Every finding on record at Seabrook Home Health Agency

This report is the result of an unannounced Federal Recertification and State Re-licensure Survey completed on May 22, 2026 at Seabrook Home Health Agency. It was determined the facility is not in substantial compliance with the requirements of Emergency Preparedness regulation §484.102, Condition of Participation for Home Health Agencies (HHAs) for this survey.

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 staff interviews and a review of facility documents, it was determined the facility failed to ensure participation in a full-scale exercise that was community-based or individual, facility-based functional exercise; or documentation of an actual natural or man-made emergency that required activation of the emergency plan. Findings include: Facility policy titled, “Emergency Preparedness Plan”, dated 06/2021, stated, “…Response: … 10. Exercise scenarios will allow the agency to evaluate its handling of communication, resources and assets, staff and patients. Each exercise whether test or actual, will be documented and evaluated for effectiveness… Review of the emergency management drill will consist of the following: 1. Reassess status of continued operations. 2. Check status of staff and patients. 3. Make any repairs or adjustments needed to continue operations… 4. An annual evaluation of the agency’s hazard vulnerability analysis and EPP including its objectives, scope, vulnerability, and effectiveness will be conducted…” Facility document titled, “Emergency Preparedness Plan”, dated 03/2023, stated, “… IX) Post Disaster Recovery: After-Action Assessment and After-Action Report (ARR): After resolution of the emergency the HSS will evaluate the effectiveness of the Emergency Management Plan, including the Communication Plan, through the completion of an After-Action Assessment and Report (AAR)… The AAR is designed as a retrospective analysis of the HSS’s response to the emergency to identify the strength’s and areas of improvement… Retention of After-Action Report: The After-Action Report will be kept by the organization for a period of three (3) years after the date of the emergency…” On 05/21/26, a review of the facility’s Emergency Preparedness Plan (EPP) documentation was conducted. The EPP documentation lacked evidence of participation in a full-scale exercise that was community-based or an individual, facility-based functional exercise; or documentation of an actual natural or man-made emergency that required activation of the emergency plan. On 05/21/26 at 10:55 AM, an interview was conducted with Staff (S)1. S1 stated, the facility did not have any documentation of an actual emergency that occurred during the past two years. S1 stated, “We certainly lived through snow storms this winter, but did not document the response.” When questioned about the last full-scale exercise conducted at the facility, S1 provided surveyors with facility document titled, “Post-Power Shutdown Action Plan." A review of facility document titled “Post-Power Shutdown Action Plan” was conducted. The document provided the plan, purpose, and objectives for a community-based exercise to be conducted on 06/05/25. The document lacked evidence that the exercise had been conducted and EPP procedures were evaluated for effectiveness. On 05/22/26 at 11:33 AM, an interview was conducted with S1. S1 confirmed the facility was unable to provide evidence that the “Post-Power Shutdown Action Plan” exercise had been conducted and EPP procedures were evaluated for effectiveness. S1 was unable to provide surveyors with any additional documentation of full-scale exercises or actual emergencies conducted during the past two years.

This report is the result of an unannounced standard-level Federal Recertification and State Re-licensure Survey completed on May 22, 2026 at Seabrook Home Health Agency. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of agency pre-survey report and staff interview, it was determined the facility failed to ensure timely transmission of Outcome and Assessment Information Set (OASIS) assessments within 30 days of completion of beneficiary assessments. Findings include: A review of the iQIES HHA (Home Health Agency) Error Summary by Agency report, with a reporting period of 01/01/25 to 12/31/25, revealed 57 (8.51%) assessments submitted to iQIES greater than 30 days after completion of the beneficiary assessments. The findings were confirmed with Staff (S) 1 on 05/22/26 at 11:33 AM. At 11:33 AM, an interview was conducted with S1. S1 explained that the facility works with an offsite coder and a clinical reimbursement nurse (CRN) to complete the OASIS documents and submit them to iQIES. S1 further explained that he/she and the CRN meet weekly to discuss any delays. S1 was unsure of the facility’s benchmark goal, he/she said, “its likely 5%.” S1 stated that they are aware of the delays but were waiting for first quarter data results before creating an improvement plan.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on staff interview and review of facility documents, it was determined the facility failed to ensure a performance improvement project was conducted annually. Findings include: On 05/21/26, a review of the facility’s Quality Assessment and Performance Improvement (QAPI) documentation from 2025 and 2026 was conducted. The QAPI documentation lacked evidence that a performance improvement project was conducted in 2025 or 2026. On 05/21/26 at 11:50 AM, an interview was conducted with Staff (S)1. S1 confirmed the facility was unable to provide evidence that a performance improvement project was conducted annually. S1 stated, projects are discussed in QAPI meetings and they should be documented, however he/she was unable to locate the documentation.

