Every finding on record at Reliacare Ltd.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 01/12/24. Standard level deficiencies cited.

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), §485.542(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: Based on the review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/10/24 at 1:00 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patients' Physicians, and Volunteers. 2. During an interview with the Administrator on 01/11/24 at 1:00 PM. the Administrator confirmed the above finding.

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 review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct any testing of the Emergency Plan since 2021. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/10/24 at 1:00 PM. The Plan lacked documentation indicating the Agency conducted any testing of the emergency plan since 2021. 2. During an interview with the Administrator on 01/11/24 at 1:00 PM, the Administrator confirmed the Agency failed to implement testing of the Emergency Plan since 2021.

Recertification survey conducted. Standard level deficiencies cited. Abbreviations: # = number POC/PsOC = Plan of care / Plans of Care

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 the clinical records review, and staff interview, it was determined that the Agency failed to ensure the Plans of Care included patient specific interventions to address the underlying risk factors pertinent to Diagnosis. This was found in 3 of 7 (Pts. # 2, 6 and 4) clinical records reviewed. Findings include: 1. Pt. # 2 was admitted to Home Health Services on 03/20/23 with Diagnosis of Gastrostomy Status. The clinical record was reviewed on 01/10/24. The Plan of Care (POC) for certification period of 11/15/23 to 01/13/24 lacked patient specific enteral feedings via Gastrostomy tube. Pt #2 clinical record for same certification period, contained SN visits 2 times a week, with SN documentation of enteral feedings of "Nutren with Fiber 1.0 every 4 hours". 2. Pt. #6 was admitted to Home Health Services on 08/18/23 with Diagnosis of Type 2 diabetes mellitus without compilations. The clinical record was reviewed on 01/10/24. The Plan of Care (POC) for certification period of 08/18/23 to 10/16/23 lacked patient specific Diabetes management interventions. 2. Patient #4 was admitted to Home Health Services on 03/20/23 with Diagnosis of Pneumonia and Encounter for Attention to Tracheostomy. The clinical record was reviewed on 01/10/24. The Plan of Care (POC) for certification period of 11/15/23 to 01/13/24 contained documentation of Tracheostomy and Enteral Nutrition. The POC lacked documentation of required patient specific interventions for Tracheostomy and Gastrostomy tube care. 3. During an interviews with the Administrator and Alternate Agency Supervisor on 01/11/24 between 11:30 AM to 1:00 PM, the Administrator and Alternate Agency Supervisor confirmed the above findings.

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: Based on clinical record review and staff interview it was determined that the Agency failed to ensure that clinical staff provide treatments only as ordered by a physician. This was found in 3 of 7 (Patients # 6, 1 and 5) clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 08/18/23 with Diagnosis of Parkinsons Disease. The clinical record was reviewed on 01/10/24. The Plan of Care (POC) for certification period of 08/18/23 to 10/16/23 contained order for PT to evaluate. Pt #6 clinical record contained weekly visits from week 1 to week 5 of certification period and 1 PT visit week 7 of certification period. No frequency orders were found in the clinical record for the PT visits after the evaluation. 2. Patient #1 was admitted to Home Health Services on 08/09/23 with Diagnosis of Dehydration. The clinical record was reviewed on 01/09/24. The signed Plan of Care (POC) for certification period of 10/08/23 to 12/06/23, included a Physical Therapy (PT) evaluation of 1 time a week for 1 week and Occupational Therapy (OT) evaluation 1 time a week for 1 week. The clinical record contained PT visits on week of 11/12/23, 11/19/23, 11/28/23 and 12/03/23. The clinical record contained OT visits on week of 11/2/23, 11/19/23 and 12/3/23. No frequency orders were found in the clinical record for PT and OT visits after the evaluation. The same clinical record contained a POC for certification period of 12/07/23 to 02/04/24, included a Physical Therapy (PT) evaluation of 1 time a week for 1 week and Occupational Therapy (OT) evaluation 1 time a week for 1 week. The clinical record contained Physical Therapy evaluation on 01/04/24 (The record lacked communication as to why Physical Therapy was started on 01/04/24 (28 days from recertification). The record lacked an Occupational Therapy evaluation as ordered. 3. Patient #5 was admitted to Home Health Services on 12/06/23 with Diagnosis of Acute Respiratory Failure with Hypoxia. The clinical record was reviewed on 01/09/24. The signed Plan of Care (POC) for certification period of 12/06/23 to 02/03/24 included Physical Therapy (PT) evaluation 1 time a week for 1 week and Occupational Therapy (OT) evaluation 1 time a week for 1 week. The clinical record contained PT visits for weeks of 12/10/23, 12/17/23, 12/24/23, and 12/31/23. The clinical record contained OT visits for weeks of 12/14/23, 12/17/23, 12/24/23, 12/31/23 and 01/07/24. No frequency orders were found in the clinical record for PT and OT visits after the evaluation. 4. During interviews with the Administrator and Alternate Agency Supervisor on 01/11/24 between 11:30 AM to 1:00 PM, the Administrator confirmed the above findings.

