Every finding on record at Quality Health Care Inc.

Based on the findings of an unannounced onsite Medicare recertification survey completed September 21, 2023, Quality Health Care, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(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 facilities]. 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: Based on a review of the agency Emergency Preparedness Plan and an interview with the agency Administrator, agency failed to ensure policies and procedures address the use of volunteers or other emergency staffing strategies in an emergency for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Findings Include: Agency policy address the use of volunteers or other emergency staffing strategies in an emergency was requested on September 21, 2023 at approximately 2:30 p.m. No policy provided. A review of the agency Emergency Preparedness Plan conducted on September 21, 2023 at approximately 2:30 p.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan addressing the use of volunteers or other emergency staffing strategies in an emergency. An interview conducted with agency Administrator on September 21, 2023 at approximately 3:00 p.m. confirmed the above findings.

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 a review of the agency Emergency Preparedness Plan and an interview with the agency Administrator, agency failed to conduct an annual 2022 tabletop excercise for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Findings Include: Agency policy address annual tabletop excercises was requested on September 21, 2023 at approximately 2:30 p.m. No policy provided. A review of the agency Emergency Preparedness Plan conducted on September 21, 2023 at approximately 2:30 p.m. revealed the following: EP #1: No documentation provided of the agency conducting an annual 2022 tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario. An interview conducted with agency Administrator on September 21, 2023 at approximately 3:00 p.m. confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey completed September 21, 2023, Quality Health Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on a review of clinical records and an interview with the agency Administrator, agency failed to ensure agency staff review all patient medications for one (1) of one (1) patient home visits observed/clinical record (CR) reviewed (CR#2). Findings Include: Agency policy for ensuring agency staff review all patient medications was requested on September 21, 2023 at approximately 2:30 p.m. No policy provided. A patient home visit was conducted on September 21, 2023 at approximately 10:30 a.m. A review of patient clinical records was conducted on September 21, 2023 at approximately 12:30 p.m. The patients start of care (SOC) is listed below: CR#2 SOC 09/04/20: Patients Plan of Care for the period of 07/31/23-09/30/23 was reviewed. The patients most recent active medication list was dated 07/21/23. During the patient home visit, the registered nurse was observed filling the patient's pillbox. XYZAL 5mg (1x daily) was included in the pillbox filling process. XYZALL was not included on the patients most recent active medication list. The following two drugs were alongside the patient's medications the registered nurse was filling the pill box with. Primidone 50mg (3x daily) and Topiramate 50mg (1x daily) were not included in the pillbox filling process. These two medications were listed on the patients most recent active medication list. Per employee #1, "I don't do these medications, the patient does them by himself. They are not on my initial medication list." The "initial medication list" the registered nurse was utilizing was a list of medications handwritten on a piece of paper in a tablet. Hydroxyzine 10mg (2x daily PRN) was alongside the patient's medications the registered nurse was filling the pill box with. This medication was not on the patients most recent active medication list. An interview conducted with agency Administrator on September 21, 2023 at approximately 3:00 p.m. confirmed the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records and an interview with the agency Administrator, agency failed to ensure orders for services include the amount, frequency, and duration for seven (7) of seven (7) clinical record (CR) certifications/recertifications reviewed (CR#1 - CR#7). Findings Include: Agency policy for including the amount, frequency, and duration of services in the patient plan of treatment was requested on September 21, 2023 at approximately 2:30 p.m. No policy provided. A review of CRs was conducted on September 21, 2023 at approximately 12:30 p.m. The patients start of care (SOC) is listed below: CR#1 SOC 10/19/18: Patients Plan of Care for the period of 08/07/23-10/06/23 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "RN-Supervisory and assessment every 60 days or PRN (as needed). CHHA (home health aide) to assist with ADL's (activities of daily living) 40 hours