Every finding on record at Senior Care at Home, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/5/24. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 12/5/24. Standard level deficiencies cited. Abbreviations: POC = Plan of Care SOC = Start of Care Pt./Pts. = Patient/Patients w/wk = week W = with # = number RN = Registered Nurse SN = Skilled Nursing MSW = Medical Social Worker PT = Physical Therapy AM = morning PM = afternoon PO = per oral MG = milligram MCG = microgram (>) = greater than UT = as directed OASIS = Outcome Assessment and Information Set

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 the review of the Error Summary report and staff interview, it was determined in 73 of 95 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 10/1/23 to 11/22/24, was reviewed on 12/5/24 at 9:30 AM. The report included error # -3330 for 73 of 95 late submissions, 76.84% of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Nursing Supervisor on 12/4/24 at 12:00 PM, it was confirmed that the error occurred.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation and interview during home visits, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/2/24. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 12/2/24 and 12/3/24: Pt. #1. SOC 10/30/24. Pt. #2. SOC 10/25/24. Pt. #3. SOC 9/27/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed from 12/2/24 and 12/4/24: Pt. #1. SOC 10/30/24. Pt. #2. SOC 10/25/24. Pt. #3. SOC 9/27/24. Pt. #4. SOC 10/23/24. Pt. #5. SOC 8/23/24. Pt. #6. SOC 3/4/24. Pt. #7. SOC 3/24/22. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During staff interviews with the Administrator and Nursing Supervisor on 12/4/23 at 11:30 AM and 2:45 PM, both confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator's name and contact information.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 5 of 7 (Pts. #1, 2, 7, 3, and 6) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. #3 was admitted to home health services on 9/27/24 with a diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 12/3/24. The clinical record contained a Face-to-Face Document with the service date of 8/12/24, which was faxed to the Agency on 9/4/24 with orders for SN and PT services. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician ordered SOC date. 5. Pt. #6 was admitted to home health services on 3/9/24 with a diagnosis of Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 12/3/24. The clinical record contained a referral from an in-patient facility with an order date of 2/26/24 for home health services and was faxed to the Agency on 2/28/24. The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician ordered SOC date. 6. The Agency Policy titled “Medical Supervision” was reviewed on 12/5/24 and required, “Special Instructions: Physician/allowed non-physician practitioner (NPP) orders are required to begin home care services…” 7. During an interview with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, it was stated that the RN should conduct the initial comprehensive assessment within 24-48 hours of the referral or the Physician SOC order date. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 10/30/24. As of 12/3/24, the record lacked a referral or Physician order to initiate service on 10/30/24. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 10/25/24. As of 12/3/24, the record lacked a referral or Physician order to initiate service on 10/25/24. 3. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record was reviewed on 12/4/24. The clinical record included the “OASIS-E Start of Care” assessment form completed by the SN on 3/24/22. As of 12/4/24, the record lacked a referral or Physician order to initiate service on 3/24/22.

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 a review of clinical records, Agency policy, and staff interviews, it was determined that in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to ensure the Physician reviewed and signed the initial POC, as required by the Agency. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the initial POC dated 10/30/24. As of 12/3/24, the POC lacked the Physician’s signature, which confirms the Physician reviewed and approved the POC. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the initial POC dated 10/25/24. As of 12/3/24, the POC lacked the Physician’s signature, which confirms the Physician reviewed and approved the POC. 3. The Agency policy titled; “Medical Supervision” was reviewed on 12/5/24. The policy included, “…2. A Plan of Care is developed for each client at the time of admission and signed by the physician/allowed non-physician (NPP) within an appropriate time frame…” 4. