Every finding on record at Professional Home Care Advantage Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/16/2024. Standard level deficiencies cited.

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 ensure testing of the emergency preparedness plan was completed. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/15/24 at 11:00 AM. The Emergency Preparedness plan did not include documentation indicating that the Agency conducted / participated in any community-based testing exercises, since 2020. 2. The findings were confirmed during the interview, with the Administrator on 02/15/24 between 11:00 AM and 1:30 PM.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC = Plan of care PT = Physical Therapy Pt / Pts = Patient / Patients SN = Skilled Nurse RN = Registered Nurse

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 clinical records review and staff interview, it was determined that for 5 of 7 (Pts. #1, 4, 5, 6 and 2) clinical records reviewed, the Agency failed to ensure the staff followed the Physician orders. 5. Patient # 2 was admitted to home health services on 12/24/23 with Diagnosis of Bilateral Primary Osteoarthritis. The clinical record was reviewed on 02/15/24. The clinical record contained a POC for certification period beginning 12/24/3 to 02/21/24 that required PT services to evaluate and treat. The clinical record lacked documentation indicating that PT evaluated patient. No modification orders were found in the record. 6. Findings of Agency staff failing to follow Physicians orders as indicated in the PsOC was confirmed during interviews with the Administrator on 02/15/24 between 10:30 AM and 1:00 PM. 3. Patient #5 was admitted to the home health services on 08/08/23 with the Diagnoses of Heart Failure , Unspecified and Type 1 Diabetes Mellitus without Complications. The clinical record was reviewed on 02/14/24. The Physician orders dated 12/06/24 and 02/04/24 required the Physical Therapy to evaluate and treat. As of 02/15/24 the PT evaluation was not conducted. The physician orders also required the Skilled Nurse to assess each visit the “ Type1 Diabetes Mellitus without Complications”. The Skilled Nurse failed to include the patient’s blood glucose results for the entire certification period of 12/06/23 thru 02/03/24. 4. Patient #6 was admitted to the home health services on 06/07/23 with the diagnoses of Bilateral Osteoarthritis of Knee and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24. The Physician orders dated 12/04/24 required the Physical Therapy to evaluate and treat. As of 02/15/24 the PT evaluation was not conducted. The physician orders also required the Skilled Nurse to assess each visit the “ Type Diabetes Mellitus without Complications”. The Skilled Nurse failed to include the patient’s blood glucose results for the entire certification period of 12/04/23 thru 02/01/24. 1. Pt. #1 was admitted to home health services on 12/29/23 with diagnoses that include Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Chest Pain on Breathing. The clinical record was reviewed on 02/14/24. The record contained the POC effective 12/29/23 requiring: "SN to perform complete physical assessment each visit with emphasis on... Chest pain on breathing... Notify the Physician immediately of any potential problems that impede the completion of patient recovery..." The SN visit notes dated 01/19/24 and 02/02/24 contained documentation that the Pt. experienced, "Chest pain on breathing". The record lacked documentation the SN notified the Physician the Pt. experienced "Chest pain on breathing" on 01/19/24 and 02/02/24. The POC effective 12/29/23 required: "PT Frequency: Eval and Treat". As of 02/14/24, the record lacked documentation the PT evaluated and treated Pt. #1. 2. Pt. #4 was admitted to home health services on 01/19/24 with diagnoses that include "Unspecified Osteoarthritis". The clinical record was reviewed on 02/15/24. The record contained the POC effective 01/19/24 requiring: "SN Frequency 1wk9". The record lacked documentation the SN provided service during the week of 1/28/24 to 2/3/24. The POC effective 01/19/24 required "PT Frequency: Eval and Treat". As of 02/15/24, the record lacked documentation the PT evaluated and treated Pt. #4.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Administrator failed to ensure information provided to Pts. was accurate and/or complete. Findings include: 1. The Pt. admission folder was reviewed on 02/14/24. The folder lacked documentation identifying the Administrator’s and Clinical Manager’s name, address, and phone number; information regarding the Agency’s transfer and discharge policies; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; correct address for the State Complaint Hotline; the Patient's Bill of Rights and Responsibilities lacked the correct phone number of the Agency. The admission folder included multiple pages with the State Complaint Hotline phone number, the reference page with multiple listing multiple contacts lacked the correct State Complaint Hotline phone number. The Administrator failed to ensure information provided daily to Pts. was accurate and/or correct. 2. The following home visits were conducted on 01/14/24 and 01/15/24: Pt. #1. SOC 12/29/23. Pt. #2. SOC 08/26/23. Pt. #3. SOC 10/06/23. During the home visits, the patient’s admission folder was observed and lacked documentation identifying the Administrator’s and Clinical Manager’s name, address, and phone number; information regarding the Agency’s transfer and discharge policies; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; correct address for the State Complaint Hotline; the Patient's Bill of Rights and Responsibilities lacked the correct phone number of the Agency. The admission folder included multiple pages with the State Complaint Hotline phone number, the reference page with multiple listing multiple contacts lacked the correct State Complaint Hotline phone number. The Administrator failed to ensure information provided daily to Pts. was accurate and/or correct. 3. The clinical records of the following Pts. were reviewed on 02/14/24 and 02/15/24: Pt. #1. SOC 12/29/23. Pt. #2. SOC 08/26/23. Pt. #3. SOC 10/06/23. Pt. #4. SOC 01/19/24. Pt. #5. SOC 08/08/23. Pt. #6. SOC 06/07/23 Pt. #7. SOC 04/15/23. The records lacked documentation the Agency provided the Pt./patient’s legal guardian with the name, address and phone number for the Administrator and Clinical Manager; transfer and discharge policy information; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; the correct State Complaint Hotline phone number and address; and the correct Agency's phone number on the Patient's Bill of Rights and Responsibilities. 4. During the entrance interview with the Administrator on 02/14/24 at 10:30 PM, the Administrator confirmed this was the Pt. admission folder used for all Pts. admitted to this Agency. 5. During an interview with the Administrator on 02/15/24 at 10:37 AM, the Administrator stated services are initiated as required, including weekends and holidays. During the same interview the Administrator confirmed he is responsible for ensuring information provided to Pts. is accurate and complete.

