Nursing confirmed the above finding.

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 ensure the Emergency plan policies and procedures were reviewed and updated biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 11/28/23. The plan lacked any dates indicating when the Agency had reviewed the plan's policies and procedures. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:45 am, the Director of Nursing stated it had been "more than 2 years" that the Agency had reviewed the Emergency Preparedness plan. During the same interview, the Administrator confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). 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 ensure the communication plan was complete. This has potential to affect all Pts. that receive services from the Agency. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 11/28/23. The plan lacked the names and contact information of direct staff, agencies providing services under a contractual agreement, and the patient's physicians. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:45 am, the Administrator and Director of Nursing confirmed the Agency failed to ensure the Agency's Emergency Preparedness communication plan was complete.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the communication plan included the contact information of Emergency Preparedness staff. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 11/28/23. The communication plan lacked names and contact information of local, State, Federal Emergency Preparedness staff, and other emergency preparedness resources. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:45 am, the Administrator and Director of Nursing confirmed the Agency failed to ensure the communication plan contain the required contact information.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct staff training relative to the Emergency plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 11/28/23. The plan lacked documentation that the Agency conducted any Emergency Preparedness plan staff training after 2020. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:45 am, the Administrator and Director of Nursing confirmed the plan lacked any documentation indicating the Agency provided staff training, regarding the Emergency plan after 2020.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number am = morning IM = intramuscular mcg = micrograms cc = cubic centimeters POC = plan of care - = to / through Pt./Pts. = patient/patients SN = Skilled Nurse RN = Registered Nurse SOC = Start of Care U/A = urinalysis C/S = culture and sensitivity

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to provide information in writing, regarding the Agency's transfer and discharge practices. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 11/27/23, and lacked documentation of the Agency's transfer and discharge policies. 2. On 11/27/23 and 11/28/23, home visits was conducted on the following Pts. Pt. #1. SOC 9/25/23 Pt. #2. SOC 9/14/23 Pt. #3. SOC 10/16/23 During the home visits, the patient's admission folder was observed, and lacked documentation of the Agency's transfer and discharge policies. 3. The clinical records of the following Pts. were reviewed from 11/27/23 to 11/29/23: Pt. #1. SOC 9/25/23 Pt. #2. SOC 9/14/23 Pt. #3. SOC 10/16/23 Pt. #4. SOC 1/9/23 Pt. #5. SOC 5/31/18 Pt. #6. SOC 2/16/23 Pt. #7. SOC 11/7/22 The clinical records lacked documentation that the Pt./patient's representative received written information pertaining to the Agency's transfer and discharge policies. 4. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:30 am, all confirmed the Agency does not provide the Pt./patient's representative with information in writing, regarding the Agency's transfer and discharge practices.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to provide the Pt./patient's representative information regarding the Administrator. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 11/27/23. The folder lacked the Administrator's name, address and phone number to file a complaint and/or grievance. 2. On 11/27/23 and 11/28/23, home visits was conducted on the following Pts. Pt. #1. SOC 9/25/23 Pt. #2. SOC 9/14/23 Pt. #3. SOC 10/16/23 During the home visits, the patient's admission folder was observed and lacked the name and contact information of the Administrator. 3. The clinical records of the following Pts. were reviewed from 11/27/23 to 11/29/23: Pt. #1. SOC 9/25/23 Pt. #2. SOC 9/14/23 Pt. #3. SOC 10/16/23 Pt. #4. SOC 1/9/23 Pt. #5. SOC 5/31/18 Pt. #6. SOC 2/16/23 Pt. #7. SOC 11/7/22 The clinical records lacked documentation that the Pt./patient's representative were provided the name and contact of the Administrator to file a complaint or grievance. 4. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:30 am, all confirmed the Agency failed to provide the Pt./patient's representative with the Administrator's name and contact information.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure informed consents contain the disciplines that will furnish care and the frequency of visits. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 11/27/23 to 11/29/23: Pt. #1. SOC 9/25/23 Pt. #2. SOC 9/14/23 Pt. #3. SOC 10/16/23 Pt. #4. SOC 1/9/23 Pt. #5. SOC 5/31/18 Pt. #6. SOC 2/16/23 Pt. #7. SOC 11/7/22 The records lacked documentation of the Pt. consenting to the disciplines that will furnish care and the frequency of visits. 2. During an interview with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 at 9:30 am, all confirmed the records lacked the disciplines to provide care/service, and their frequency.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure physician orders were followed, as indicated on the POC and/or verbal order. This was found in 3 of 7 (Pts. #1, 5 and 4) clinical records reviewed. 3. The clinical record of Pt. #4 was reviewed on 11/28/23. Pt#4. was admitted to Home Care services on 1/9/23 with Diagnosis of Encounter for fitting adjustment of urinary device. The certification period 9/6/23 to 11/4/23 contained a physician order dated 10/17/23 that required - "RN to collect urine specimen from suprapubic catheter catheter for UA and C/S effective date 10/17/23." The SN visit notes dated 10/17, 10/20, 10/24 lack documentation of RN collecting urine sample as ordered by the Physician. 4. During interviews with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 between 9:30 am and 10:30am all confirmed that Agency staff failed to follow physician orders as indicated in the POC or written order. Findings include: 1. The clinical record of Pt. #1 was reviewed on 11/27/23. Pt. #1 was admitted to Home Care services on 9/25/23 with the primary diagnosis of Cellulitis of Right Lower Limb. The record contained the POC for the certification period of 9/25/23 to 11/23/23 which required, “…Frequency of Visits: SN: 1 Visit (s), Every 1 Week (s) for 9 Week (s)…” The record lacked documentation the SN provided any service during the weeks of 11/5/23 to 11/11/23, 11/12/23 to 11/18/23, and 11/19/23 to 11/23/23. 2. The clinical record of Pt. #5 was reviewed on 11/28/23. Pt. #5 was admitted to Home Care services on 5/31/18 with the primary diagnosis of Deficiency of Other Specified B Group Vitamins. The record contained the POC for the certification period of 9/2/23 to 10/31/23 which required, “…Frequency of Visits: SN: 1 Visit (s), Every 1 Month (s) Recertification period 9/2/23 – 10/31/23… RN to administer Vitamin B12 1000 mcg (1cc) IM monthly…” The record contained the SN visit note dated 10/3/23, and the recertification comprehensive assessment dated 10/31/23, both indicating the RN administered Vitamin B12 1000 mcg IM twice during the month of October 2023. The SN failed to provide service as required on the POC.