An investigation was conducted on 06/06/2023 for Complaint #IL2320725/98902. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by:

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined the Agency failed to ensure qualifications of the home health aide prior to providing care to patient. 1. On 06/06/2023 the personnel file for the Home Health Aide(HHA) date of hire 05/11/2023 was reviewed. The file lacked any documentation of competency evaluations or orientation provided by the Agency. 2. During an interview with the Administrator on 10:35 AM on 06/06/2023 she stated the HHA is certified. 3. During an interview with the Agency Supervisor on 06/06/2023 at 12:30 PM, she stated she did not have any training documents for the HHA. 4. On 06/06/2023 the clinical record for patient #1 was reviewed. The record included HHA visits notes assigned to the HHA as well as visit notes assigned to caregivers on 05/13/2023, 05/14, 05/15 and 05/16/2023. The notes were signed by the Agency Supervisor. During an interview with the Agency Supervisor on 06/06/2023 at 2:00 PM she stated the care was provided by the caretakers and the HHA. They were unable to document in system so she assisted them with documentation. 5. During an interview with the Administrator and Agency Supervisor on 06/06/2023 between 3:15 and 4:00 PM the above findings were confirmed.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, staff interview and policy review, it was determined the Agency failed to provide the home health aide with a written plan of care. Findings include: 1. On 06/06/2023, Patient #1's clinical record was reviewed. The clinical record included a plan of care dated, 05/13/2023 that included, "...home health aide to provide assistance with personal care and ADL's as indicated by limitations on functional and physical status impeding self-care..." 2. The record included Home Health Aide notes dated 05/13/2023, 05/14/2023, 05/15/2023 and 05/16/2023. The record lacked an individualized written plan of care established by the registered nurse for the home health aide. 3. A policy titled, "Home Health Aide Duties" was reviewed on 06/06/2023. The policy inluded, "...b. The RN develops the plan of care... c. The written instructions provided to the home health aide must specify the task to be provided and how frequently to provide it..." 4. During an interview with the Agency Supervisor at 1:30 PM, she stated a home health aide plan of care was not established.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Administrator failed to maintain a clear line of organization between agencies. Findings include: 1. On 06/06/2023 Patient #1's clinical record was reviewed. The clinical record included an OASIS start of care completed by the Agency Supervisor dated 05/13/2023. The OASIS included frequency and duration for skilled nursing daily, speech therapy, physical therapy and occupational therapy to evaluate and treat. The OASIS also included, "...Admission Summary/F2F Addendum...24-hour skilled nurse care and assistance required..." The clinical record included a plan of care for a certification period of 05/13/2023 through 07/11/2023. The plan of care included, "...SN frequency daily... ST evaluate and treat... PT evaluate and treat... OT evaluate and treat... home health aide to provide assistance with personal care..." During an interview with the Agency Supervisor at 2:30 PM, she stated the plan of care was for the home health agency. The clinical record included a signed home health service consent dated 05/13/2023. The clinical record included skilled nursing notes and home health aide notes from 7:00 AM on 05/13/2023 through 9:15 AM on 05/16/2023 documenting 24- hour care. 2. During an interview with the Administrator form 3:15 PM to 4:00 PM, she acknowledged the above documents were completed in the clinical record using the home health agency electronic documenting system. She stated Patient #1 was originally going to be admitted as a private duty patient because the patient needed 24-hour care. 3. During an interview with the Administrator at 4:00 PM, the above findings were confirmed.

