Every finding on record at Primecare Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/26/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Recertification survey conducted. Standard Level deficiencies cited. Abbreviations: SN = Start of Care SOC = Start of Care Pt / Pts = Patient / Patients OASIS = Outcome and Assessment Information Set OT = Occupational Therapy

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Agency's OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency's past 12 months OASIS submission report was reviewed on 07/24/24. The report contained information that out of the Agency's 720 OASIS assessment reports, (9.72%) were submitted beyond the required time frame of 30 days. 2. During an interview with the Administrator and Clinical Manager on 07/25/24 at 10:30 AM. The Administrator and Clinical Manager confirmed the Agency's late OASIS submission.

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 for 3 of 7 (Pts. #1, 2 and 6) clinical records reviewed, the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline. Findings Include: 1. The following clinical records were reviewed on 07/24/24: Pt. #1. SOC: 06/19/24. Pt. received SN, Home Health Aide and Physical Therapy services. Pt. #2. SOC: 05/03/24. Pt. received SN services. The records lacked documentation that at the SOC, the Pt./patient's representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. Pt #6 was admitted to home health services on 12/14/23 with Diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 07/24/24. The clinical record contained an admission order dated 12/14/23 for SN, PT and OT services. The clinical record also contained patient admission consents that lacked the disciplines that will provide services. 3. During an interview with the Administrator and Clinical Manager on 07/25/24 at 10:30 AM, the above finding was confirmed.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [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 (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the plan contained volunteers. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness plan was reviewed on 6/22/21 at 11:40 AM. The Plan lacked any volunteers. 2. During an interview 6/23/21 at 11:45 AM with the Administrator, Clinical Manager, Quality Assurance and Performance Improvement Coordinator, and RN/Alternate Clinical Manager, the Administrator confirmed the Agency's Emergency Plan lacked volunteers.

Names and Contact Information CFR(s): 484.102(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).] 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: . A. Based on the review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/22//21 at 11:40 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patient Physicians, and Volunteers. 2. During an interview 6/23/21 at 11:45 AM with the Administrator, Clinical Manager, Quality Assurance and Performance Improvement Coordinator, and RN/Alternate Clinical Manager, the Administrator confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 6/24/21. Standard level deficiency cited. Abreviations: Pt./Pts. = Patient/Patients SOC = Start of Care E = Employee AM = Morning PM = Evening SOC = Start of Care IU = International Units mg = milligrams mcg = micrograms RN = Registered Nurse COVID-19 = Coronavirus 2019

