Every finding on record at Promesa Home Health Inc

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 11/29/22 at 09:45 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Administrator. Census: Licensed and Certified: 5 An exit conference was conducted on 12/02/2022 at 01:00 p.m. with the Adm. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Administrator - Adm Alternate Administrator – AA Alternate Director of Nursing - ADON Registered Nurse - RN Licensed Vocational Nurse - LVN L & C - Licensed and Certified POC - Plan of Care SN - Skilled Nurse PAS- Personal Assistant Services QAPI - Quality Assurance and Performance Improvement TAC- Texas Administrative Code EPRP- Emergency Preparedness Response Plan

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the facility's 1 of 1 written emergency preparedness and response plan failed to describe an alternate mode of communication or alert systems in the event of telephone or power failure. This failure has the potential to negatively impact the facility's active patients if the agency is unable to function and meet its communication needs during a disaster. Findings Include: Review of the facility's Emergency Preparedness Manual included a form titled "Continuity of Operations Business Plan" with date of 05/26/22, identified by the Admin/DON on 12/02/22 at 10:45 am as the Emergency Preparedness Plan. The form revealed in part in the “Response Phase" section: “a. The following primary mode of communication/alternate communication or alert system in the event of telephone or power failure will be put into place: Cell phones, if not working, 2-way radio w/5-mile radius…” Further review of the Emergency Preparedness Manual and Emergency Preparedness and Response Plan revealed the facility's Emergency Preparedness and Response Plan failed to describe alternate forms of communication or alert systems for telephone or power failure if the cell phone service was unavailable. During an interview on 12/02/22 at 10:45 p.m. with the Admin/DON, the Surveyor asked to see the 2-way radios with 5-mile radius fully charged, docked and ready to go in the event of an emergency. Admin/DON confirmed that the facility did not have 2-way radios and therefore failed to describe an alternate form of communication in the event of an emergency in its Emergency Preparedness Plan. Facility policy manual form titled “Emergency Preparedness and Response Plan with no revision date, no page number revealed in part: “Communication Plan: The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following: Primary and alternate means for communicating with the agency staff…”

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 11/29/22 at 09:45 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Administrator. Census: Licensed and Certified: 5 An exit conference was conducted on 12/02/2022 at 01:00 p.m. with the Adm. The preliminary findings were discussed. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator - Adm Alternate Administrator – AA Alternate Director of Nursing - ADON Registered Nurse - RN Licensed Vocational Nurse - LVN L & C - Licensed and Certified POC - Plan of Care SN - Skilled Nurse PAS- Personal Assistant Services QAPI - Quality Assurance and Performance Improvement TAC- Texas Administrative Code EPRP- Emergency Preparedness Response Plan