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must 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: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: . A. Based on review of the Emergency Preparedness Plan/Policies and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually; failed to ensure its Emergency Plan was based on a facility and community risk assessment, utilizing an all hazards approach; failed to ensure the Emergency Plan included volunteers; failed to have an Emergency Communication plan that included the required names and contact information; and failed to provide Emergency Preparedness staff training and testing of the Emergency Plan. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency failed to review and update its Emergency Plan and policies biannually (E0004). 2. The Agency failed to ensure its Emergency Plan was based on a facility and community risk assessment, utilizing an all hazards approach (E-0006). 3. The Agency failed to ensure the Emergency Plan included volunteers (E0024). 4. The Agency failed to have an Emergency Communication Plan that included the required names and contact information (E0030). 5. The Agency failed to provide Emergency Preparedness staff training and testing of the Emergency Plan (E-0036). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate direction or supervision in the event of an emergency or disaster.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(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 Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/1/21 at 10:15 AM. This plan was titled "Disaster Plan," and was last revised April 2008. The plan/policy lacked documentation it was reviewed/revised since April 2008. 2. During an interview with the Administrator and the Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above finding.

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 review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/1/21 at 10:15 AM. The plan lacked a facility and community based risk assessment, using an all hazards approach. 2. During an interview with the Administrator and the Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above finding.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan included volunteers. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/1/21 at 10:15 AM. The Plan did not include the use of volunteers. 2. During an interview with the Administrator and the Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above finding.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on the review of the Agency's Emergency Preparedness Plan, policy review, and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/1/21 at 10:15 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patients' Physicians, and Volunteers. 2. The Agency policy titled, "Environmental Emergency/Disaster" was reviewed on 2/3/21 at 11:00 AM. The policy required: "...Employer shall prepare for an environmental emergency/disaster by: developing and maintaining a current list of names and contact details for individual staff members who have training for emergencies..." 3. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above finding.

EP Training and Testing CFR(s): 484.102(d) *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, review of personnel files, policy review and staff interview, it was determined the Agency failed to provide Emergency Preparedness staff training and testing of the Emergency Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/1/21 at 10:15 AM. The Plan lacked documentation the Agency conducted staff training or testing of emergency preparedness procedures upon orientation or biannually. The Agency also was unable to provide documentation that full-scale or tabletop testing exercises were conducted. 2. The personnel files of employees were reviewed on 2/2/21, beginning at 9:40 AM: E #2. DOH 10/21/20. E #3. DOH 9/18/20 E #4. DOH 8/7/16. E #5. DOH 10/5/20. The personnel files lacked documentation the Agency provided any Emergency Preparedness staff training. 3. The Agency policy titled, "Environmental Emergency/Disaster" was reviewed on 2/3/21 at 11:00 AM. The policy required: "...Practice and test action plan regularly. Ensure everyone knows their roles and responsibilities. Provide instruction and train employees on how to handle environmental disasters/emergencies during orientation and annually thereafter. Training records shall include: dates when training was given; summary on what training was given..." 4. During an interview with the Administrator and the Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the Agency failed to provide Emergency Preparedness staff training or testing of its Emergency Plan.

