Every finding on record at Prime Home Health Services, Inc

Recertification survey completed. Standard level deficiencies cited. Abbreviations: LPN= Licensed Practical Nurse Pt. = Patients RN = Registered Nurse SN = Skilled Nurse SOC= Start of Care

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 the Emergency preparedness Plan review and staff interview, it was determined that the Agency failed to comply with the Condition of Participation 42 CFR 484.102(a)(1)(2) Risk assessment. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 07/20/23 at 10:00 AM. The plan lacked a facility and community-based risk assessment after 2019. 2. During an interview with the Administrator on 07/20/23 at 11:00 AM, the Administrator confirmed the above finding.

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 the Emergency Preparedness Plan review and staff interview, it was determined that the Agency failed to comply with the requirements of the EP testing program. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 07/19/23 at 11:30 AM. The Emergency Preparedness did not include documentation indicating that the Agency conducted / participated in any testing exercise or drill since 2020. 2. During an interview with the Administrator on 07/20/23 at 11:00 AM, the Administrator confirmed that the Agency failed to conduct / participate in a community and/or facility-based testing or drill since 2020.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: LPN= Licensed Practical Nurse POC=Plan of care Pt. = Patients RN = Registered Nurse SN = Skilled Nurse SOC= Start of Care

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 the Plans of care review and Staff interview, it was determined that the Agency failed to ensure the Staff conformed to the Physician orders in the plan of care. This was found in 5 of 7 (Pts. #1, 2, 7, 4 and 5) Plans of Care reviewed. 4. Pt # 4 was admitted to Home Health Services on 08/12/22 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 07/19/23 at 12:00 PM. The clinical record contained a POC for certification period beginning 06/08/23, that required OT service to evaluate patient week of 06/25/23. The clinical record lacked an OT evaluation visit for certification period 06/08/23. 5. Pt # 5 was admitted to Home Health Services on 05/05/2023 with Diagnosis of Osteoarthritis of Knee. The clinical record was reviewed on 07/18/23 at 2:00 PM. The record contained a POC beginning 05/05/23 that required SN visit 1 time a week for 9 weeks. The clinical record lacked SN weekly visits for weeks 2, 3 and 4 of certification period. 6. During the interview with the Administrator and Acting Supervisor, on 07/20/23 at 2:30 PM, it was confirmed that the Staff did not follow the Physicians orders. Findings include: 1. Patient (Pt.) #1 was admitted to the Home Health Agency on 08/12/22 with the Diagnoses: Bilateral Primary Osteoarthritis of Hip and Type 2 Diabetes Mellitus without Complications. The Physician orders dated 06/08/23 required the Skilled Nurse 1 time a week for 9 weeks to monitor blood sugar levels. The SN did not assess the patient blood glucose during the weeks of: 06/11/23, 06/18/23 and 06/25/23 (weeks #1, #2 and #3). 2. Patient (Pt.) #2 was admitted to the Home Health Agency on 09/28/21 with the Diagnoses: Hypertensive Chronic Kidney Disease w Stage 1-4/ unspecified Chronic Kidney. The Physician orders dated 09/28/21 required the SN 1 time a week for 8 weeks to assess the patient. The SN did not visit/assess the patient the weeks of 07/02/23 and 07/09/23 (weeks #7 and #8). 3. Patient (Pt.) #7 was admitted to the Home Health Agency on 06/23/21with the Diagnoses: Alzheimer’s Disease. The Physician orders required the SN 1 time a week for 9 weeks to assess the patient. The SN did not visit/assess the patient the week of 01/08/23 (week #3).

