Every finding on record at Seasons of Care Health Services, LLC

EMERGENCY PREPAREDNESS SURVEY The following deficiencies are based on the emergency preparedness survey completed 08/17/23.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and staff interview, the agency failed to ensure the emergency preparedness plan and policies were updated at least every two years. This had the potential to affect all patients receiving services from the agency. The agency census was 16. Findings include: Review of emergency preparedness plan revealed the Emergency Preparedness and Response Disaster Planning and Emergency Operations Plan policies and procedures were last updated 03/20/21. Interview on 08/16/23 at 1:50 PM with Staff P confirmed the emergency preparedness plan was last updated on 03/20/21.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(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, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and 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 facilities 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: Based on record review and staff interview, the agency failed to establish and maintain an Emergency Preparedness Training and Testing program. This could potentially affect all patients receiving services from the agency. The census was 16. Findings include: Review of the agency policy titled, “Emergency Preparedness and Response Disaster Planning and Emergency Operations Plan,” effective 11/15/2017, did not reveal a training and testing program. Review of an undated agency policy titled, “Seasons of Care Health Services Emergency Operations Plan and All-Hazard Emergency Preparedness Policy,” revealed all staff shall receive emergency preparedness training appropriate for their position on a yearly basis. Staff will receive initial and annual Emergency Preparedness Training. Interview on 08/17/23 at 11:28 AM with Staff P revealed there was no documentation that training or testing was completed.

Partial Extended Recertification Survey An entrance conference was conducted on 08/15/23 at 9:00 AM with a home health aide and again at 10:27 AM with the Administrator. An exit conference was conducted on 08/17/23 at 5:00 PM with administrative staff. The following deficiencies are based on the partial extended recertification survey completed on 08/17/23. Pure Health at Home 368025, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, medical record review, policy review, and staff interview, the agency failed to complete a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for one of two patients reviewed (Patient #2). The census was 16. Findings include: Review of the agency policy titled, “Administration of Medications and Therapies,” last revised 09/08/20, revealed all prescription medication, over the counter medications and/or container labels are to be reviewed at each visit. The medication review includes a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions. A home visit was made to Patient #2 on 08/16/23 at 2:00 PM with Staff G present. Staff G filled the weekly pill box for Patient #2. Review of the current medication profile revealed Patient #2 takes Biocal (calcium supplement) one tab daily, Daily Fiber Packet 51.7% one tablespoon daily, Hydralazine HCL (for high blood pressure)10 milligrams (mg) twice a day, Mometasone Furoate Nose Suspension (steroid) 50 micrograms (mcg) two sprays in each nostril every day, and Ondansetron HCL Powder (prevents nausea) 4 mg as needed. Interview on 08/16/23 at 2:10 PM with Staff G revealed Patient #2 did not take these medications. Two pill bottles observed in the home were labeled to take Loratadine 10 mg daily with a fill date of 07/29/23, and cholecalciferol (vitamin D3) 25 mcg D3 1,000 Units daily with a fill date of 03/30/23. The patient's medication profile did not include these medications. Review of the medication profile revealed an order for Ensure one can three times a day and Miconazole Nitrate Powder (antifungal medication) use twice a day. Interview on 08/16/23 at 2:20 PM with Staff G confirmed the Loratadine and cholecalciferol were not listed on the medication profile. She also stated Patient #2 also took Cranberry 500 mg two daily, which was not listed on the medication profile. She further stated that Patient #2 only drank the Ensure once a day and used the powder once a day. She confirmed the medication profile did not match the medications in Patient #2's home.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure each patient received home health services that are written in an individualized plan of care for three of seven patient records reviewed (Patient #2, #3 and #6). The census was 16. Findings include: Review of the agency policy titled, “Missed Visit Policy,” last reviewed 08/24/2018, revealed the agency will adhere to the physician’s orders for frequency and types of visits. The physician is informed of any missed visits that deviate from the patient’s Plan of Care signed by the physician. 1. Review of the medical record for Patient #2 and the physician ordered plan of care dated 07/19/23 revealed orders for skilled nursing (SN) to visit six times a week for eight weeks starting 07/23/23. Review of the visit sheets for the week of 08/06/23 revealed only four visits were made. There was no documentation the physician was notified that services were not provided as ordered. 2. Review of the medical record for Patient #3 and the physician ordered plan of care dated 06/24/23 revealed orders for physical therapy (PT) to visit two times a week for three weeks starting 06/25/23 then once a week for four weeks starting 07/16/23. Review of the visit sheets from 06/24/23 to 07/23/23 revealed during the week of 07/02/23, PT only made one visit and no visits were made the week of 07/16/23. There was no documentation the physician was notified that services were not provided as ordered. 3. Review of the medical record for Patient #6 and the physician ordered plan of care dated 05/29/23 revealed orders for skilled nursing to visit once a week for two weeks starting 06/11/23 and PT to visit two times a week for four weeks starting 05/28/23. Review of the visit sheets for the week of 06/18/23 revealed only one visit was made by PT and no skilled nursing visits were made. There was no documentation the physician was notified that services were not provided as ordered. Interview on 08/17/23 at 1:48 PM with Staff P confirmed services were not provided as ordered and that there was no documentation the physician was notified.