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 2:45 PM, the Nursing Supervisor stated the Agency require the POC to be reviewed, and signed by the Physician within 30 days of the effective date of the POC. During the same interview, both 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 a review of clinical records, Agency policy, and staff interviews, it was determined that in 5 of 7 (Pts. #1, 2, 7, 3 and 6) clinical records reviewed, the Agency failed to ensure staff provide treatment or service, as ordered by the Physician. 3. Pt. #3 was admitted to home health services with the diagnosis of Congenital Hypothyroidism without Goiter. The clinical record was reviewed on 12/4/24. The clinical record included the POC effective 10/23/24 which required, “SN Frequency: 1wk9.” The clinical record lacked documentation of a second SN visit for the week of 10/27/24 to 11/2/24. The clinical record also lacked a Physician order indicating a change in the SN visit frequency. 4. Pt. #6 was admitted to home health services with the diagnosis of Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 12/4/24. The clinical record included the POC for the certification period of 3/4/24 to 5/2/24 which required, “MSW Frequency: 1w1.” As of 12/5/24, the clinical record lacked documentation of a MSW visit. 5. The Agency policy titled, “Physician/Allowed Non-Physician Practitioner (NPP) Orders” was reviewed on 12/5/24 and required, “Policy: All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP).” 5. During staff interview with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to home health services on 10/30/24 with the diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 12/3/24. The clinical record included the POC dated 10/30/24 that required, “SN Frequency: 1 wk9… SN to perform medication review each skilled nursing visit…” The SN visit notes dated 11/5/24, 11/9/24, and 11/18/24 lacked a medication review; and lacked a Physician order for the second SN visit conducted during the week of 11/3/24 to 11/9/24 (11/9/24). The POC dated 10/30/24 required, “SN for observation/assessment of pain…” The SN visit note dated 11/18/24 lacked a pain assessment. 2. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the POC dated 10/25/24 that required, “SN Frequency: 1 W 9… SN to perform medication review each skilled nursing visit and reconcile medications as indicated”. The POC and Medication Profile, both dated 10/25/24 contained “Carvedilol 3.125 MG Oral Tablet 1 Tablet Daily By mouth (PO), Fluticasone Propionate 220 MCG 2 Puffs Twice Daily, …Good Sense Pain Relief Extra St (Strength) 500 MG Oral Tablet 1 tablet every 6 hours as needed By mouth (PO), Tylenol Extra Strength 500 MG Oral Tablet 1 tablet every 6 hours as needed By mouth (PO), Hydrochlorothiazide 25 MG Oral Tablet 1 Tablet Daily By mouth (PO), Lisinopril-Hydrochlorothiazide 10 MG-12.5 MG Oral Tablet 1 tablet daily By mouth (PO)”. A home visit was conducted on 12/3/24 with Employee #5. During the home visit, the medications were observed, and an interview was conducted with Pt. #2. Observed Vitamin D 50 MCG (2000 UT) tablet Take 1 tablet by mouth daily (labeled with the original date “09/03/2024”. Observed “Carvedilol 6.25 MG 1 Tablet twice a day by mouth”, the Pt. stated there were no changes with this medication since the SOC on 10/25/24. Pt. #2 stated, Fluticasone Propionate was discontinued “about a month ago”. The Pt. stated, GoodSense Pain Relief was discontinued by the Physician “about a month ago”, duplicate drug therapy was identified, the Pt. is also taking Tylenol Extra Strength. Pt. #2 stated Hydrochlorothiazide was discontinued by the Physician “about a month ago”, duplicate drug therapy identified, the Pt. is also taking Lisinopril-Hydrochlorothiazide. Pt. #2 stated the SN was aware of the medication changes. The POC lacked Vitamin D. The weekly SN visit notes dated 11/14/24 and 11/26/24 lacked a medication review. The record lacked documentation the SN reviewed and reconciled the medications as required in the POC. The POC dated 10/25/24 required, “Notify Physician of… Pain Level: greater than (>) 7 /10 (Pain level rating: 0 equal no pain, to 10 that equal severe pain). The weekly SN visit note dated 11/26/24 lacked documentation the SN assessed Pt. #2 for pain. 3. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included the POC for the certification period of 11/19/22 to 1/17/23 that required the SN to “Cleanse wounds with Betadine, apply triple antibiotic to wound bed, apply Calcium Alginate to wound bed, cover with ABD pad and wrap with kerlix”. The "OASIS-E Recertification" assessment form completed by the SN and dated 1/17/23 contained, the SN cleaned Wounds #1 (left lateral ankle), #2 (left medial ankle), and #3 (left medial calf) with “normal saline”. The SN failed to provide wound care as ordered in the POC.