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 observation and staff interview, it was determined the Administrator failed to ensure a pre- designated person is assigned in writing to cover the duties of the Administrator when he is not available. Findings include: 1. During the entrance interview on 02/14/2024 at 10:00 AM. The Administrator stated the Clinical Manager was out on maternity leave. During the same interview the Administrator stated that he covers for the Clinical Manager and that the Clinical Manager was expected to return 02/14/2024. 2. During an interview with the Clinical Manager on 02/14/2024 at 11:30 AM, the Clinical Manager stated she is not returning fully to work schedule. The Clinical Manager added that the Administrator was covering the duties as the Clinical Manager while performing duties as the Administrator. 3. During an interview with the Administrator on 02/14/2024 at 11:30 AM the Administrator stated and confirmed he is fulfilling both duties of Administrator and Clinical Manager and he has no pre - assigned alternate Administrator while covering for the Clinical Manager.

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 clinical records review and staff interview, it was determined that for 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure the discharge summaries were complete and sent to the physician. 2. Patient # 7 was admitted to home care services on 04/15/23 with Diagnosis of Bilateral Primary Osteoarthritis. The clinical record was reviewed on 02/15/24. The clinical record contained a discharge document SN assessment dated 12/07/23. The clinical record lacked documentation indicating that a discharge summary was completed and sent to the Physician. 3. Finings of the discharged records not having a discharge summary were confirmed during interviews with the Administrator on 02/15/24 between 11:30 AM and 1:00 PM. Findings include: 1. Patient #6 was admitted to the home health services on 06/07/23 with the diagnoses of Bilateral Osteoarthritis of Knee and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24. The clinical record included an incomplete discharge document dated for 12/-04/23 -02/01/24 that lacked the discharge summary.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on home visit observations, clinical records review and staff interview, it was determined that for 5 of 7 (Pts. #2, 3, 5, 1 and 4) clinical records reviewed, the Agency failed to ensure all entries were clear, complete and authenticated. __. Pt. #1 was admitted to home health services on 12/29/23 with diagnoses that include Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Chest Pain on Breathing. The clinical record was reviewed on 02/14/24. The record contained a SOC order completed by the SN. The SOC order lacked the name/signature of the SN that obtained the physician's order, date the order was written, pertinent diagnoses, and discipline(s) to provide service, as required by the Agency's SOC order. The SOC comprehensive assessment form completed by the SN and dated 12/29/23, lacked the Emergency Preparedness priority code and date of the referral. The assessment contained documentation that the Pt. lives with others in the home, the assessment lacked the name, age, sex and relationship of those that reside with the Pt., as required by the SOC comprehensive assessment form. The form titled "Beneficiary Elected Transfer" completed by the SN, signed by the SN, Pt. and dated 12/29/23 lacked the name of the Agency the Pt. previously received home health services, and notification that the Pt. is currently receiving services from this Agency, as required by the Agency's form. The form titled "Notice of Medicare Non-Coverage" completed by the SN, signed by the SN, Pt. and dated 12/29/23 lacked the effective date that home health coverage will end, as required by the CMS form. __. Pt. #4 was admitted to home health services on 01/19/24 with diagnoses that include "Unspecified Osteoarthritis". The clinical record was reviewed on 02/15/24. The record contained the Telephone Order dated 1/19/24 and completed by the SN. The Order lacked "Pertinent Diagnoses" and the disciplines to provide service, as required by the Agency's Physician order form. ___. During interviews with the Administrator on 02/15/24, the Administrator confirmed the above findings. 2. Patient #3 was admitted to the Home Health Services on 10/06/23 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24 and included incomplete SN visit notes. The SN visit notes lacked the documentation of the blood glucose results that was observed in the patient’s home records for the entire certification period, 12/04/23 thru 02/15/24. 3. Patient #5 was admitted to the Home Health Services on 08/08/23 with the diagnoses of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 02/14/24 and included an incomplete Skilled Nursing note dated 02/06/24 and 02/13/24. The Skilled Nurses notes lacked the signature of the clinician. 