42 CFR484.80 (f)(3): Eligible training and competency evaluation organizations. A Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care. 42 CFR 484.102 Emergency Preparedness. Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 2/4/21. This applies even if the agency is not currently conducting aide training and/or competency evaluation. A Focused Infection Control survey (FIC) was conduced on 2/4/21. Standard level deficiencies cited. Abbreviations: Pt./Pts.= Patient/Patients SN= Skilled Nurse RN= Registered Nurse PT = Physical Therapy/Therapist POC/PsOC= Plan of Care/Plans of Care SOC= Start of Care DOH= Date of Hire AM= Morning PM= Afternoon/Evening INR= International Normalized Ratio E= Employee #= Number mg= milligram cm= centimeters wk= week COVID-19 = Coronavirus Disease 2019 - = to

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: . A. Based on review of the Agency's Pt. admission folder, observations and interviews during home visits, clinical record review and staff interview, it was determined the Agency failed to ensure Pts. received a copy of the Agency's transfer and discharge policy. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed Findings include: 1. The Agency Pt. admission folder provided by the Agency was reviewed on 2/1/21 at 11:00 AM. The folder lacked a copy of the Agency's transfer and discharge policy. 2. The following clinical records were reviewed from 2/1/21 to 2/4/21: Pt. #1. SOC 1/20/21. Pt. #2. SOC 1/30/21. Pt. #3. SOC 1/28/21. Pt. #4. SOC 10/9/20. Pt. #5. SOC 1/5/21 Pt. #6. SOC 11/20/20. Pt. #7. SOC 10/24/20. The clinical records lacked a copy of the Agency's transfer and discharge policy. 3. The following home visits were conducted on 2/2/21 from 10:00 AM to 2:30 PM: Pt. #1. SOC 1/20/21 Pt. #2. SOC 1/30/21 Pt. #3. SOC 1/28/21 During the home visits, the Pt. admission folders were reviewed. The folders lacked a copy of the Agency's transfer and discharge policy. During the home visits, interviews were conducted with the Pts./Pt. Caregivers. The Pts./Pt. Caregivers were not aware of the Agency's transfer and discharge policy. 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator indicated the same admission folder is given to all Patients .

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: . A. Based on review of clinical record, observation and interview during a home visit, review of Agency policies and staff interview, it was determined the Agency failed to ensure the initial assessment was accurate.This was found in 2 of 3 Pts. (Pt. #1 and 2) home visits conducted. Findings include: 1. Pt. #2. SOC 1/30/21. Primary Diagnosis: Unilateral Primary Osteoarthritis, Unspecified Knee. Pt. #2's clinical record was reviewed on 2/2/21 at 11:30 AM. The record included the 1/30/21 assessment titled "RN Assessment - Start of Care." This assessment contained a section titled "Potential Risk for Infection Assessment," on which the box was checked "No risk for infection assessment performed." The boxes for "wounds" and Post-op other surgery" were not checked. This assessment also included a section titled "Integumentary Assessment," on which the box was checked "no problems identified." The box for "Wound(s)" was not checked. A home visit was conducted on 2/2/21 at 2:30 PM, along with E #6. Pt. #2 had a large dressing on the knee area of his/her left leg. Pt. #2 stated this dressing was from his recent left total knee replacement surgery, from which was just discharged from the hospital on 1/29/21. Pt. #2 stated there were staples under this dressing. The RN Start of Care assessment was inaccurate. 2. Pt. #1. SOC 1/20/20. Primary Diagnosis: Acute Kidney Failure, unspecified. The clinical record was reviewed on 2/2/21 at 9:30 AM which included the 1/20/20 assessment titled "RN Assessment-Start of Care." This assessment has a section associated with Intra Venous Catheters and Kidney/Urinary Catheters and/or Ostomies. The section was left blank. A home visit was conducted on 2/2/21 at 10:00 AM. During the home visit, an observation was made of the patient's portacath and bilateral nephrostomy tubes. The RN Start of Care assessment was inaccurate. 2. The Agency policy titled "Clinical Admission Procedure" was reviewed on 2/3/21 at 10:30 AM. The policy required: "...Focus on Admission Visit: The initial visit allows the Nurse or Physical Therapist to perform a detailed assessment of the Patient...Completing the comprehensive assessment, performing a complete physical assessment, past medical history..." 3. The Agency policy titled "The Nursing Process" was reviewed on 2/3/21 at 10:40 AM. The policy required: "...Assessment begins with the initial contact with the Patient or Caregiver...Included in the ongoing assessment are past and present medical history...physical assessment..." 4 . During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above findings.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: . A. Based on a review of closed clinical records and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was updated at discharge. This was found in 1 of 2 (Pt. #7) closed clinical records reviewed. Findings include: 1. Pt. #7. SOC 10/24/20. Diagnosis: Pain due to Internal Orthopedic Device/Graft. The clinical record was reviewed on 2/2/21 at 10:30 AM. The record included documentation the SN provided services on 10/24/20 and 10/30/20; and PT provided services for the weeks of 10/25/20 to 10/31/20, 11/1/20 to 11/7/20 and that the Agency discharged the Pt. on 11/7/20. The record lacked documentation of an updated comprehensive assessment upon discharge. 2. During an interview with the Administrator and Agency Supervisor on 2/3/20 at 3:00 PM, the Agency Supervisor confirmed the comprehensive assessment was not updated at discharge.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: . A. Based on clinical record review, observation and interview during the home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure the PsOC included all the medications and treatments ; failed to ensure the POC was followed per physician orders ; failed to ensure Agency developed a policy for immunization screening; failed to ensure physician was notified of Pt. transfer to an Inpatient Facility; and failed to ensure patient discharge plan change was communicated to the physician. This has the potential to affect all Pts receiving services. Findings include: 1. In 2 of 3 clinical records reviewed wherein home visits conducted, the Agency failed to ensure PsOC included all the medications and treatments (G574). 2. In 4 of 7 clinical records reviewed, the Agency failed to ensure the POC was followed per physician orders (G578). 3. In 7 of 7 clinical records reviewed, the Agency failed to ensure Agency developed a policy for immunization screening (G582). 4. In 2 of 2 clinical records reviewed , the Agency failed to ensure physician was notified of Pt. transfer to Inpatient facility (G590). 5. In 1 of 2 closed clinical records reviewed, the Agency failed to ensure that patient discharge plan change was communicated to the Physician. (G598). The cumulative effect of these systemic practices resulted in Agency's inability to provide care effectively and ensure Pts received the care and services as required on the PsOC.