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 a review of clinical records and staff interview, it was determined the Agency failed to complete a discharge summary, ensure a copy of the transfer and/or discharge summary was sent to the Physician. This was found in 3 of 7 (Pts. #6, 7 and 4) clinical records reviewed. 3. The clinical record of Pt. #4 was reviewed on 11/28/23. Pt. #4 was admitted to Home Care services on 1/9/23 with Diagnosis of Encounter for fitting adjustment of urinary device. The certification period 9/6/23 to 11/4/23 contained a Transfer Comprehensive Assessment dated 10/06/23. The clinical record lacked evidence that a transfer summary was sent to the physician or the accepting facility. 4. During interviews with the Administrator, Director of Nursing, and the Nursing Supervisor/Quality Control on 11/29/23 between 9:30 am and 10:30am all confirmed that Agency staff failed to complete and send discharge / transfer summary to the physician. Findings include: 1. The clinical record of Pt. #6 was reviewed on 11/28/23. Pt. #6 was admitted to Home Care services on 2/16/23 with the primary diagnosis of Displaced Fracture of Olecranon Process without Intraarticular Extension of left Ulna. The record contained the Discharge Comprehensive Assessment completed by the Occupational Therapist and dated 2/26/23, the form included documentation that Pt. #6 was discharged from Agency. As of 11/28/23, the record lacked a discharge summary. 2. The clinical record of Pt. #7 was reviewed on 11/28/23. Pt. #7 was admitted to Home Care services on 11/7/22 with the primary diagnosis of Bell's Palsy. The record contained the “Transfer Summary” completed by the RN and dated 12/11/22, the form included documentation that Pt. #7 was transferred to an inpatient facility. As of 11/28/23, the record lacked documentation the Physician was sent a copy of the Transfer Summary.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Emergency Preparedness Plan, and staff interview, it was determined that the Agency failed to ensure that the Agency conducted a testing of the Emergency Preparedness to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/06/2021 at 9:00 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted any testing exercise or drills since 2017. 2. During an interview with the DON on 01/07/2021 at 11:00 AM, the DON confirmed that the Agency has no documentation supporting that Agency conducted testing of the Emergency Preparedness.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 01/08/2021. The facility was in compliance with the requirements for Infection control for COVID-19. Identification of abbreviations: DON = Director of Nursing POC = Plan of care PT = Physical Therapy Pt./Pts. = Patient/patients SN = Skilled Nurse SOC = Start of care

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: . A. Based on clinical records review and staff interviews, it was determined that the Agency failed to ensure patients received services as ordered by the physician in the POC. This was found in 3 of 7 clinical records reviewed (Pts. # 4, 7 and 6 ). Findings include: 1. Pt. # 4 SOC 11/30/20 Diagnoses: Squamous cell Carcinoma of Skin, Lymphoid Leukemia and Anxiety Disorder. The clinical record was reviewed on 01/06/2021 at 10:00 AM. The clinical record contained a POC for certification period 11/30/20 to 01/28/21 that required SN services 2 times a week for 9 weeks. The clinical record lacked SN visit notes for weeks 4 and 5 of certification period. No modification orders were found in the clinical record. During an interview with the DON on 01/07/21 at 10:30AM the DON confirmed that patient is active with Home Care services. 2. Pt. # 7 SOC 07/23/20 Diagnoses: Multiple Fractures of Ribs, Spinal Stenosis and Low Back Pain. The clinical record was reviewed on 01/06/2021 at 11:30 AM. The clinical record contained a POC for certification period 07/23/20 to 09/20/20 that required PT frequency of service as 1 time a week for 1 week and 2 times a week for 5 weeks. The clinical record lacked 2 PT visit notes for week 4 and 1 PT visit note for week 5 of frequency order. No modification physician orders were found in the clinical record. 3. Pt. #6 SOC 07/14/20 Diagnoses: Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Type 2 Diabetes Mellitus. The clinical record was reviewed on 01/06/21 at 11:00 AM. The Plan of Care dated 07/14/20 was modified on 08/24/20 with a Physician order. The Physician order required the Registered Nurse: 1 time a week for 2 weeks to assess and monitor the patient. The Nurse documented a visit on 08/24/20 (week #1). The Nurse did not provide any services for week #2 and the patient was transferred to the hospital on 09/09/20 (week #3). 4. The findings related to the staff not providing services as indicated in the Plans of Care, were confirmed with the Administrator and DON during interviews on 01/07/21 between 10:00 and 11:15 AM.