1. Patient # 2 was admitted to home health services on 08/26/23 with Diagnosis of Bilateral Primary Osteoarthritis. A SN home visit was conducted on 02/15/24 at 9:30 AM. During an interview with the visiting nurse, the SN stated she has been providing SN visits weekly for certification period beginning 12/24/23. The clinical record was reviewed on 02/15/24. The clinical record contained weekly SN visit notes for certification period beginning 12/24/3 with a different clinician name.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. 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 the Agency failed to ensure the facility-based and community-based risk assessment, utilizing an all hazards approach was reviewed and updated every 2 years. This has the potential to affect all Pts. served by the Agency. Findings include: 1. On 3/15/21 at 1:45 PM, the Emergency Preparedness Plan last updated in "November 2017" was reviewed. The Plan contained the "2017 Hazard Vulnerability Analysis" form which lacked documentation the Agency had reviewed and revised the form since 2017. 2. During an interview with the Administrator and the Office Manager on 3/17/21 at 2:30 PM, the Administrator confirmed the Agency failed to review and update the risk assessment every 2 years.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) [(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: . A. Based on clinical record review and staff interview, it was determined the Agency failed to develop Individualized Emergency Preparedness Plans for 3 of 7 (Pt. #5, 6, and 7) clinical records reviewed. Findings include: 1. Pt. #5. SOC: 2/10/21 Primary Diagnosis: Polyosteoarthritis, Unspecified. The clinical record was reviewed on 3/16/21 at 10:30 AM. The record contained the SOC comprehensive assessment dated 2/10/21. This comprehensive assessment did not contain an individualized emergency plan, which included the potential disasters that Pt. #5 may face within the home, and how and when Pt. #5 is to contact emergency officials. 2. Pt. #6. SOC: 5/18/20. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/16/21 at 11:15 AM. The record contained the SOC comprehensive assessment dated 5/18/20. This comprehensive assessment did not contain an individualized emergency plan, which included the potential disasters that Pt. #6 may face within the home, and how and when Pt. #6 is to contact emergency officials. 3. Pt. #7. SOC: 7/14/20. Primary Diagnosis: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 3/16/21 at 1:00 PM. The record contained the SOC comprehensive assessment dated 7/14/20. This comprehensive assessment did not contain an individualized emergency plan, which included the potential disasters that Pt. #7 may face within the home, and how and when Pt. #7 is to contact emergency officials. 4. During an interview with the Administrator and the Office Manager on 3/17/21 at 1:50 PM, the Administrator confirmed the above findings.

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, Agency policy and staff interview, it was determined the Agency failed to ensure the Plan contain volunteers. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness Plan last updated in "November 2017" was reviewed on 3/15/21 at 1:45 PM. The Plan lacked any volunteers. 2. The Agency's policy titled, "Staff Management During An Emergency" was reviewed on 3/15/21 at 1:45 PM. The policy required: "...8. The agency will incorporate... volunteers into the staffing strategy when needed to address address any surge in needs during an emergency..." 3. During an interview with the Administrator and Office Manager on 13/17/21 at 2:30 PM, the Administrator confirmed the Agency failed to incorporate volunteers into the Agency's Emergency Preparedness Plan.

Development of Communication Plan CFR(s): 484.102(c) (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). This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Emergency Preparedness Plan, Agency policy and staff interview, it was determined the Agency failed to develop a communication plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Emergency Preparedness Plan last updated on "November 2017" was reviewed on 3/15/21 at 1:45 PM. The Plan contained the forms: "Agency Emergency Contact List, Staff Call Down List and List of Vendors". All of the forms mentioned above were left blank. As of 3/15/21, the Agency lacked an Emergency Preparedness communication plan. 2. The Agency's policy titled, "Communications Capabilities During Emergencies" was reviewed on 3/15/21 at 2:10 PM. The policy required: "Objective To maintain reliable communications capabilities for the purpose of communicating response efforts to staff, patients, and external organizations...9. The agency will maintain the names and contact information of the following as part of its communication plan: a. Staff b. Physician c. Other home health agencies or other sources of collaboration or assistance d. Volunteers e. Contracting company with the agency f. Relevant state and local emergency preparedness staff..." 3. During an interview with the Administrator and the Office Manager 3/17/21 at 2:30 PM, the Administrator confirmed the Agency failed to develop a communication plan.