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 may choose to include. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, observations during home visits and clinical record review, and staff interview, it was determined the Agency failed to ensure PsOC included all medications and treatments. This was found in 2 of 7 clinical records reviewed (Pt. #2 and 3) . Findings include: 1. Pt. #2. SOC 1/30/21. Primary Diagnosis: Unilateral Primary Osteoarthritis, Unspecified Knee. Pt. #2's clinical record was reviewed on 2/2/21 at 11:30 AM. A home visit was conducted on 2/2/21 at 2:30 PM, along with E #6. A copy of Pt. #2's POC, effective 1/30/21 was reviewed during this home visit. During the home visit, Pt. #2 presented his/her medications for review, which included the following: Finasteride 1 mg daily; Meloxicam 15 mg daily; Oxycodone 5 mg, 1 tablet every 4 to 6 hours, as needed for breakthrough pain; and Gabapentin 100 mg three times a day. In addition, Pt. #2 stated had been taking Finesteride "for 10 years." Pt. #2 also stated has been taking Meloxicam, Oxycodone, and Gabapentin "since my discharge from the hospital on 1/29/21." None of these medications were listed on Pt. #2's POC. Listed on this POC was Amlodipine 10 mg daily. Pt. #2 denied ever taking Amlodipine. Pt. #2 had a large dressing on the knee area of his/her left leg. Pt. #2 stated this dressing was from his recent left total knee replacement surgery, from which was just discharged from the hospital on 1/29/21. Pt. #2 stated there were staples under this dressing, and the Surgeon instructed not to change this dressing or get it wet, and that the Agency Nurse was to change this dressing on 2/5/21. There were no directions for the left knee surgical wound site care listed on the POC. The POC was incomplete. 2. Pt. #3. SOC 1/29/21. Primary Diagnosis: Dissection of Thoracoabdomial Aorta. The clinical record was reviewed on 2/2/21 at 1:20 PM. The SOC comprehensive assessment dated 1/29/21 included "2 cm incisions on upper chest status post chest tube removal, minimal drainage, incisions cleaned and redressed." The POC lacked continued care instructions associated with status post chest tube removal site. 3. During an interview with the Administrator and Agency Supervisor on 2/02/21 at 11:45 AM, 2:00 PM and 2:30 PM, the Administrator and Agency Supervisor confirmed the Agency failed to ensure the PsOC included all medications and treatments.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: . A. Based on a clinical record review and staff interview, it was determined the Agency failed to ensure the POC was followed per physician's order. This was found in 4 of 7 (Pts. # 4, 5, 6 and 7) clinical record reviews. Findings include: 1. Pt. #4. SOC 10/9/20. Primary Diagnosis: Chronic Kidney Disease Stage 2. The clinical record was reviewed on 2/2/21 at 3:00 PM. The POC dated from certification period 12/12/20 to 2/09/21 required, " ...Medical Social Worker to assess ... Home Health Aide to provide assistance ... Occupational therapy evaluation will be performed ..." The clinical record lacked an assessment from a Medical Social Worker and Occupational Therapist. The clinical record also lacked documentation of care provided by a Home Health Aide. 2. Pt. #5 SOC 1/5/21. Primary Diagnosis: Type 1 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 2/2/21 at 3:30 PM. The record contained the POC dated from certification period of 1/5/21 to 3/5/21 which included, " ...SN Frequency: 1week1, 1weekk4 ..." The clinical record lacked SN visits during the weeks beginning 1/10/21, and 1/24/21. 3. Pt. #6. SOC 11/20/20. Diagnoses: Chronic Obstructive Pulmonary Disease, Shortness of Breath and Muscle Weakness. The closed/discharged clinical record was reviewed on 2/2/21 at 12:00 PM. The record contained a POC for the certification period of 11/20/20 to 1/18/21. The POC also required: "Orders for Discipline and Treatment, Frequency: Home Health Aide, 3 times a week for eight weeks starting 11/22/20." The record lacked documentation that Home Health Aide services were provided from 11/20/20 to 1/18/21. 4. Pt. #7. SOC 10/24/20. Diagnoses: Pain due to Internal Orthopedic Device/Graft and Presence of right artificial knee joint. The closed/discharged clinical record was reviewed on 2/2/21 at 10:30 AM. The record contained a POC for the certification period of 10/24/20 to 12/22/20. The POC also required: "Orders for Discipline and Treatment, Frequency: RN one time a week for one week, one time a week for five weeks." The record lacked documentation that SN services were provided for the weeks of 11/1/20 to 12/7/20. 5. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, review of Agency policies and staff interview, it was determined the Agency failed to develop a policy for immunization screening. This was found in 7 of 7 ( Pt. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The following clinical records were reviewed from 2/1/21 to 2/4/21: Pt. #1. SOC 1/20/21. Pt. #2. SOC 1/30/21. Pt. #3. SOC 1/28/21. Pt. #4. SOC 10/9/20. Pt. #5. SOC 1/5/21 Pt. #6. SOC 11/20/20. Pt. #7. SOC 10/24/20. The clinical records reviewed lacked immunization screening at the Start of Care. 2. The Agency's "Policy and Procedure Manual" was reviewed on 2/1/21 at 1:00 PM. This manual lacked a policy regarding Pt. screening/administration of influenza and pneumococcal vaccinations. 3. An additional Agency "Policy and Procedures" binder was reviewed on 2/2/21 at 10:00 AM. This binder lacked a policy regarding Pt. screening/administration of influenza and pneumococcal vaccinations. 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, the Administrator confirmed the above finding.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to ensure the Agency failed to ensure physician was notified of Pt. transfer to an Impatient facility. This was found in 2 of 2 (Pt. #4 and 6 ) clinical records reviewed, wherein the Pt. was transferred to an inpatient facility. Findings include: 1. Pt. #6 SOC 11/20/20. Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 2/2/21 at 12:00 PM. The record contained the POC for the certification period of 11/20/2020 to 1/18/2021 which included the SN visit note dated 12/19/20 that Pt. #6 was transferred to an inpatient facility. As of 2/3/21, the record lacked physician notification of Pt. #6's inpatient transfer. 2. Pt. #4. SOC 10/9/20. Primary Diagnosis: Chronic Kidney Disease Stage 2. The clinical record was reviewed on 2/2/21 at 2:45 PM. The PT visit note dated 1/19/21 included documentation that Pt. #4 was transferred to an inpatient facility. As of 2/3/21, record lacked physician notification of Pt. #4's inpatient transfer. 3. The Policy "Transfer, Referral and Discharge Procedure" dated 5/97 was reviewed on 2/3/21 at 2:00 PM. The Policy includes: "1. Transfer: whenever a ...patient requires transfer to another facility for any reason, the following procedures will be followed: a) physician is to be notified." 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at from 2:45 PM to 3:45 PM, the above findings were confirmed. The Administrator and Agency Supervisor confirmed the physician was not notified of the transfers.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interviews, it was determined the Agency failed to ensure patient discharge plan change was communicated to the physician. This was found in 1 of 1 (Pt. #7), clinical record reviewed, wherein pt. requested to be discharged from skilled services. Findings include: 1. Pt. #7. SOC 10/24/20. Primary Diagnosis: Pain due to Internal Orthopedic Device/Graft. The clinical record was reviewed on 2/2/21 at 10:30 AM. The record included a POC for the certification period of 10/24/20 to 12/22/20 requiring the SN and PT to provide services. The PT visit note dated 11/7/20 included documentation that the Agency discharged the Pt. on 11/7/20 due to Pt. and family request. The record lacked documentation that the plan to discharge the Pt. from the agency was communicated to the physician. 2. During an interview with the Administrator and Agency Supervisor on 2/3/20 at 3:00 PM, the Administrator confirmed the unplanned discharge was not communicated to 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 information regarding the Clinical Manager (Agency Supervisor) and their contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency Pt. admission folder was reviewed on 2/1/21 at 11:00 AM. The folder lacked information identifying the Agency Supervisor's name and contact information. 2. The following clinical records were reviewed from 2/1/21 to 2/4/21: Pt. #1. SOC 1/20/21. Pt. #2. SOC 1/30/21. Pt. #3. SOC 1/28/21. Pt. #4. SOC 10/9/20. Pt. #5. SOC 1/5/21 Pt. #6. SOC 11/20/20. Pt. #7. SOC 10/24/20 The clinical records reviewed lacked information identifying the Agency Supervisor's name and contact information. 3. The following home visits were conducted on 2/2/21 from 10:00 AM to 2:30 PM: Pt. #1 SOC 1/20/21 Pt. #2 SOC 1/30/21 Pt. #3 SOC 1/28/21 During the home visits, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Agency Supervisor. Also, Pt./Caregiver interviews were conducted during these home visits. The Pts./Pt. Caregivers were not aware of the Agency Supervisor's name and how to contact that individual. 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at from 2:45 PM to 3:45 PM, Administrator indicated the same admission folder is given to all Patients .