Survey date: December 6, 7 & 8, 2023 The facility is in compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies for this survey.

This was a Federal Recertification survey conducted at Seabrook Home Health Agency on December 6, 7 & 8, 2023, to determine compliance with 42 CFR Part 484 - Conditions of Participation for Home Health Agencies. Standard-level deficiencies were cited.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on staff interview, it was determined that the Home Health Agency failed to ensure the skilled professional services of a medical social worker, are provided directly or through written agreement, to patients who need the service. Findings include: On 12/6/23 at 10:37 AM, during the entrance conference, Staff 1 (S1), the Administrator, confirmed that the facility provides social work services to patients. On 12/7/23, during an interview with S2, the Director of Nursing, he/she explained that if patients needed social work services, they were referred to the social worker who works in the medical practice office, which is not a part of the home health agency. S2 stated that the patients would have to set up an appointment with the social worker and go to the medical office to see the social worker. S2 confirmed that the social worker is not an employee of the Home Health agency nor does the Home Health Agency have a contract with the social worker. N.J.A.C. 8:42-9.1

The facility is in substantial compliance with Appendix Z-Emergency Preparedness for All Provider and Supplier Types, Interpretive Guidance 484.22, Conditions of Participation for Home Health Agencies, for this survey only.

This was a Federal Recertification Survey and Federal COVID-19 Focused Infection Control Survey conducted May 19, 20, and 21, 2021. Seabrook Home Health Agency is not in compliance with 42 CFR Part 484, Subpart B requirements, for Home Health Agencies. As a result of this survey, Condition and Standard level deficiencies were cited. The following Conditions of Participation (CoP) are out of compliance: 484.70 Infection Prevention and Control 484.75 Skilled Professional Services 484.75 Compliance with Federal, State, Local Law

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on staff interview, review of facility documents and review of grievances for the years 2020 and 2021, it was determined the facility failed to ensure resolutions were communicated to the complainants for four (4) of six (6) grievances reviewed. Findings include: 1. Review on 5/19/21 at 10:00 AM of facility document:The Quality Improvement Program Concern/Complaint Log, for the years 2020 and 2021, indicated the following: a. The date the complaints were received was documented on the 2020 log as follows: 10/8/20, 10/30/20, 12/21/20, 2/1/21, 2/3/21, and 3/9/21. b. Review on 5/19/21 at 10:20 AM, of facility document Home Health Services Concern/Complaint Form, indicated four (4) of six (6) of the complaint forms did not indicate the resolution information was communicated to the patient or his/her representative filing the complaint, nor was the date of communication indicated. c. Resolution information was missing on the following dates: i. 12/21/20 ii. 2/1/21 iii. 2/3/21 iv. 3/10/21 2. The above findings were reviewed with Staff #2 and confirmed during the exit conference held on 5/21/21.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, review of facility policies and procedures and nationally recognized guidelines, and staff interview, it was determined the facility failed to ensure its infection control program adheres to acceptable standards of practice. Findings include: 1. The facility failed to ensure its infection control program adheres to acceptable standards of practice in limiting contamination to surfaces directly need for patient care. (Cross refer to Tag G-682) 2. The facility failed to ensure its infection control program includes methods for surveillance, identification, prevention, and investigation of communicable diseases. (Cross refer to Tag G-684) 3. The facility failed to ensure its infection control program educates staff on maintaining the recommended contact time for approved disinfectants. (Cross refer to Tag G-686)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on observation in one (1) of four (4) home visits, staff interview, and review of CDC guidelines, it was determined the facility failed to ensure separation between clean and soiled equipment is maintained. Findings include: Reference: CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf) page 50 states, "During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from 'clean' to 'dirty', and confining or limiting contamination to surfaces that are directly needed for patient care." 1. On 5/21/21 at 11:00 AM, during a home visit for Patient #8, the following was observed: a. After assessing the patient's oxygen level, Staff #9 placed the pulse oximeter directly next to clean equipment, without disinfecting it. b. After assessing the patient's blood pressure, Staff #9 placed the blood pressure cuff, without it being disinfected, directly next to clean patient care equipment. 2. The above findings were confirmed with Staff #2. B. Based on observation and staff interview, it was determined the home health agency failed to ensure COVID-19 screening questions are completed prior to visitors entering the facility. Findings include: Reference: Facility document titled, Screening Questions, States, "In the past 2 weeks have you been: Diagnosed with or exposed to an individual with COVID-19? ... In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? ..." 1. Upon arrival at the home health agency, through the Gatehouse, the following was noted: a. On 5/19/21 at approximately 9:15 AM, the Security Guard did not ask the following screening questions prior to allowing entry to the facility: i. In the past 2 weeks have you been: Diagnosed with or exposed to an individual with COVID-19? ii. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? b. On 5/20/21 at approximately 9:15 AM, the Security Guard did not ask the following screening questions prior to allowing entry to the facility: i. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? c. On 5/21/21 at approximately 9:15 AM, the Security Guard did not ask the following screening questions prior to allowing entry to the facility: i. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? 2. The above findings were confirmed by Staff #2. C. Based on observation in three (3) of four (4) home visits, staff interview, and review of facility documents, it was determined the home health agency failed to ensure COVID-19 screening questions are completed prior to staff entering patient residences. Findings include: Reference: Facility document titled, Screening Questions, States, "In the past 2 weeks have you been: Diagnosed with or exposed to an individual with COVID-19? ... In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? ... Have you traveled outside of North America or been on a cruise ship in the past 14 days and not yet been cleared? ..." 1. On 5/19/21, prior to a home visit for Patient #5, the following was noted: a. Staff #5 did not ask the patient the following screening questions: i. In the past 2 weeks have you been: Diagnosed with or exposed to an individual with COVID-19? ii. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? iii. Have you traveled outside of North America or been on a cruise ship in the past 14 days and not yet been cleared? 2. On 5/20/21, prior to a home visit for Patient #2, the following was noted: a. Staff #10 did not ask the patient the following screening questions: i. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? 3. On 5/20/21, during a home visit for Patient #5, the following was noted: a. Staff #8 did not ask the patient the following screening questions: i. In the past 2 weeks have you been: Diagnosed with or exposed to an individual with COVID-19? ii. In the past 2 days have you or anyone in your household experienced: Fever, chills, or body aches? ... Sore throat or coughing ... Nausea, vomiting or diarrhea? ... Sinus congestion, loss of sense of taste or smell? iii. Have you traveled outside of North America or been on a cruise ship in the past 14 days and not yet been cleared? 4. The above findings were confirmed with Staff #2.