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 review of the Agency's Emergency Preparedness Plan, In Service binder, personnel files, and staff interview, it was determined the Agency failed to conduct Emergency Preparedness testing. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness Plan last updated on "November 2017" was reviewed on 3/15/21 at 1:45 PM. The Plan lacked documentation the Agency conducted any testing exercises with the staff. 2. The Agency's "In Service" binder was reviewed on 3/16/21 at 9:20 AM. The binder lacked any documentation of Emergency Preparedness testing. 3. The personnel files of the direct staff/employees (E #1, E#2, E #3, and E #4) were reviewed on 3/16/21 at 9:40 AM. The personnel files lacked any documentation of Emergency Preparedness testing. 4. During an interview with the Administrator and the Office Manager on 3/17/21 at 2:30 PM, the Administrator confirmed the Agency failed to conduct any Emergency Preparedness testing.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 3/18/21. Standard level deficiency cited. DON = Director of Nursing RN = Registered Nurse SN = Skilled Nurse AM = Morning PM = Afternoon/Evening Pt./Pts. = Patient/Patients POC/PsoC = Plan of Care/Plans of Care SOC = Start of Care COVID 19 = Coronavirus 2019 mg = milligrams tab = tablet mcg = micrograms IU = International Units mg/dl - milligrams per deciliter bid = twice a day EPP = Emergency Preparedness Plan Res. Rate = Respiratory Rate > = greater than < = less than F = Fahrenheit FBS = Fasting Blood Sugar RBS = Random Blood Sugar Temp = Temperature lbs = pounds

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure care was provided as indicated in the POC and specific to the Pt. This was found in 4 of 7 (Pts. #1, 2, 4 and 6 ) clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/26/20. Diagnoses: Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease. The clinical record was reviewed on 3/15/21 at 2:30 PM. The record contained the PsOC for the certification period of 12/25/20 to 2/22/21 and effective 2/23/21 requiring: "SN to notify physician of any significant changes with patient's conditions such as: Blood Pressure >160/90 or 105 or 24 or 101 F or 5 lbs per week..." The weekly SN visit notes from 1/25/21 to 2/15/21, 3/5/21, 3/12/21 lacked the patient's weight to assess for a weight gain/loss. The recertification comprehensive assessment form dated 2/22/21 lacked the patient's weight, blood pressure, heart rate, res. rate and temp. The SN failed to assess the Pt. as indicated on the PsOC for ranges within the above parameters . 2. Pt. #2. SOC 12/2/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Low Back Pain. The clinical record was reviewed on 3/16/21 at 11:25 AM. The record contained the PsOC for the certification period of 12/2/20 to 1/30/21 and effective 1/31/21 requiring: "SN to notify physician of any significant changes with patient's conditions such as: Blood Pressure >160/90 or 250 mg/dl or 300 mg/dl or 105 or 24 or 101 F or 5 lbs per week..." The weekly SN visit notes from 2/10/21 to 3/3/21 lacked the patient's weight and blood sugar. The recertification comprehensive assessment completed by a RN and dated 1/27/21 lacked the patient's blood pressure, blood sugar, heart rate, res.rate and weight. The SN failed to assess the Pt. as indicated on the PsOC for ranges within the above parameters. A home visit was conducted with the Administrator on 3/16/21 at 2:30 PM. During the home visit an interview was conducted with the Pt. and caregiver that stated, the Pt. is not a diabetic and do not need to have the blood sugar checked. The POC was not personalized for Pt. #2. 3. Pt. #4. SOC 10/12/20. Diagnoses: Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/15/21 at 3:15 PM. The record contained the PsOC for the certification periods of 12/11/20 to 2/8/21 and effective 2/9/21 requiring: "Weight gain/loss of > 5lbs per week". The weekly SN visit notes from 1/29/21 to 2/5/21 and 2/17/21 to 3/10/21 lacked the patient's weight. The SN failed to assess for a weight loss or gain, as required by the PsOC. The PsOC effective 12/11/20 and 2/9/21 required: "SN to notify physician of any significant changes with patient's conditions such as... Blood Sugar FBS: Greater Than > 250 MG/DL or 300 MG/DL or 300 mg/dl < 60 mg/dl... SN to assess and observe on the following disease processes: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease..." The record also included the SN comprehensive recertification assessment dated 11/10/20, and weekly SN visit notes from 11/28/20 through 1/2/21. Neither the comprehensive recertification assessment nor any of the SN visits notes listed contained any RBS or FBS readings. There were no clinical notes regarding whether or not Pt. #6 was refusing to monitor Blood Sugar Levels. 5. During an interview with the Administrator and Office Manager on 3/17/21 from 1:50 PM to 3:00 PM, the Administrator confirmed the above findings, and stated the SN must monitor and record the Patient's weight, FBS and/or RBS readings, whether taken by the SN or the Pt./Caregiver. If the Pt. refuses to allow weight or Blood Sugar Levels to be taken, the Pt./Caregiver should be taught the importance of weight and Blood Sugar Level monitoring. The Physician should be notified of the Patient's refusal, and the this should be documented in the clinical record.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, observations and interview during home visits, and staff interview, it was determined the Agency failed to ensure Pts. were provided a written list of their medications. This was found in 3 of 3 Pts. (Pt. #1, 2, and 3) home visits conducted. Findings include: 1. Pt. #1. SOC 10/26/20. Diagnoses: Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease. The clinical record was reviewed on 3/15/21 at 2:30 PM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period of 2/23/21 to 4/23/21 which contained a list of the patient's medications with the dosage, frequency, route of administration, classification and effective date of each medication. A home visit was conducted with the DON on 3/16/21 at 1:00 PM. During the home visit the Pt. admission folder was observed and reviewed, the folder lacked a written list of the patient's medications. During an interview with the Pt.