Every finding on record at Reliable Home Health Care, Inc

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Plan was accurate, reviewed and updated biennially. Findings include: 1. The Agency's policy titled; "Emergency Preparedness Plan" was reviewed on 11/9/22 at 1:00 PM. The Plan contained: "Unless the emergency renders the agency office unusable, the Incident Command Center will be located at ..." The Plan lacked the correct address of the Agency/Incident Command Center. The Agency's "Emergency Preparedness Plan" lacked the date it was initiated, reviewed and/or updated. As of 11/9/22, the "Emergency Preparedness Plan" was inaccurate and lacked documentation indicating the plan was reviewed and revised every 2 years. 2. During an interview with the Clinical Director on 11/9/22 at 2:40 PM, the above findings were confirmed.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on a review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the risk assessment was reviewed and updated biennially. Findings include: 1. On 10/8/22 at 3:50 PM, the Agency's Clinical Director presented two (2) binders titled "Emergency Preparedness Plan". Both binders were reviewed on 11/9/22 at 1:00 PM. Each binder contained an undated all hazard risk assessment form. The risk assessment forms lacked dates, indicating the risk assessment was reviewed and revised every 2 years. 2. During an interview with the Clinical Director on 11/9/22 at 2:40 PM, the above findings were confirmed.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update the policies and procedures biennially. Findings include: 1. On 10/8/22 at 3:50 PM, the Agency's Clinical Director presented two (2) binders titled "Emergency Preparedness Plan". Both binders were reviewed on 11/9/22 at 1:00 PM. Each binder contained policies and procedures which lacked dates, indicating that policies and procedures were reviewed and updated every 2 years. 2. During an interview with the Clinical Director on 11/9/22 at 2:40 PM, the above findings were confirmed.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(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 facilities]. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness Communication Plan biennially. Findings include: 1. The Agency's "Emergency Preparedness Plan" was reviewed on 11/9/22 at 1:00 PM. As of 11/9/22, the Communication Plan lacked any dates indicating it was reviewed and updated every 2 years. 2. During an interview with the Clinical Director on 11/9/22 at 2:40 PM, the above findings were confirmed.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Communication Plan was complete. Findings include: 1. The Agency's "Emergency Preparedness Plan" was reviewed on 11/9/22 at 1:00 PM and lacked the names and contact information of the direct staff, contract staff/contract agencies, and the patient's physicians. 2. During an interview with the Clinical Director on 11/9/22 at 2:40 PM, the above findings were confirmed.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times Q/q =every w/W/wk = week # = number AM = morning PO = by mouth SN = Skilled Nurse POC = Plan of care SOC = Start of care mcg = microgram MG/mg = milligram IM = Intramuscular PsOC = Plans of Care IU = International Units PM = afternoon/evening Pt./ Pts. = Patient/Patients

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT 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 the initial assessment visit was done within 48 hours of the referral date. This was found in 3 of 7 (Pts. #2, 3 and 4) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/3/22. Primary Diagnosis: Unspecified Acute Kidney Failure. The clinical record was reviewed on 11/9/22 at 7:30 AM. The record contained the "Home Heath Referral and Face to Face Encounter" form completed by the Physician and faxed to the Agency on 2/25/22. The SOC comprehensive assessment was conducted on 3/3/22 (6 days after the Agency received the referral). The record lacked documentation that the Pt. was not discharged from an inpatient facility, or there was a Physician-ordered SOC date. As of 11/9/22, the record lacked documentation the Agency initiated service within 48 hours of the referral date. 2. Pt. #3. SOC 2/10/22. Primary Diagnosis: Stage 2 Pressure Ulcer of Other Site. The clinical record was reviewed on 11/9/22 at 11:30 AM. The record contained a prescription signed by the Physician on 1/18/22 and faxed to the Agency on 1/20/22, requiring the Agency to provide "Health Care". The SOC comprehensive assessment was conducted on 2/10/22 (21 days after the Agency received the referral). The record lacked documentation that the Pt. was not discharged from an inpatient facility, or there was a Physician-ordered SOC date. As of 11/9/22, the record lacked documentation the Agency initiated service within 48 hours of the referral date. 3. Pt. #4. SOC 7/11/20. Primary Diagnosis: Unspecified Vitamin B12 Deficiency Anemia. The clinical record was reviewed on 11/7/22 at 4:00 PM. The record contained a "Home Health Referral and Face to Face Encounter" form completed by the Physician and faxed to the Agency on 7/6/20. The SOC comprehensive assessment was conducted on 7/11/20 (5 days after the Agency received the referral). The record lacked documentation that the Pt. was not discharged from an inpatient facility, or there was a Physician-ordered SOC date. As of 11/7/22, the record lacked documentation the Agency initiated service within 48 hours of the referral date. 4. During an interview with the Clinical Director on 11/9/22 at 1:50 PM, the Clinical Director confirmed the Agency failed to ensure the initial assessment visit was done within 48 hours of receipt of the referral.