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing care and/or service. This was found in 5 of 7 (Pts. #1, 2, 3, 5 and 6) clinical records reviewed, wherein Pt. COVID-19 screening was required. Findings include: 1. Pt. #1. SOC 6/8/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 6/22/21 at 11:40 AM. The record contained Home Health Aide and Skilled Nursing visit notes indicating services were provided once weekly from 6/6/21 to 6/19/21. The record lacked documentation that during those dates, Pt. was screened for signs and symptoms of COVID-19 prior to the visits. During a home visit conducted for Pt. # 1 on 6/21/21 at 3:00 PM, the E #1(Home Health Aide) was interviewed and stated that Pt. COVID- 19 screenings are to be documented on the software system. 2. Pt. #2. SOC 3/8/21. Primary Diagnosis: Lumbago Right Side with Sciatica. The clinical record was reviewed on 6/22/21 at 1:58 PM. The record contained Physical Therapy visit notes indicating services were provided twice weekly from 5/30/21 to 6/19/21. The record lacked documentation that during those dates, the Pt. was screened for signs and symptoms of COVID-19 prior to the visits. During a home visit conducted for Pt. #2 on 6/22/21 at 10:00 AM, E #2 (Physical Therapist) was interviewed and stated that COVID-19 screenings for the pt. are to be documented on the software system. 3. Pt. #3. SOC 4/30/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 6/21/21 at 12:30 PM. The record contained Skilled Nursing visit notes indicating services were provided on 4/30/21, and once weekly from 5/15/21 to 6/14/21. The record lacked documentation that during those dates, the Pt. was screened for signs and symptoms of COVID-19 prior to the visits. 4. Pt. #5. SOC 6/2/21. Primary Diagnosis: Arteriosclerotic Heart Disease. The clinical record was reviewed on 6/22/21 at 10:30 AM. The record contained Skilled Nursing visit notes indicating services were provided once weekly from 6/2/21 to 6/22/21. The record lacked documentation that during those dates, the Pt. was screened for signs and symptoms of COVID-19 prior to the visits. 5. Pt. #6. SOC 12/9/20. Primary Diagnosis: Unspecified Fracture Upper End Left Tibia. The clinical record was reviewed on 6/22/21 at 9:30 AM. The record contained Physical Therapy visit notes indicating services were provided on 12/11/20, 12/14/20, 12/16/20, 12/28/20, and 1/8/21. The record lacked documentation that during those dates, the Pt. was screened for signs and symptoms of COVID-19 prior to the visits. 6. The Agency policy titled "Emergency Preparedness Plan: COVID-19" was reviewed on 6/23/21 at 10:00 AM. The policy required: "...Patient shall be screened on admission and throughout episode for exposure to COVID-19..." 7. During an interviews on 6/23/21 at 11:20 AM and 11:45 AM with the Administrator, Clinical Manager, Quality Assurance and Performance Improvement Coordinator, and RN/Alternate Clinical Manager, the Clinical Manager stated the Clinician should screen the Pt. for signs and symptoms of COVID-19 prior to each home visit, and document the results of this screening in the Patient's clinical record.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on observations and interviews during home visits, review of clinical records and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 2 of 7 (Pts. # 1 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/8/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. A home visit was conducted on 6/21/21 at 3:00 PM with E #1 (Home Health Aide). During the home visit, an interview was conducted with the Pt and the patient's medications were reviewed. The following medication bottles were found at patient's home: Warfarin 2 mg 1 tablet by mouth daily. Pt. #1's family stated that Pt. #1 takes only 4 kinds of medications in a day and warfarin was one of them. The clinical record was reviewed on 6/22/21 at 11:40 AM. The record contained a "Medication Profile" form completed by the RN and dated 6/8/21 to 8/6/21. The "Medication Profile" included the following: Eliquis 2.5 mg 1 tablet every 12 hours by mouth, Digoxin 125 mcg (0.125 mg) oral tablet 1 tablet daily by mouth but were not found at Pt. #1's home at the time of the visit. The medication "Warfarin 2 mg" was not listed on the medication profile. The Medication Profile was not complete and accurate. 2. Pt. #2. SOC 3/8/21. Primary Diagnosis: Lumbago Right Side with Sciatica. A home visit was conducted on 6/22/21 at 10:00 AM with E#2 (Physical Therapist). During the home visit, an interview was conducted with the Pt. and Pt. #2's medications were reviewed. The Pt. stated taking the following medications: Tylenol Extra Strength 500 mg tablets, Multivitamins, Vitamin D 3 2000 IU, Vitamin B6 100 mg, Calcium with Magnesium, Zinc and D3 (333mg/133mg/5mg/200IU). The clinical record was reviewed on 6/22/21 at 1:58 PM. The record contained a "Medication Profile" form completed by the RN and dated 5/24/21 to 7/22/21. The record "Medication Profile" included the following: Cetirizine 10 mg oral tablet 1 tablet daily by mouth, Montelukast Sodium 10 mg 1 tablet daily by mouth, but were not found at Pt. #2's home at the time of the visit. The medications bottles labeled, "Tylenol, Multivitamins, Calcium, Vitamin D and Vitamin B6" were found during the home visit but were not listed on the medication profile. The Medication Profile was not complete and accurate. 3. The Agency policy "Medication Orders" was reviewed on 6/23/21 at 10:30 AM. The policy requires, "8 ...The Medication Profile will be accurate ..." 4. The Agency policy "Medication Reconciliation" was reviewed on 6/23/21 at 10:35 AM. The policy requires, "2. Medications ordered while the patient is receiving care will be compared to the medication list profile. The medication list/profile will be updated with each new or changed medication." 5. An interview was conducted with the Administrator, Clinical Manager, RN/Alternate Clinical Manager and RN/Alternate Clinical Manager/Quality Assurance and Performance Improvement Coordinator on 6/23/21 at 11:20 AM. During the same interview, the Administrative staff confirmed the above findings.