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Policies and Procedure Manuals, Policy and Procedure COVID-19 binders and staff interview, it was determined the Agency failed to maintain and implement a surveillance program to identify, prevent, control, monitor and track staff and Pts. with infections. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's "Policy and Procedure COVID-19" and "Policy and Procedure Manual" binders were reviewed on 2/2/21 at 2:00 PM. The "Policy and Procedure Manual" binder contained the "Infection Control Program" policy which included: "D. Tracking and Reporting System All patient's infections will be reported as follows: Patient Infections: 1. Record of patient infection form .... 2. Infection control person will enter reports .... 3. Data will be analyzed quarterly, and a summary report will be completed ... ... 4. The Quarterly Infection Control Data will be complied and analyzed .... 5. The person responsible for Infection Control will work with all clinical staff .... Staff Infections: 1. Upon notification of an employee communicable disease, the person responsible ... 2. Data from the record of employee communicable form will be entered in ....." Tracking Infections: 1." Infections will be tracked on an ongoing basis. The tracking system will include initial infection control data..." As of 2/4/21, the Agency lacked documentation of actions taken by the Agency to monitor and track Pts. and staff infections. 2. During an interview with the Administrator and Agency Supervisor on 2/2/21 and 2/3/21 from 2:30 PM to 3:30 PM, the above findings were confirmed. The Administrator stated, surveillance procedures are not being followed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician orders; This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy review and staff interview, it was determined the Agency failed to ensure the consent for treatment was incorporated into the clinical record. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed on 2/2/21 from 9:30 AM to 1:45 PM: Pt. #1. SOC 1/20/21. Pt. #2. SOC 1/30/21. Pt. #3. SOC 1/28/21. Pt. #4. SOC 10/9/20. Pt. #5. SOC 1/5/21 Pt. #6. SOC 11/20/20. Pt. #7. SOC 10/24/20. Clinical records reviewed lacked a consent for treatment. 2. The Agency policy dated 11/1/18 "Clinical Record Content and Electronic Signature" was reviewed on 2/4/21 at 11:00 AM. The policy included: "...Patient Chart... Patient Data... Home Health Consent Form." 3. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 2:00 PM, the Administrator stated the patient's consent form is reviewed with the Pt. during the SOC visit. The form is signed by the Pt. or the patient's representative and entered in the clinical record. The consents for service should have been signed by either the Pt . or family representative. 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 11:45 AM, 2:00 PM and 2:30 PM. The Administrator stated the consents are sometimes left in the patient's home, not incorporated in the clinical record. During the same interview, the Administrator and Agency Supervisor confirmed the clinical records indicated above lacked a consent for treatment.