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, interview and observation during a home visit and staff interview, it was determined the Agency failed to ensure the medications recorded on the PsOC were accurate and complete. This was found in 1 of 7 (Pt. #3) clinical records reviewed. Findings include: 1. Pt. #3. SOC 2/10/22. Primary Diagnosis: Stage 2 Pressure Ulcer of Other Site. The clinical record was reviewed on 11/9/22 at 11:30 AM. The record contained the POC for the certification period of 8/9/22 to 10/7/22 and 10/8/22 to 12/6/22 which included the medication: "Haloperidol 1 MG oral tablet 1 mg q daily by mouth (PO)". A home visit was conducted on 11/9/22 at 10:00 AM with Employee #2. During the home visit, an interview was conducted with the caregiver and the medications were observed which included: Calcium with Vitamin D 1 tablet daily by mouth (taken for more than 1 year), D3 1000 IU (25 mcg) daily by mouth (taken for more than 1 year), Ferrous Sulfate 324 EC tablet 1 tablet by mouth once daily (prescription bottle was dated 7/14/22 as the start date), Folate 666 mcg DFE (400 mcg Folic Acid) 1 tablet daily by mouth (taken for more than 1 year), Omeprazole DR 400 mg capsule take 1 capsule by mouth daily (taken for more than 1 year), Aspirin 81 mg daily by mouth (taken for more than 1 year), Vitamin C 500 mg by mouth daily (taken for more than 1 year), and Multivitamin 1 tablet by mouth daily (taken for more than 1 year). The caregiver also stated, "the doctor stopped the Haloperidol about a month after it was started (start date 3/17/22), the doctor said it wasn't needed anymore". As of 11/9/22, the PsOC effective 8/9/22 and 10/8/22 lacked Calcium with Vitamin D, D3, Ferrous Sulfate, Folate, B12, Omeprazole DR, Aspirin, Vitamin C and Multivitamin; and continued to list Haloperidol that was discontinued. 2. During an interview with the Clinical Director on 11/9/22 at 1:50 PM, the Clinical Director confirmed the medications recorded on the PsOC were inaccurate and incomplete.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observation and interview during a home visit and staff interview, it was determined the Agency failed to ensure the SN update the POC to reflect current wound care as prescribed by the Physician. This was found in 1 of 2 (Pt. #3) clinical records reviewed, wherein wound care was required. Findings include: 1. Pt. #3. SOC 2/10/22. Primary Diagnosis: Stage 2 Pressure Ulcer of Other Site. The clinical record was reviewed on 11/9/22 at 11:30 AM. The record contained the POC effective 10/8/22 that required: "SN Frequency: 1w9...SN to perform wound care to lower back. Cleanse wound with dermal, apply iodoform cover and secure with mepilex, using aseptic technique..." A home visit was conducted on 11/9/22 at 10:00 AM with Employee #2. During the home visit, observed Employee #2 remove the old dressing to the stage 2 lower back wound, clean the wound with wound cleanser, applied "Medihoney and an adhesive dressing. During an interview with Employee #2, the employee stated the Physician changed the wound care about 2 weeks ago. As of 11/9/22, the record lacked documentation the SN updated the POC to reflect the new wound care protocol. 2. During an interview with the Clinical Director on 11/9/22 at 1:50 PM, the Clinical Manager confirmed the SN failed to update the POC to reflect current wound care as prescribed by the Physician.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: A. Based on a review of the Agency's Pt. admission folder, observation and interviews during home visits, clinical record review and staff interview, it was determined the Agency failed to provide Pts./patient representatives information regarding the Clinical Director. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's admission folder was reviewed on 11/7/22 at 2:24 PM and lacked the Clinical Director's name and contact information. 