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 observation, staff interview, and review of facility documents, it was determined the facility failed to ensure the implementation of CDC guidelines to address prevention and control strategies for mitigating the spread of COVID-19. Findings include: Reference: Reference: Centers for Disease Control and Prevention (CDC) webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html titled, "Using Personal Protective Equipment (PPE); Updated Aug. 19, 2020" states, "... . How to Put On (Don) PPE Gear: ... . Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears. ... . Face Mask Do's and Don'ts for Healthcare Personnel. Clean your hands and put on your face mask so that it fully covers your mouth and nose. ... . When wearing a face mask don't do the following: Don't wear your face mask under your nose or mouth. ... ." 1. On 5/19/21 at 9:45 AM, upon entrance to the agency lobby, Staff #12 (greeter), was observed wearing a surgical mask beneath her/his nose. 2. On 5/19/21 at 9:50 AM, Staff #15 was observed wearing a surgical mask beneath her/his nose. 3. On 5/20/21 at 9:40 AM, Staff #12 was observed wearing a surgical mask beneath her/his nose. 4. On 5/20/21 at 9:45 AM, Staff #15 was observed wearing a surgical mask beneath her/his nose. 5. On 5/21/21 at 1:35 PM, Staff #15 was observed wearing a surgical mask beneath her/his nose. 6. Upon interview on 5/20/21 at 10:25 AM, Staff #4 confirmed the facility follows CDC Guidelines for its infection control mitigation. 7. Staff #2 confirmed the above findings.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: A. Based on (2) of two (2) home visit observations for wound care management, staff interview, review of policy and procedure, and review of manufacturer's instructions (IFUs) for use of disinfectants, it was determined the facility failed to ensure staff are educated on maintaining recommended contact time for approved disinfectants. Findings include: Reference #1: Facility Policy Infection Prevention and Control Safe & Sanitary Environment states, "To maintain a safe and sanitary environment through cleaning and disinfection and / or sterilization of equipment ... .3. Non-critical items - (i.e., furniture, stethoscopes, ...) a. Clean items with a hospital grade disinfectant ... b. Must follow manufacture's instructions for use. ..." Reference #2: Oxivir Tb manufacturer's instruction for use state, " ... Wipes 1. Apply undiluted .... 2. All surfaces must remain visibly wet for 1 minute for viruses and bacteria, 5 minutes for Hepatitis C and Mycobacterium tuberculosis. To kill E-Coli, P. vulgariiss, P. aeruginosa, S. aureus and Fungi use a 10 minute contact time. 1. During a home visit, Staff #5, was observed using Oxivir Tb to disinfect equipment. a. Upon interview, Staff #5 was unsure of the required contact time to kill viruses and bacteria. 2. On 5/20/21 at 10:35 AM, Staff #4, an Infection Preventionist, stated the approved disinfectant for the Home Health Agency is Oxivir Tb wipes. a. Staff #4 further stated the contact time was two (2) minutes. 3. During a home visit, Staff #9, was observed using Super Sani-Cloths to disinfect equipment. 4 Staff #4 confirmed the above findings. B. Based on staff interview conducted between 5/19/21-5/21/21, it was determined the facility failed to ensure staff are aware of whom to direct any infection control questions. Findings include: 1. On 5/19/21, Staff #1 and Staff #2 stated the Infection Preventionist is Staff #4. 2. Upon review of personnel files, it was confirmed that Staff #4 is the Infection Preventionist. 3. Upon interviews conducted between 5/19/21-5/21/21, Staff #5, Staff #8, Staff #9, and Staff #10, stated they direct all infection control questions to Staff #1, a Physical Therapist. 4. Staff #2 confirmed Staff #1 is a Physical Therapist and staff direct all infection control questions to him/her.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on staff interview, it was determined the Home Health Agency failed to ensure the skilled professional services of a medical social worker, are provided directly or through written agreement, to patients who need such services. Findings include: 1. The facility failed to ensure skilled professional services of a medical social worker are available to all patients. (Cross refer to Tag G-702) 2. The facility failed to ensure a designated Registered Nurse performs annual evaluations for the facility's Registered Nurses. (Cross refer to Tag G-704)