#1, the Pt. stated the Agency did not provide a written list of the medications. 2. Pt. #2. SOC 12/2/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Low Back Pain. The clinical record was reviewed on 3/16/21 at 11:25 AM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period of 1/31/21 to 3/31/21 which contained a list of the patient's medications with the dosage, frequency, route of administration, classification and effective date of each medication. A home visit was conducted with the Administrator on 3/16/21 at 2:30 PM. During the home visit the Pt. admission folder was observed and reviewed, the folder lacked a written list of the patient's medications. During an interview with the patient's caregiver, the caregiver stated the Pt. did not have a written list of the medications. 3. Pt. #3. SOC 10/26/20. Primary Diagnosis: Primary Osteoarthritis. The clinical record was reviewed on 3/15/21 at 3:00 PM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period of 2/23/21 to 4/23/21 which contained a list of the patient's medications with the dosage, frequency, route of administration, classification and effective date of each medication. A home visit was conducted with E #3 on 3/16/21 at 3:00 PM. During the home visit the Pt. admission folder was observed and reviewed, the folder lacked a written list of the patient's medications. During an interview with the Pt., the Pt. stated they did not have a written list of the medications. 4. During an interview with the Administrator and the Office Manager on 3/17/21 from 1:50 PM to 3:00 PM, the Administrator confirmed the Pts. indicated above lacked a written list of their medications.

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 review of clinical records, Agency policy, and staff interview, it was determined that the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and services. This was found in 7 of 7 (Pts. #1, 2, 4, 3, 5, 6, and 7) clinical records reviewed. Findings include 1. Pt. #1. SOC 10/26/20. Diagnoses: Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease. The clinical record was reviewed on 3/15/21 at 2:30 PM. The record contained the weekly SN visit notes from 1/25/2 to 2/15/21, 3/5/21 and 3/12/21 which lacked documentation the SN screened the Pt./caregiver for COVID-19 symptoms, prior to providing service as required by the Agency. 2. Pt. #2. SOC 12/2/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Low Back Pain. The clinical record was reviewed on 3/16/21 at 11:25 AM. The record contained the recertification comprehensive assessment dated 1/27/21, and the weekly SN visit notes from 2/10/21 to 3/10/21 which lacked documentation the SN screened the Pt./caregiver for COVID-19 symptoms, prior to providing service. 3. Pt. #4. SOC 10/12/20. Diagnoses: Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/15/21 at 3:15 PM. The record contained the weekly SN visit notes dated 1/29/21, 2/5/21, and 2/17/21 to 3/10/21 which lacked documentation the SN screened the Pt./caregiver for COVID-19 symptoms, prior to providing service. 4. Pt. #3. SOC 10/26/20. Primary Diagnosis: Primary Osteoarthritis. The clinical record was reviewed on 3/15/21 at 3:00 PM. The record contained weekly SN visits notes dated 1/11/21 through 2/15/21, and 2/26/21 through 3/13/21, indicating the SN provided service. There was no documentation the SN screened Pt. #3/Pt. #3's Caregiver for signs and symptoms of COVID-19 prior to any of these visits. 5. Pt. #5. SOC: 2/10/21 Primary Diagnosis: Polyosteoarthritis, Unspecified. The clinical record was reviewed on 3/16/21 at 10:30 AM. The record contained the SOC comprehensive assessment dated 2/10/21, as well as weekly SN visit notes dated 2/17/21 through 3/15/21. There was no documentation the SN screened Pt. #5/Pt. #5's Caregiver for signs and symptoms of COVID-19 prior to any of these visits. 6. Pt. #6. SOC: 5/18/20. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/16/21 at 11:15 AM. The record contained weekly SN visits notes dated 11/28/20 through 1/2/21, indicating the SN provided service. The record also included a Physical Therapy evaluation dated 9/22/20, indicating the Physical Therapist provided service. There was no documentation the SN or the Physical Therapist screened Pt. #6/Pt. #6's Caregiver for signs and symptoms of COVID-19 prior to any of these visits. 7. Pt. #7. SOC: 7/14/20. Primary Diagnosis: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 3/16/21 at 1:00 PM. The record contained weekly SN visits notes dated 11/11/20 through 12/30/20, indicating the SN provided service. The record also included a Physical Therapy evaluation dated 10/2/20, indicating the Physical Therapist provided service. There was no documentation the SN or the Physical Therapist screened Pt. #7/Pt. #7's Caregiver for signs and symptoms of COVID-19 prior to any of these visits. 8. The Agency's policy titled "Operational Protocols" was reviewed on 3/17/21 at 11:30 AM. The policy required: "...Screen Patients and other household members for COVID-19 like illness...in advance and by phone if possible..." 9. During an interview with the DON on 3/17/21 at 12:05 PM, the DON stated COVID-19 Pt./Caregiver screening should be performed by phone prior to each clinician's home visit, and documented in the Patient's medical record. 10. During an interview with the Administrator and the Office Manager on 3/17/21 from 1:50 PM to 3:00 PM, the Administrator confirmed the lack of COVID-19 Pt. screenings.