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 record review and interview, the Agency Administrator failed to manage the daily operations of the agency as follows: The administrator failed to ensure, the agency had on-hand, 2-way radios, as described in their Emergency Preparedness Response Plan (EPRP) for use as their alternate mode of communication in the event of telephone or power failure. The administrator failed to include a staff member from every discipline in its quality assessment and performance improvement (QAPI) meeting for three of the four years reviewed (2019, 2020, 2021). These failures could result in the agency patients at risk of receiving substandard care and negative patient care outcomes. Findings include: 1. Review of the agency's Emergency Preparedness Manual included a form titled "Continuity of Operations Business Plan" with date of 05/26/22, identified by the Admin/DON on 12/02/22 at 10:45 am as the Emergency Preparedness Plan. The form revealed in part in the “Response Phase" section: “a. The following primary mode of communication/alternate communication or alert system in the event of telephone or power failure will be put into place: Cell phones, if not working, 2-way radio w/5-mile radius…” Further review of the Emergency Preparedness Manual and Emergency Preparedness and Response Plan revealed the agency's Emergency Preparedness and Response Plan failed to describe alternate forms of communication or alert systems for telephone or power failure if the cell phone service was unavailable. During an interview on 12/02/22 at 10:45 p.m. with the Admin/DON, the Surveyor asked to see the 2-way radios with 5-mile radius fully charged, docked and ready to go in the event of an emergency. Admin/DON confirmed that the Agency did not have 2-way radios and therefore failed to describe an alternate form of communication in the event of an emergency in its Emergency Preparedness Plan. Agency policy manual form titled “Emergency Preparedness and Response Plan with no revision date, no page number revealed in part: “Communication Plan: The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following: Primary and alternate means for communicating with the agency staff…”. 2.Record review of 2019 QAPI binder quoted in part,” QAPI 1st Quarter 2019, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. 60 Day Summary/Case Conference, 5. Infection Control/Adverse Events, 6. Complaints, 7. Emergent Care Services…Disciplines involved: Census: 48, discharged 19, Skilled nurse” signed and dated by only nursing discipline on 04/15/19. Record review of 2019 QAPI binder quoted in part,” QAPI 2nd Quarter 2019, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. 60 Day Summary/Case Conference, 5. Infection Control/Adverse Events, 6. Complaints, 7. Emergent Care Services…Disciplines involved: Census: 38, discharged 22, Skilled nurse and Physical Therapy” signed and dated by only nursing discipline on 07/08/19. Record review of 2019 QAPI binder quoted in part,” QAPI 3rd Quarter 2019, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. 60 Day Summary/Case Conference, 5. Infection Control/Adverse Events, 6. Complaints, 7. Emergent Care Services…Disciplines involved: Census: 44, discharged 12, Skilled nurse” signed and dated by only nursing discipline on 10/04/19. Record review of 2020 QAPI binder quoted in part,” QAPI 1st Quarter 2020, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Census: 46, 9 SOC (start of care), 7 Discharges…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. Infection Control/Adverse Events, 5. Complaints… Disciplines involved: Skilled nurse and Physical Therapy” signed and dated by only nursing discipline on 03/17/20. Record review of 2020 QAPI binder quoted in part,” QAPI 2nd Quarter 2020, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Census: 43, 3 SOC (start of care), 7 Discharged…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. Infection Control/Adverse Events, 5. Complaints… Disciplines involved: Skilled nurse” signed and dated by only nursing discipline on 04/07/20. Record review of 2020 QAPI binder quoted in part,” QAPI 3rd Quarter 2020, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Unduplicated Census: 45, Discharges 3, Admissions 1…Aspects of care/Topics monitored: Promptness of Delivery of services, Case conference, Clinical Records, Infection Control, Adverse Events, Complaints… Disciplines involved: Skilled nurse” signed and dated by only nursing discipline on 10/15/20. Record review of 2020 QAPI binder quoted in part,” QAPI 4th Quarter 2020, Analysis of a representative sample of services furnished to clients contained in both active and closed records…Census: 34, 2 SOC (start of care), 6 Discharged…Aspects of care/Topics monitored: 1. Delivery of services, 2. Clinical Records, 3. Therapy, 4. Infection Control/Adverse Events, 5. Complaints… Disciplines involved: Skilled nurse and Physical Therapy” signed and dated by only nursing discipline on 01/05/21. Record review of 2021 QAPI binder quoted in part,” QAPI 3rd Quarter 2021, Dated September 30, 2021…Analysis of a representative sample of services furnished to clients” signed and dated by only nursing discipline on 07/21/21. Record review of 2022 QAPI binder revealed no further evidence of agency excluding staff members from other disciplines to the QAPI meetings. In an interview with the Administrator on 12/02/22 at 11:30 a.m., Administrator identified QAPI binders for year 2019, 2020, 2021 and 2022. Administrator stated the QAPI committee for the agency consisted of the Administrator, Assistant administrator, the owners of the agency and quality assurance nurses. Administrator confirmed the agency did not include staff from each discipline, including PAS or therapy, in QAPI meetings for the following dates: 04/19/2021, 07/08/19, 10/04/19, 01/05/21, 07/21/21, and 01/15/21. He stated that a “consultant came in for year 2022 and started to fix the issue”. Record review of agency policy, quoted in part, “QAPI.001 Quality Improvement Program…The performance improvement activities are planned in a collaborative, interdisciplinary manner throughout the organization. [Agency]’s performance improvement is a coordinated and collaborative effort, the approach to improving performance involves multiple departments and disciplines in establishing the plans, processes and mechanisms that comprise performance improvement activities….Appropriate reporting of information to the Board of Directors to provide the leaders with the information needed to fulfill its responsibility for the quality of patient care, treatment and services and safety of patients and others is a required mandate of this plan…Necessary information is communicated among departments/services when opportunities to improve patient care, treatment and/or services and patient/staff safety practices impact more than one (1) department/service”. Record review of agency policy, quoted in part, “ADM.019 Role of the Administrator…The administrator will hire competent staff, supervise/ patient satisfaction survey reports and address any concerns that become apparent from the reports. A. Administrator Responsibilities: An Administrator must be responsible for implementing and supervising the administrative policies of the agency and administratively supervising the provision of all services. At a minimum the administrator must: organize and direct the agency’s ongoing functions; ensure that the documentation of services provided is accurate and timely; employ or contract with qualified personnel” Record review of agency policy, quoted in part, “ADM.O12 Administrative Authorities…[Agency] maintains administrative control and established lines of authority for delegations of responsibility concerning the delivery of patient care and services. The administrator has the overall authority and responsibility for operation and administrative function of the agency. The Director of Nursing (DON) reports to the administrator. The DON has overall responsibility for coordination of day-to-day patient care and management of the health care providers of the agency.