2. The following home visits were conducted on 11/7/22 at 3:30 PM and 11/9/22 from 9:00 AM to 10:30 AM: Pt. #1. SOC 9/14/22. Pt. #2. SOC 3/3/22. Pt. #3. SOC 2/10/22. During the home visits of Pts. #1 and 3, the Pt. admission folders were observed and lacked the Clinical Director's name and contact information. During the home visits, an interview was conducted with the Pt. or patient's representative of Pts. #1, 2 and 3, that stated they were not aware of the Clinical Director's name and contact information. Pt. #2 was unable to locate the Pt. admission folder. 3. The clinical records of the following Pts. were reviewed from 11/7/22 at 4:00 PM to 11/9/22 at 2:16 PM, and lacked documentation that the Pts./patient's representative was provided the Clinical Director's name and contact information: Pt. #1. SOC 9/14/22. Pt. #2. SOC 3/3/22. Pt. #3. SOC 2/10/22. Pt. #4. SOC 7/11/20. Pt. #5. SOC 9/22/22. Pt. #6. SOC 6/3/22. Pt. #7. SOC 5/9/22. 4. During interviews with the Clinical Director on 11/9/22 at 1:50 PM and 3:30 PM, the Clinical Director confirmed the Agency does not inform Pts./patient's representative the Clinical Director's name and contact information.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT 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 staff provide service as required in the POC. This was found in 2 of 7 (Pts. 2 and 4) clinical records reviewed. Findings include: 1. Pt. #2. SOC 3/3/22. Primary Diagnosis: Unspecified Acute Kidney Failure. The clinical record was reviewed on 11/9/22 at 7:30 AM. The record contained the Resumption of Care comprehensive assessment completed by the SN and dated 9/22/22; and the Resumption of Care POC for the certification period of 8/30/22 to 10/28/22, requiring the SN to provide service "1wk5". The record lacked documentation the SN provided service during the weeks of 10/9/22 to 10/15/22 and 10/16/22 to 10/22/22. 2. Pt. #4. SOC 7/11/20. Primary Diagnosis: Unspecified Vitamin B12 Deficiency Anemia. The clinical record was reviewed on 11/7/22 at 4:00 PM. The record contained the POC for the certification period of 8/30/22 to 10/28/22 that required: "...SN frequency: 1W9... administer vitamin B12 1000 mcg IM Q week...". As of 11/7/22, the record lacked documentation the SN provided service during the weeks of 9/11/22 to 9/17/22, 9/18/22 to 9/24/22, 9/25/22 to 10/1/22, 10/9/22 to 10/15/22 and 10/16/22 to 10/22/22. The POC effective 8/30/22 contained an update to the POC which was the Physician's order dated 10/13/22 requiring: "PT to eval and treat". The PT completed a communication note dated 10/24/22 indicating, the PT will attempt to schedule a visit during the week of 10/24/22. The record lacked documentation that the PT evaluated the Pt. during the week of 10/24/22 or attempted to schedule an evaluation visit during that week. 3. During an interview with the Clinical Director on 11/9/22 at 1:50 PM, the Clinical Director confirmed staff failed to provide service as indicated in the POC.

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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 4/15/21. Principal Diagnosis: Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 11/9/22 at 1:00 PM. The record contained a Discharge comprehensive assessment dated 9/17/22, indicating that Pt. #6 was discharged from the Agency. As of 11/9/22, the record lacked documentation that a copy of the Agency's "Home Health Discharge Summary" was sent to the Physician. 2. Pt. #7. SOC 9/2/21. Principal Diagnosis: Bilateral Primary Osteoarthritis Of Knee. The closed clinical record was reviewed on 11/9/22 at 2:16 PM. The record contained a Discharge comprehensive assessment dated 7/3/22, indicating Pt.#7 was discharged from the Agency. The clinical record lacked documentation the Agency sent a copy of the Agency’s “Home Health Discharge Summary” to the Physician. 3. During an interview with the Clinical Director on 11/9/22 at 3:30 PM, the above findings were confirmed.