Every finding on record at Saanvi Group of Pennsylvania, LLC

Based on the findings of an unannounced onsite Medicare recertification survey completed on January 16, 2025, 1st Care Home Health Services of Pennsylvania was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan and an interview with an agency Board Member, agency failed to ensure policies and procedures address the use of volunteers or other emergency staffing strategies in an emergency for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Agency policy requested on January 16, 2025 at approximately 12:00 p.m.. No specific policy provided related to the use of volunteers. A review of the agency Emergency Preparedness Plan conducted on January 16, 2025 at approximately 10:00 a.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan addressing the use of volunteers or other emergency staffing strategies in an emergency. An interview conducted with an agency Board Member on January 16, 2025 at approximately 12:15 p.m. confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey completed on January 16, 2025, 1st Care Home Health Services of Pennsylvania was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of agency policy, a review of clinical records, and an interview with an agency Board Member, agency failed to send a discharge summary 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 home health agency (HHA) (if any) within five (5) business days of the date of the order for discharge from the responsible physician, per policy, for two (2) of five (5) discharged clinical records (CR) reviewed (CR#11, CR#13). Agency policy reviewed on January 16, 2025 at approximately 12:00 p.m. Policy '5.22 Transfer & Discharge Policy' 'Discharge Procedure' (5) "Prior to discharging the patient the attending physician shall be notified. A written discharge summary must be completed, and a copy sent to the physician within five (5) business days of discharge will be maintained in the clinical record." A review of CRs was completed on January 16, 2025 at approximately 11:45 a.m. The patients start of care (SOC) is listed below. CR#11 SOC 12/04/24: Patient discharged from agency on December 30, 2024. Documentation provided of the Discharge Summary being sent to the physician on January 7, 2025. (6 business days). CR#13 SOC 11/11/24: Patient discharged from agency on December 6, 2024. Documentation provided of the Discharge Summary being sent to the physician on December 16, 2025. (6 business days). An interview conducted with an agency Board Member on January 16, 2025 at approximately 12:15 p.m. confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey completed January 19, 2022, 1st Care Home Health Services of Pennsylvania was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare recertification survey completed January 19, 2022, 1st Care Home Health Services of Pennsylvania was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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: Based on a review of agency policy, observations, and an interview with an agency Board Member, the agency failed to ensure that everyone entering the health care facility is screened and triaged for COVID-19 for one (1) of one (1) observations (Observation #1) and failed to maintain a coordinated agency-wide program for the surveillance of communicable disease by failing to ensure all staff are screened and triaged for COVID-19 for one (1) of one (1) interviews (Interview #1). CMS-QSO-20-18-HHA (03/10/2020) 'Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)' 'Guidance' states " ...... . Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19". "How should HHAs monitor or restrict home visits for health care staff? Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work". Agency policy/procedures reviewed on January 19, 2022 at approximately 2:00 p.m. The agency 'COVID-19 Office Policy' states ".....Daily temperature check to all employees and anyone coming into the office." No specific policy related to COVID-19 screening for field staff prior to entering patients homes provided. Observation #1: On January 19, 2022 at approximately 1:00 p.m. the state surveyor reviewed the 'COVID-19 Screening Log'. No temperature screening nor symptom screening conducted for three (3) agency employees (EF#9, EF#10, EF#12) who were present at the agency office on January 18, 2022. No temperature screening nor symptom screening conducted for two (2) agency employees (EF#11, EF#12) who were present at the agency office on January 19, 2022. Interview #1: On January 19, 2022 at approximately 1:30 p.m. an interview was conducted with the agency Board Member. The Board Member was asked if agency employees in the field, who report directly to the patients house to start their daily work shift, are self screening for COVID-19 symptoms and documenting the results. The Board Member stated "The field staff currently self screen prior to their shifts but do not document the screening process". An interview conducted with the agency Board Member on January 19, 2022 at approximately 3:45 p.m. confirmed the above findings.

Based on the findings of an onsite unannounced home health agency complaint investigation conducted on February 23, 2021, 1st Care Home Health Agency was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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: Based on a review of agency policy, on-site observation, and an interview with the agency vice-president, the agency did not maintain a coordinated agency-wide program for the surveillance of communicable disease by failing to document that visitors were screened for COVID-19. Findings Include: Upon arrival at the agency location and entry into the agency office on February 23, 2021, at approximately 11:00 A.M., the surveyor was not screened for signs/symptoms of COVID-19. There were no signs posted on the exterior of the agency office to notify visitors that masks and Covid-19 screening is required prior to entry to the office. Survey Form 'COVID-19 Focused Infection Control Survey: Acute and Continuing Care' section "Entering the Facility/Triage/Registration/Visitor Handling" asks "Is signage posted at facility entrances with visitation restrictions and screening procedures. Does the facility have a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure (for example: exposure to COVID-19 screening questions and assessment of symptoms of illness)". CMS-QSO-20-18-HHA (03/10/2020) 'Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs)' 'Guidance' states " ...... . Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19". Review of agency policies on February 23, 2021, at approximately 12:00 P.M. revealed that the agency policies did not address the screening of visitors for signs/symptoms of COVID 19. An interview conducted with agency vice-president on February 23, 2021, at approximately 3:30 p.m. confirmed the above findings.