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, clinical record review, and staff interview, it was determined the Agency failed to ensure the clinical record contained accurate medication records. This was found in 3 of 3 Pts. (Pt. #1, 2, and 3) home visits conducted. Findings include: 1. Pt. #3. SOC 10/26/20. Primary Diagnosis: Primary Osteoarthritis. A home visit was conducted on 3/16/21 at 3:00 PM, along with E #3. During this home visit, an observation was made of Pt. #3's medications, which was compared with Pt. #3's medication profile. This medication profile did not include the following medications: Vitamin D3 2,000 IU daily; Vitamin B12 1,000 mcg daily; Iron 65 mg daily; and Turmeric/Curcumin 450 mg/10 mg daily. Pt. #3 stated Pt. #3 had been taking these medications "for 2 to 3 years." This medication profile included "diskus inhaler 1 puff bid." Pt. #3 presented Fluticasone Propionate and Salmeterol diskus inhaler 500/50 (mcg), labeled "1 inhalation twice a day." The clinical record was reviewed on 3/15/21 at 3:00 PM. The clinical record did not contain any new Physician orders for Vitamin D3, Vitamin B12, Iron, Turmeric/Curcumin, or Fluticason and Salmeteral diskus inhaler. As of 3/16/21, the medication profile was inaccurate. 2. Pt. #1. SOC 10/26/20. Diagnoses: Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease. The clinical record was reviewed on 3/15/21 at 2:30 PM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period of 2/23/21 to 4/23/21 which contained: "Aspirin 81 mg . take 1 tab po daily; Vitamin B12 1000 mg . take 1 tab po daily; Colestipol 1 mg . take 1 tab po bid." A home visit was conducted with the DON on 3/16/21 at 1:00 PM. During the home visit the patient's medications were observed and Aspirin, Vitamin B12 and Colestipol were not present. An interview was conducted with the Pt. that stated: "I don't have it", the Pt. reported that he/she was out of the medications for at least 2 weeks. During interview, the DON stated "The nurse should check the patient's medications every week, and if the Pt. was low or out of medication, then the nurse would notify the doctor that refills are needed." 3. Pt. #2. SOC 12/2/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Low Back Pain. The clinical record was reviewed on 3/16/21 at 11:25 AM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period of 1/31/21 to 3/31/21 which contained: "Calcium 600 mg oral Tab. Take one Tab. by mouth daily." A home visit was conducted with the Administrator on 3/16/21 at 1:00 PM. During the home visit the patient's medications were observed, and an interview was conducted with the Pt. and caregiver that stated: The Pt. did not take Calcium in 2020 and 2021. Other medications observed were: Ibuprofen 200 mg per capsule, the caregiver stated the Pt. takes 3 capsules by mouth every midday for over a year; Vitamin D 2,000 IU daily by mouth for the past 2 months; and Vitamin B12 1000 mcg daily by mouth for the past 3 to 4 years. During the same interview, the caregiver stated the Physician was aware that the Pt. takes Ibuprofen, Vitamin D, and Vitamin B12. As of 3/16/21, the "Patient Medication Profile" was inaccurate to contain Calcium and lacked Ibuprofen, Vitamin D and Vitamin B12. 4. During an interview with the Administrator and Office Manager on 3/17/21 from 1:50 PM to 3:00 PM, the Administrator confirmed Patient Medication Profiles were inaccurate.