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 a review of clinical records, Agency policy review 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 11/20/20. Diagnoses: Chronic Obstructive Pulmonary Disease, Shortness of Breath and Muscle Weakness. The closed/discharged clinical record was reviewed on 2/2/21 at 12:00 PM. SN note dated 12/19/20 indicated Pt .#6 was transferred to an inpatient facility on 12/19/20. The clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the physician. 2. Pt. #7. SOC 10/24/20. Diagnoses: Pain due to Internal Orthopedic Device/graft and Presence of right artificial knee joint. The closed/discharged clinical record was reviewed on 2/2/21 at 10:30 AM. The record contained the Discharge Summary dated 11/7/20. As of 2/2/21, the clinical record lacked documentation the Agency sent a copy of the Discharge Summary to the physician. 3. The Agency's policy titled "Transfer, Referral and Discharge Procedure" required: "h) Case Manager must complete their respective Discharge OASIS Summary and insurance discharge summary indicating summary of care provided and goals met at the time of their patient's discharge ..." 4. During an interview with the Administrator and Agency Supervisor on 2/3/21 at 3:30 PM, the Administrator and Agency Supervisor confirmed the above findings. The Administrator stated Pt. #6 lacked a transfer/discharge summary and were therefore not sent to the physician and Pt.#7's discharge summary was not sent to the physician.