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: A. Based on one of (1) of two (2) home visits for wound care observations, and review of facility policy and procedure, it was determined the facility failed to ensure their policy for handwashing is implemented. Findings include: Reference #1: Facility Policy Hand Hygiene states, " ...5. Procedure technique for hand washing with soap and water: The CDC Guidelines for Hand Hygiene: when cleaning your hands with soap and water *wet hands wit clean running water *apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. *Rinse hands with clean water ... ." 1. A home care visit was conducted on 5/19/21 at 12:30 PM. Upon observation of the visit for Patient #5, Staff #5 missed six (6) of six (6) opportunities to wash his/her hands according to facility policy and CDC Guidelines. a. Staff #5 turned on the faucet, applied soap to his/her hands, wet his/her hands and rubbed his/her hands together under running water for less than 20 seconds. 2. Staff #5 confirmed he/she applied soap, wet his/her hands, and rubbed his/her hands together under running water for less than 20 seconds. B. Based on staff interview, it was determined the facility failed to ensure skilled professional services of a medical social worker are provided directly or through written agreement to patients who need such services. Findings include: 1. Upon interview, Staff #2 stated, "We do not have a social worker on our staff." 2. Staff #2 was unable to provide documented evidence of a written agreement to provide medical social work services. 3. The above findings were confirmed with Staff #2.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on staff interview, it was determined the home health agency failed to ensure a designated Registered Nurse performed annual nursing evaluations. Findings include: 1. On 5/20/21 at 11:01 AM, review of facility personnel nursing files indicated the annual performance evaluations were signed off by various Registered Nurses. 2. There was no evidence in three (3) of three (3) Registered Nurse Position Descriptions, to indicate that part of their job is to evaluate the Registered Nurses in the agency. 3. On 5/20/21 at 11:25 AM, Staff #2 stated, "Our nurses evaluate each other." 4. The above findings were confirmed with Staff #2.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on staff interview, review of facility documents, and review of Chapter 42 - Licensing Standards for Home Health Agencies, it was determined the facility failed to ensure a full-time Director of Nursing is appointed by the Governing Body. Findings include: Reference #1: Chapter 42 - Licensing Standards for Home Health Agencies 8:42-7.3(a) states, "The governing authority shall appoint a full-time Director of Nursing, who shall be available at all times. An alternate or alternates shall be designated in writing to act in the absence of the director." 1. On 5/19/21 at 10:05 AM, Staff #1 stated he/she was the Director of Nursing. 2. On 5/19/21 at 1:20 PM, Staff #1 stated he/she was a Physical Therapist. 3. On 5/19/21 at 1:23 PM, Staff #1 and Staff #2 stated, "We do not have a Director of Nursing." 4. Review of the facility Governing Body minutes lacked evidence of a Director of Nursing or an Alternate Director of Nursing. 5. On 5/21/21 at 10:50 AM, a review of Staff #1's personnel file confirmed Staff #1 is a Physical Therapist. 6. The above finding was confirmed with Staff #2 on 5/21/21.