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: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure a discharge summary was completed by the RN and sent to the Physician within 5 business days of the Patient's discharge. This was found in 2 of 2 records reviewed (Pts. #6 and 7) wherein the Pt. was discharged from Agency. Findings include: 1. Pt. #6. SOC: 5/18/20. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/16/21 at 11:15 AM. The record included a comprehensive discharge assessment dated 1/9/21, which indicated Pt. #6 was discharged. The record did not contain an RN discharge summary. 2. Pt. #7. SOC: 7/14/20. Primary Diagnosis: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 3/16/21 at 1:00 PM. The record included a comprehensive discharge assessment dated 1/6/21, which indicated Pt. #6 was discharged. The record did not contain an RN discharge summary. 3. During an interview with the Administrator and the Office Manager on 3/1721 at 1:50 PM, the Administrator confirmed the SN did not complete a discharge summary and send it to the Physician within 5 days, as required.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, observation during a home visit, Agency policy, and staff interview, it was determined the Agency failed to ensure that clinical documentation entered into the clinical record was complete and accurate. This was found in 7 of 7 (Pts. #1, 2, 4, 3, 5, 6 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/26/20. Diagnoses: Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease. The clinical record was reviewed on 3/15/21 at 2:30 PM. The Agency's SN visit note contained a section requiring the "Patient's Signature, Employee's Signature, date, time in and time out. The record included the weekly SN visit notes from 1/25/21 to 2/15/21, 3/5/21, 3/12/21 which lacked the "Patient's Signature, Employee's Signature (person that conducted the visit), date, time in and time out, as required by the Agency's SN visit note. The recertification comprehensive assessment form dated 2/22/21 lacked the nurse's signature/name that completed the assessment form and date. The "Consent... Services and Agreement" form signed by the Pt., RN and dated 10/26/20, required the RN to place a checkmark next to "Yes" or "No", indicating whether the Pt. had Advance Directives, these sections was left blank. The "Notice of Medicare Non-Coverage" form dated 10/26/20 and signed by the Pt. included: "The effective date coverage of your current... services will end:" The form required the RN to enter the date that services will no longer be covered by Medicare. This section was left blank. The recertification comprehensive assessment form dated 2/22/21 completed by the RN lacked: Emergency Preparedness priority code, Advance Directives information, Emergency contact information; assessment of eyes, oral/mouth, neck and throat, pain assessment, blood pressure, pulse, temperature, res. rate, cardiac sounds, breath sounds, nutritional requirements, breast assessment, endocrine/hematopoetic assessment, risk fall assessment, care preferences/patients personal goals, teaching/training and plan for the next visit, all required by the Agency's form. Effective 1/31/21 (current certification period), the SN was required to provide service 1 time a week for 9 weeks. The record lacked documentation the SN provided any service during the week of 1/31/21 to 2/6/21, until a home visit was conducted with the Administrator on 3/16/21 at 2:30 PM. During the home visit, the patient's admission folder was observed and contained a form which included the patient's blood pressure, temperature, respirations, heart rate and the nurses initials with the date of 2/3/21. As of 3/16/21, the record lacked a SN visit note for 2/3/21. 2. Pt. #2. SOC 12/2/20. Diagnoses: Primary Generalized (Osteo) Arthritis and Low Back Pain. The clinical record was reviewed on 3/16/21 at 11:25 AM. The record contained the weekly SN visit notes from 2/10/21 to 3/10/21 which lacked the "Patient's Signature, Employee's Signature (person that conducted the visit), date, time in and time out, as required by the Agency's SN visit note. The recertification comprehensive assessment form dated 1/27/21 lacked the nurse's signature/name that completed the assessment form, and the date the form was entered into the medical record. The "Consent... Services and Agreement" form signed by the Pt., RN and dated 12/1/20 contained an Advance Directives inquiry section which was left blank. The recertification comprehensive assessment form dated 1/27/21 completed by the RN lacked: Emergency Preparedness priority code, Advance Directives information, Emergency contact information; assessment of eyes, oral/mouth, neck and throat, pain assessment, condition of skin, vital signs, homebound status, cardiac and respirator status, appetite, nutritional requirements, nutritional health assessment, breast assessment, care preferences/patients personal goals, teaching/training and plan for the next visit, all required by the Agency's form. 3. Pt. #4. SOC 10/12/20. Diagnoses: Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/15/21 at 3:15 PM. The record contained the weekly SN visit notes from 1/29/21 to 2/5/21, and 2/17/21 to 3/10/21 which lacked the "Patient's Signature, Employee's Signature (person that conducted the visit), date, time in and time out. The recertification comprehensive assessment form dated 2/7/21 lacked the nurse's signature/name that completed the assessment form, and the date the form was entered into the medical record. The "Consent... Services and Agreement" form signed by the Pt., RN and dated 10/12/20 contained an Advance Directives inquiry section which was left blank. The "Notice of Medicare Non-Coverage" form dated 10/12/20 and signed by the Pt. included: "The effective date coverage of your current... services will end:" The form required the RN to enter the date that services will no longer be covered by Medicare. This section was left blank. The "Financial Responsibility" form dated 10/12/21 required the RN to place a checkmark next to the patient's source of payment. The form was completed by the RN, and lacked a checkmark indicating the payment source for Pt. #4. 