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 clinical record review and staff interview , the Agency failed to ensure physician signature was obtained on initial POC. This was found on 3 of 7 (Pt .#4, 6 and 7) clinical records reviewed. Findings Include: 1. Pt. #4. SOC 10/9/20. Primary Diagnosis: Chronic Kidney Disease Stage 2. The clinical record was reviewed on 2/2/21 at 3:00 PM. The record included a POC with certification period of 10/9/20 to 12/7/20. As of 2/3/21 at 3:30 PM, the POC lacked the physician's signature. 2. Pt .#6. SOC 11/20/20. Diagnosis: Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 2/2/21 at 12:00 PM. The record contained a POC for certification period of 11/20/20 to 1/18/21. As of 2/3/21 at 3:30 PM, the POC lacked the physician's signature. 3. Pt .#7. SOC 10/24/20. Diagnosis: Pain due to Internal Orthopedic Device/Graft and Presence of Right Artificial knee Joint. The closed clinical record was reviewed on 2/2/21 at 10:30 AM. The record contained a POC for certification period of 10/24/20 to 12/22/20. As of 2/3/21 at 2:00 PM, the POC lacked the physician's signature. 4 . During an interview with the Administrator and Agency Supervisor on 2/3/21 at 3:45 PM, the Administrator confirmed the above findings.