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy, and staff interviews, it was determined in 1 of 7 (Pt. #7) clinical records reviewed, the Agency failed to ensure there was coordination of care between care providers to ensure Pt. needs were met. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included the weekly SN visit notes from 11/25/22 to 2/10/23 that included the Pt. had 3 open wounds (Wound #1- left lateral ankle; Wound #2- left medial ankle; Wound #3- left medial calf). The POC for the certification period of 11/19/22 to 1/17/23 included “Patient’s personal healthcare goal(s): wounds will heal…”. The same POC required the SN/caregiver “Cleanse wounds with Betadine, apply triple antibiotic to wound bed, apply Calcium Alginate to wound bed, cover with ABD pad and wrap with kerlix. Wound dressing to be done twice weekly and as needed…” The SN visit notes from 11/25/22 to 2/10/23 lacked any improvement in the wounds, utilizing the wound care described above. The record lacked documentation that the SN notified the Physician that Pt. outcomes were not being met, and that the Pt. required a different wound care treatment. The “Social Work Discharge” note completed by the MSW on 9/6/22 contained, “Pt. suffers from Dementia and need 24/7 care. Daughter is overwhelmed… MSW recommended increasing private care, SNF (Skilled Nursing Facility), and respite, daughter declined…” The record included an “OASIS-E Death at Home” assessment form completed by the SN, dated 2/13/23; and the Physician order dated 2/13/23 with communication that the Pt. died at home. The record lacked documentation the SN coordinated care with the Physician regarding the social issues in home. 2. The Agency’s policy titled; “Medical Supervision” was reviewed on 12/5/24. The policy required, “… Purpose To assure the participation of physicians/allowed non-physician practitioners (NPP) in the development and maintaining of the client plan of care… Special Instructions… 4. Physician/allowed non-physician practitioner (NPP) will be contacted when any of the following occurs… d. Caregiver support or home environment changes… 13. Agency Responsibilities include… d. Periodic updates on client condition/progress…” 3. During staff interviews with the Administrator, and Nursing Supervisor on 12/4/24 at 2:45 PM, both confirmed the SN failed to coordinate care between health providers to ensure Pt. outcomes were met and address social issues in the home.

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 a review of clinical records, Agency policy, and staff interviews, it was determined in 1 of 1 (Pt. #7) clinical record reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure that written Pt. care instructions were provided to the Home Health Aide. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included Home Health Aide visit notes, 2 times a week from 11/23/22 to 2/9/23 that contained documentation the Home Health Aide provided personal care. The last “HHA (Home Health Aide) Care Plan” completed by the RN providing instructions to the Aide was dated “7/22/2022 - 9/19/2022”. The record lacked a Care Plan for the Home Health Aide to provide personal care from 11/23/22 to 2/9/23. 2. The Agency’s policy titled; “Home Health Aide: Assignment” was reviewed on 12/5/24. The policy required, “…Purpose… To provide direction and supervision of care provided by Home Health Aides…” 3. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 2:45 PM, the Administrator stated the RN is required to review and update the HHA Care Plan “every 60 days”. During the same interview, both confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined in 1 of 1 (Pt. #7) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The closed clinical record was reviewed on 12/3/24. The clinical record included Home Health Aide visit notes, 2 times a week from 11/23/22 to 2/9/23 that contained documentation the Home Health Aide provided personal care. As of 12/3/24, the record lacked documentation the RN supervised the Home Health Aide from 11/23/22 to 2/9/23. 2. During staff interviews with the Administrator, and Nursing Supervisor on 12/4/24 at 2:45 PM, both confirmed the RN failed to conduct Home Health Aide supervision every 14 days.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations and interviews during home visits, clinical record reviews, Agency policy and staff interview, it was determined in 4 of 7 (Pts. #2, 7, 3 and 4) clinical records reviewed, the Agency failed to ensure the clinical record was complete and accurate, and that clinical notes included documentation relative to the services provided. 3. Pt. #3 was admitted to home health services on 9/27/24 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 12/3/24. The SN visit notes dated 9/30/24, 11/6/24, 11/14/24 and 11/27/24 lacked documentation of Pt. #3’s weight. During an interview conducted with the visiting RN/Nursing Supervisor on 12/5/24 at 12:00 PM, it was stated that Pt. #3’s weight should be recorded weekly. 