per week." No duration included in the orders. CR#2 SOC 09/04/20: Patients Plan of Care for the period of 07/31/23-09/30/23 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "RN- initial assessment. RN- Reassessment every 60 days or PRN. Skilled nurse - Pill box Weekly." No duration included in the orders. CR#3 SOC 06/06/22: Patients Plan of Care for the period of 06/06/22-08/05/22 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "RN- initial assessment. RN- Reassessment every 60 days or PRN. Skilled nurse - Wound care 3 x week to the right foot 4th and 5th toe interspace and left foot 2nd toe ulcer. Clean with wound cleanser, apply soap and water. Pat dry, apply idosorb ointment, secure with gauze and cling." No duration included in the orders. CR#4 SOC 12/22/21: Patients Plan of Care for the period of 02/21/21-04/22/22 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "RN- initial assessment. RN- RN supervisory every 30 days. RN reassessment every 30 days or PRN. Skilled nurse - Wound care 1 x week. Wound #1 LLE lymphedema. 1. Clean with wound cleanser, apply Unna boot. 2. Primary dressing/topical medication coban with 50% stretch. 3. Secure with n/a" No duration included in the orders. CR#5 SOC 05/07/19: Patients Plan of Care for the period of 08/26/21-10/24/21 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "CHHA to assist with ADL's 40 hours per week. RN supervisory every 30 days or PRN. RN re-assessment every 60 days or PRN." No duration included in the orders. CR#6 SOC 01/14/16: Patients Plan of Care for the period of 08/19/22-10/17/22 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "RN supervisory visit every 30 days. RN reassessment every 60 days or PRN. HHA to assist with ADL's 29 hours per week." No duration included in the orders. CR#7 SOC 10/31/18: Patients Plan of Care for the period of 12/14/21-02/11/22 reviewed. 'Home Health Certification and Plan of Care' section 'Orders for Discipline and Treatment (Specify Amount/Frequency/Duration' state "CHHA to assist with ADL's 35 hours per week. RN supervisory every 30 days or PRN. RN reassessment every 60 days or PRN." No duration included in the orders. An interview conducted with agency Administrator on September 21, 2023 at approximately 3:00 p.m. confirmed the above findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on a review of clinical records and an interview with the agency Administrator, agency failed to ensure services being furnished based on a physician's verbal order were put into writing by agency personnel authorized to do so for three (3) of three (3) patient clinical records (CR) reviewed (CR#4, CR#5, CR#7). Findings: Agency policy for ensuring agency staff obtaining physician's verbal order were put into writing by agency staff authorized to do so was requested on September 21, 2023 at approximately 2:30 p.m. No policy provided. A review of patient clinical records was conducted on September 21, 2023 at approximately 12:30 p.m. The patients start of care (SOC) is listed below: CR#4 SOC 12/22/21: Patients Plan of Care for the periods of 12/22/21-02/20/21 and 02/21/21-04/22/22 were reviewed. The 'Home Health Certification and Plan of Care' certification period 12/22/21-02/20/21, signed by the physician on 01/20/22, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. The 'Home Health Certification and Plan of Care' certification period 02/21/21-04/22/22, signed by the physician on 03/15/22, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. CR#5 SOC 05/07/19: Patients Plan of Care for the periods of 04/28/21-06/26/21, 06/27/21-08/25/22, and 08/26/21-10/24/21 were reviewed. The 'Home Health Certification and Plan of Care' certification period 04/28/21-06/26/21, signed by the physician on 05/13/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. The 'Home Health Certification and Plan of Care' certification period 06/27/21-08/25/22, signed by the physician on 07/14/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. The 'Home Health Certification and Plan of Care' certification period 08/26/21-10/24/21, signed by the physician on 09/08/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. CR#7 SOC 10/31/18: Patients Plan of Care for the periods of 08/16/21-10/14/21, 10/15/21-12/13/21, and 12/14/21-02/11/22 were reviewed. The 'Home Health Certification and Plan of Care' certification period 08/16/21-10/14/21, signed by the physician on 08/21/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. The 'Home Health Certification and Plan of Care' certification period 10/15/21-12/13/21, signed by the physician on 10/28/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. The 'Home Health Certification and Plan of Care' certification period 12/14/21-02/11/22, signed by the physician on 12/28/21, section 'Nurse Signature and Date of Verbal SOC (start of care) where applicable' was blank with no entry. An interview conducted with agency Administrator on September 21, 2023 at approximately 3:00 p.m. confirmed the above findings.