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on the clinical record review, policy review and Staff interview, it was determined the LPN supervisory visit was not conducted by the RN. This was found in 1 of 1 clinical records (Pt. #2) with the LPN services. Findings include: 1. Patient (Pt.) #2 was admitted to the Home Health Agency on 09/28/21 with the Diagnoses: Hypertensive Chronic Kidney Disease w Stage 1-4/ unspecified Chronic Kidney. The Physician orders dated 09/28/21 required the SN 1 time a week for 8 weeks to assess the patient. Weekly visits were conducted by the Licensed Practical Nurse (LPN). The contracted Registered Nurse conducted a visit on 06/15/23 (week #4) and did not document the LPN supervision. 2. The Agency's policy titled "Licensed Practical Nurse Supervision" reviewed on 07/20/23 at 12:15 PM, required "...2...b...The Registered Nurse supervisory visit... every 30 days. Supervisory visits are to be documented in the client's chart..." 3. The findings were confirmed during the interview with the Administrator and Acting Supervisor on 07/20/23 at 2:50 PM.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on the onsite observations and Staff interview, it was determined the Agency lacked a designated Clinical Manager, during all operating hours. This was observed 3 of 4 survey days (07/18, 07/19 and 07/20/23). Findings include: 1.On 07/18/23, it was observed the Agency lacked a designated Clinical Manager, during the Agency's operating hours which are 9:00 AM to 5:00 PM. It was observed that no Clinical Manger was available to assist with the survey during the Agency's operating hours of 9:00 AM to 3:00 PM on 07/18/23. 2. On 07/19/23 and 07/20/23, it was observed the Agency lacked a designated Clinical Manager from 9:00 AM to 1:00 PM. The Clinical Manager was unavailable to assist with the survey during the hours of 9:00 AM to 1:00 PM, 07/18/23 thru 07/20/23. On 07/20/23, during the interview with the Acting Agency Supervisor at 1:00 PM, it was confirmed that she works for another organization from 4:00 AM to 12 noon. The Acting Agency Supervisor was observed onsite at 1:00PM 3. The findings were confirmed during the interview with the Administrator and Acting Agency Supervisor on 07/21/23 at 10:00 AM.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on the clinical records review and Staff interview, it was determined the Agency failed to ensure the clinical record was complete. This was found in 3 of 7 clinical records (Pt. #2, 4 and 5) reviewed. 2. Pt # 4 was admitted to Home Health Services on 08/12/22 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 07/19/23 at 12:00 PM. The clinical record contained an incomplete admission consent. The consent document lacked patient name. 3. Pt # 5 was admitted to Home Health Services on 05/05/2023 with Diagnosis of Osteoarthritis of Knee. The clinical record was reviewed on 07/18/23 at 2:00 PM. The clinical record lacked admission consents for SOC episode 05/05/23. 4. During the interview with the Administrator and Acting Supervisor, on 07/20/23 at 2:30 PM, it was confirmed that the clinical records were incomplete. Findings include: 1. Patient (Pt.) #2 was admitted to the Home Health Agency on 09/28/21 with the Diagnoses: Hypertensive Chronic Kidney Disease w Stage 1-4/ unspecified Chronic Kidney. The clinical record included a documentation of the oxygen saturation level as “18”. During the interview with the Agency Supervisor, it was stated that “18” was not a completed documentation but an error.

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on the onsite observations , review of the organization chart and Staff interview, it was determined the Agency lacked a designated Clinical Manager. This was observed 4 of 4 survey days (07/18, 07/19, 7/20 and 07/21/23). Findings include: 1. On 07/18/23 at 9:45 AM, during the entrance interview with the Administrator, it was observed the Agency lacked a Clinical Manager and the Agency's organizational chart did not include a designated Clinical Manager. During the interview with the Administrator, it was stated that the Agency Supervisor (Employee #2) resigned June 15, 2023 and Employee #3 is acting as the Agency's Supervisor. 2. On 07/20/23, during the interview with the RN /Acting Agency Supervisor (Employee #3) at 1:00 PM, it was confirmed that she works for another organization from 4:00 AM to 12 noon and currently acting as the Agency Supervisor from 1:00 PM to 8:30 PM, 3. The above findings were confirmed during the interview with the Administrator and Acting Agency Supervisor on 07/21/23 at 9:45 AM.