4. Pt. #4 was admitted to home health services on 9/27/24 with the diagnosis of Congenital Hypothyroidism without Goiter. The clinical record was reviewed on 12/3/24. The SN visit notes dated 11/6/24, 11/13/24, 11/20/24 and 11/27/24 lacked documentation of interventions, response to care/treatment and goals. 5. The Agency document titled, “Clinical Documentation” was reviewed on 12/5/24 and required, “Purpose: To ensure that there is an accurate record of the services provided, client response and ongoing need for care.” 6. During staff interviews with the Administrator and Nursing Supervisor on 12/4/24 at 11:30 AM and at 2:45 PM, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted to home health services on 10/25/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/3/24. The clinical record included the weekly SN visit notes from 10/31/24 to 11/26/24 lacked documentation of any SN interventions and response to treatment/services provided during the visits. 2. Pt. #7 was admitted to home health services on 3/24/22 with the diagnosis of Atherosclerosis of Native Arteries of Left Leg with Ulceration of Ankle, Non-Pressure Chronic Ulcer of Left Ankle Limited to Breakdown of Skin, and Pressure Ulcer of Other Site. The clinical record was reviewed on 12/3/24. The clinical record included the POC for the certification period of 11/19/22 to 1/17/23 which included documentation that Pt. #7 had 8 wounds, identified as Wound #1 (left lateral ankle), Wound #2 (left medial ankle), Wound #3 (left medial calf, Wound #4 (right lateral foot), Wound #5 (right heel), Wound #7 (right buttock), Wound #8 (left posterior heel), and Wound #9 (left mid foot). The POC effective 11/19/22 required the SN to provide wound care weekly and instruct the caregiver on performing the wound care. The weekly SN visit notes from 11/25/22 to 1/6/23, and the "OASIS-E Recertification" assessment form completed by the SN and dated 1/17/23 lacked any documentation pertaining to Wounds #5, #7, #8, and #9, including a description of the wounds or whether wound care was provided. During an interview with the Administrator on 12/4/24 at 2:45 PM, the Administrator stated Pt. #7 did have 8 wounds as described in the POC dated 11/19/24. During the same interview, the Administrator confirmed the SN visit notes indicated above lacked any documentation pertaining to Wounds #5 #7, #8, and #9.

Recertification survey completed. Standard level deficiencies cited.

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), §485.625(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, 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: A. Based on a review of the Agency's Emergency Preparedness Plan and staff interview it was determined that the Agency failed to conduct or participate in a full scale community based or Agency based testing every 2 years. Findings include: 1. The Agency's Emergency Plan was reviewed on 10/06/2021 at 11:00 AM. The Emergency Plan contained documentation for Tabletop exercise on 2019, a disaster drill for 2020 and a tabletop drill for 2021. The Emergency Preparedness Plan lacked documentation indicating that the Agency performed a full scale community based or Agency based testing every 2 years as required by regulation. 2. Findings of the Agency failing to conduct a full scale community based or Agency based testing every 2 years was confirmed during an interview with the acting Administrator on 10/07/2021 at 11:00 AM.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC= Plan of Care PsOC= Plans of Care SOC= Start of Care Pt. = Patient Pts.= Patients PT= Physical Therapy SN= Skilled Nurse HHA= Home Health Aide AM= Morning PM= Afternoon/Evening

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: A. Based on clinical records review and staff interview it was determined that the Agency failed to ensure that the physician or allowed practitioner reviewed and approved the PsOC every 60 days, after the SOC date. This was found in 4 of 6 clinical records reviewed where services provided exceeded 60 days. (Pts. #1,2,3 and 4) Findings include: 1. Pt. #1 SOC 01/26/2021 Diagnoses: Heart Failure and Hemiplegia following cerebral infarct. The clinical record was reviewed on 10/05/2021 at 11:30 AM. The record contained a POC for certification period 05/26/2021 to 07/24/2021 that as of 10/07/2021 lacked evidence that the physician or allowed practitioner reviewed and approved care and services for the certification period. The record contained weekly SN visit notes during the certification period. 2. Pt.