4. Pt. #3. SOC 10/26/20. Primary Diagnosis: Primary Osteoarthritis. The clinical record was reviewed on 3/15/21 at 3:00 PM. The record contained a comprehensive recertification assessment dated 2/22/21, which contained the sections "Refused Care" and "Care Preferences/Patient's Personal Goals." Both of these sections were blank, and the assessment was not signed and dated by the RN performing the assessment. The record also included weekly SN visits notes dated 1/11/21 through 3/13/21, indicating the SN provided service. All of these SN visit notes were not signed and dated by the SN rendering service. 5. Pt. #5. SOC: 2/10/21 Primary Diagnosis: Polyosteoarthritis, Unspecified. The clinical record was reviewed on 3/16/21 at 10:30 AM. The record contained the SOC comprehensive assessment dated 2/10/21, which contained the sections "Emergency Preparedness, History of Falls, Fall Risk, Pain Assessment, Vital Signs, Homebound Status, Cardio-Respiratory Status, Gastrointestinal Tract, Nutritional Health Assessment, Mental Status, Fall Risk Assessment Tool, Refused Care, Strengths/Limitations, Care Preferences/Patient's Personal Goals, Emergency Preparedness Care Planning, Orders for Services,Frequency and Duration of Visits, Functional Rehab Screening, Discharge Plans, Identified Problems, Emergency Contact, and Teaching/Training." All of these sections were blank, and the assessment was not signed and dated by the RN performing the assessment. The record also included weekly SN visit notes dated 2/17/21 through 3/15/21. All of these SN visit notes were not signed and dated by the SN rendering service. 6. Pt. #6. SOC: 5/18/20. Primary Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/16/21 at 11:15 AM. The record contained a recertification assessment dated 11/10/20, which contained the sections "Body System Review, Pain Assessment Tool, Integumentary Status, Braden Risk Assessment Scale, Respiratory Status, Homebound Status, Cardio-Respiratory Status, Gastrointestinal Tract, Nutritional Health Assessment, Endocrine/Hematopoetic, Musculoskeletal /Neurological, Mental Status, Fall Risk Assessment, Refused Care, Risk Factors/Hospital Admission/Emergency Room, Care Preferences/Patient's Personal Goals, and Teaching/Training." All of these sections were blank, and the assessment was not signed and dated by the RN performing the assessment. The record also included a discharge comprehensive assessment dated 1/9/21, which contained the section "Clinical Record Items," which was blank. This discharge assessment was not signed by the RN performing the assessment. The record also included weekly SN visits notes dated 11/28/20 through 1/2/21, indicating the SN provided service. All of these SN visit notes were not signed and dated by the SN rendering service. 7. Pt. #7. SOC: 7/14/20. Primary Diagnosis: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 3/16/21 at 1:00 PM. The record contained a recertification assessment dated 11/7/20, which contained the sections "Emergency Preparedness, Body System Review, Pain Assessment Tool, Integumentary Status, Braden Risk Assessment Scale, Respiratory Status, Homebound Status, Cardio-Respiratory Status, Gastrointestinal Tract, Nutritional Requirements, Nutritional Health Assessment, Other Assessments, Fall Risk Assessment, Therapy Need and Plan of Care, Refused Care, Risk Factors/Hospital Admission/Emergency Room, Care Preferences/Patient's Personal Goals, and Teaching/Training." All of these sections were blank, and the assessment was not signed by the RN performing the assessment. The record also included a discharge comprehensive assessment dated 1/6/21, which was not signed and dated by the RN performing the assessment. The record also contained weekly SN visits notes dated 11/11/20 through 12/30/20, indicating the SN provided service. All of these SN visit notes were not signed and dated by the SN rendering service. 8. The Agency policy titled "Medical Documentation and Amendment Guidelines" was reviewed on 3/17/21 at 11:00 AM. The policy required: "...A complete and legible medical record shall be maintained for each individual who is evaluated and/or receives clinical treatment...All entries shall be signed or initialed/authenticated by the provider..." 9. During an interview with the DON on 3/17/21 at 12:05 PM, the DON stated all comprehensive assessments and visit notes should be fully completed, and must be signed and dated by the clinician rendering care to the Pt. 10. During an interview with the Administrator and Office Manager on 3/21/21 from 1:50 PM to 3:00 PM, the Administrator confirmed the lack of complete documentation, signatures, and dates in the clinical record.