#2 SOC 07/28/2021 Diagnosis: Hypertension. The clinical record was reviewed on 10/06/2021 at 10:00 AM. The record contained a POC for certification period 07/28/2021 to 09/25/2021 that as of 10/07/2021 lacked evidence that the physician or allowed practitioner reviewed and approved care for the certification period. The record contained SN and PT visits for the certification period. 3. Pt.#3 SOC 07/28/2021 Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 10/06/2021 at 11:00AM. The record contained a POC for certification period 07/28/2021 to 09/25/2021 that as of 10/07/2021 lacked evidence that the physician or allowed practitioner reviewed and approved care for this certification period. The record contained SN visits for the certification period. 4. Pt. #4 SOC 03/29/2021 Diagnosis: Alzheimer’s Disease. The Clinical Record was reviewed on 10/05/2021 at 12:30 PM. The record included a POC with a certification period of 07/27/2021 to 09/24/2021. The record included SN and HHA visit notes for the certification period. As of 10/07/2021 the record lacked evidence that the physician or allowed practitioner reviewed and approved care and services for the certification period. 5. Findings of Agency failing to have Physicians or allowed practitioner review and approve the PsOC every 60 days were confirmed during interviews with the acting Administrator on 10/07/2021 between 10:00 AM and 11:30 AM.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to provide services as ordered by the Physician in the POC. This was found in 5 of 7 (Pts. # 4, 5, 6, 7 and 3) clinical records reviewed. 5. Pt.#3 SOC 07/28/2021 Diagnosis: Type 2 Diabetes Mellitus. The clinical record was reviewed on 10/06/2021 at 11:00AM. The record contained a POC for certification period 07/28/2021 to 09/25/2021 that required SN services 2 times a week for 2 weeks and 1 time a week for 7 weeks. The clinical record lacked SN visits for weeks 4, 5 and 6 of certification period. No physician modification orders were found in the record. 6. Findings of the Agency staff failing to provide services as ordered by the physician in the PsOC were confirmed during interviews with the acting Administrator on 10/07/2021 between 10:00AM and 11:00AM. Findings include: 1. Pt. #4 SOC 03/29/2021 Diagnosis: Alzheimer’s Disease. The Clinical Record was reviewed on 10/05/2021 at 12:30 PM. The record included a POC with a certification period of 07/27/2021 to 09/24/2021. The Clinical Record also included a POC with a certification period of 09/25/2021 to 11/23/2021. The PsOC required SN services 1 time a week for 9 weeks and HHA services 2 times a week for 9 weeks. The record lacked documentation of a SN visit and 2 HHA visits for the weeks beginning 09/05/2021 and 09/26/2021. No physician modification orders were found in the record. 2. Pt. #5 SOC 009/08/2021 Diagnosis: Hemiplegia following cerebral infarction affecting left non-dominant side. The clinical record was reviewed on 10/06/2021 at 11:30 AM. The record included a POC with a certification period of 09/08/2021 to 11/06/2021. The POC required PT services 1 time a week for 5 weeks. The record lacked documentation of PT visits for weeks beginning 09/12/2021, 09/19/2021 and 09/26/2021. No physician modification orders were found in the record. 3. Pt. #6 SOC 04/22/2021 Diagnosis: Polyosteoarthritis. The Clinical Record was reviewed on 10/06/2021 at 10:15 AM. The record included a PT evaluation with a certification period of 04/22/2021 to 06/20/2021. The evaluation required PT services 1 time a week for 9 weeks. The record lacked documentation of a PT visit for the week of 06/13/2021. No physician modification orders were found in the record. 4. Pt. #7 SOC 11/24/2021 Diagnosis: Parkinson’s Disease. The Clinical Record was reviewed on 10/06/2021 at 1:00 PM. The record included a PT Re-evaluation dated 01/21/2020. The Re-evaluation required PT services 1 time a week for 9 weeks. The record lacked documentation of a PT visit for the week of 02/21/2021. No physician modification orders were found in the record.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on staff interview, it was determined that the Administrator failed to ensure that skilled nursing and other therapeutic services were under direct supervision in the absence of the Agency Supervisor. Findings include: 1. During the entrance interview on 10/05/2021 at 9:15 AM the acting Administrator stated that she is the Agency Supervisor. The Administrator is unavailable, and she is the pre-designated Administrator. During the same interview the acting Administrator stated that no pre-assigned backup staff is assigned in the absence of the Agency Supervisor. 2. During an interview with the acting Administrator on 10/07/2021 at 10:00 AM, the finding of the Administrator not having a pre-assigned backup individual to serve in the absence of the Agency Supervisor was confirmed.