Every finding on record at Senior Citizens Home Health Care, Inc

The following Condition level deficiencies were identified during an Emergency Preparedness Survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/10/22 through 1/13/22 at: Senior Citizens Home Health Care, Inc. 25334 Five Mile Rd. Redford, MI 48239 42 CFR §484.102: Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, and specific guidance to be followed in the event of a crisis, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could potentially, negatively affect the health and safety of all 37 patients actively serviced by this Agency in the event of a disaster (E0004); failed to develop an Emergency Preparedness policy/Plan, that had been reviewed and updated and included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for staff and all 37 patients currently serviced by this agency (E0024); failed to develop and maintain an emergency preparedness communication plan that included contact information for patient's physicians, volunteers and entities under arrangement, which had the potential to negatively affect the health and safety of the 37 patients currently serviced by this agency, resulting in the lack of communication in the event of an actual emergency (E0030); failed to ensure all staff received initial and annual training in the Agency's emergency preparedness program, including training on the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual disaster or emergency. This deficient practice could potentially affect the 37 patients currently serviced by this Agency (E0037); and failed to provide documented evidence of staff's participation in the required community/facility based full-scale exercises, since its initiation in 2009, and in light of the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all 37 patients currently serviced by this Agency (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.

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), §485.625(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 record review and interview, the Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years, and specific guidance to be followed in the event of a crisis, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could potentially, negatively affect the health and safety of all 37 patients actively serviced by this Agency in the event of a disaster. On 1/10/22 at 10:45 a.m., the agency's Emergency Preparedness documentation was reviewed. During the review, it was noted that the Agency's plan was not dated. Further review revealed an address to another agency had been crossed out with a black ink pen. There was no specific language that directed staff in the event of an emergency. During the review, the Administrator (Adm #1) was asked where staff would meet in the event of an emergency and reported, "Well, it depends." Adm #1 had no clear knowledge of the information requested. Additionally, staff were queried about the agency's Emergency Preparedness plan and where they were to meet in the event of a disaster. The Office Manager (OM #1) and Intake Coordinator (IC #1) replied, "Across the street." There was no clear guidance noted in the Agency's Emergency Preparedness Plan. There was no documented evidence that showed the agency had developed an Emergency Preparedness plan that had been reviewed/updated and included the appropriate guidance in accordance with the requirements of this section. These findings were reviewed with and confirmed by Adm #1 during an interview on 1/13/22 at 12:32 p.m.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop an Emergency Preparedness policy/Plan, that had been updated every 2 years and included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs during the COVID-19 crisis, resulting in the potential for the interruption in needed care and services for staff and all 37 patients currently serviced by this agency A review the agency's Emergency Preparedness documents was conducted on 1/10/22 at 10:45 a.m. During the review, it was noted that the documents provided were undated. There was no indication that the documents had been reviewed and updated as per this requirement. Additionally, there was no specific language that included a process for the integration or use of volunteers, as appropriate, or other staffing strategies with local, regional, State, and Federal officials to address surge needs during an emergency and the COVID-19 crisis. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/13/22 at 12:32 p.m.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient's physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of the 37 patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency's emergency preparedness documents on 1/10/22 at 11:00 a.m., it was noted that there was no contact information for all current staff, patient's physicians, or volunteers as appropriate. These findings were reviewed with the Administrator during an interview on 1/13/22 at 12:32 p.m..

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees, and failed to maintain documentation of trainings, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 1/10/22 at 11:00 a.m., The Agency's Administrator (Adm #1) was asked to provide evidence of initial training for all staff employed by the agency, including all contracted staff. Adm #1 was unable to provide documented evidence that all staff, including contracted staff received the required training in Emergency Preparedness. During the review, The Office manager (OM #1) and Intake Coordinator (IC #1) were queried on where the emergency meeting point was located. Both responded, "Across the street." They were unable to give an exact location to meet in the event of an emergency. Additionally, Adm #1 was queried about the emergency meeting point and responded, "It depends." Adm #1 had no knowledge of where staff would meet in the event of a disaster. Further review revealed that there was no inclusion of the above information in the Agency's plan. The Agency failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees, and failed to maintain documentation of trainings. These findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

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: Based on record review and interview, the Agency failed to provide documented evidence of staff's participation in the required community/facility based full-scale exercises, since its initiation in 2009, and in light of the Covid-19 pandemic, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all 37 patients currently serviced by this Agency. Findings include: During review of the agency's Emergency Preparedness documents on 1/10/22, it was noted that there was no documented evidence that all agency staff, including regularly utilized contracted staff participated in trainings or exercises used to test the Agency's emergency plan. These findings were reviewed with the Administrator (Adm #1) at the time of discovery.

The following Condition and Standard level deficiencies were identified during a Medicare authorized Recertification Survey concurrent with a Focused Infection Control Covid-19 Survey, conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/10/22 through 1/13/22 at: Senior Citizens Home Health Care 25334 Five Mile Rd. Redford, MI 48239 This agency had no additional branch locations. Clinical records reviewed for this survey included: 4 records with home visits; 6 records without home visits, for a total of 10 records reviewed. The agency provided Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, Registered Dietician, Speech Therapy and Home Health Aide services. The following Condition level deficiencies were identified: 42 CFR§484.55 Comprehensive Assessment of Patients 42 CFR§484.70 Infection Prevention and Control. 42 CFR 484.75 Skilled Professional Services. 42 CFR §484.102 Emergency Preparedness. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 2 (MR's #2 and 4) of 4 patients observed during home visits, were included in the overall planning of care including the timeliness of services received; and failed to inform the patient/caregiver in advance of the days in which services would be provided resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: MR #2: The patient's start of care (SOC) was 12/29/21 with diagnoses that included fractured lumbar vertebrae and falls. The plan of care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 1/10/22 at 12:30 p.m., a home visit was conducted by the Physical Therapist (CM #1). During a review of the patient's admission packet in the home, it was noted that there was no calendar of proposed visits to be made by the RN or PT. The RN had not provided the patient with a proposed visit schedule at the SOC. Further, the PT had not completed a visit schedule at the time of the initial PT evaluation. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 1:45 p.m. MR #4: The patient's SOC was 12/27/21 with diagnoses that included CVA (stroke), Hemiplegia and Diabetes Mellitus. The POC ordered SN, PT and Occupational Therapy (OT) services to be provided. On 1/11/22 at 1:00 p.m., a home visit was conducted by the Licensed Practical Nurse (LPN #1). During a review of the patient's admission packet in the home, it was noted that there was no calendar of proposed visits to be made by the RN, OT or PT. The disciplines failed to provide the patient with a calendar of proposed visits at the SOC. Upon completion of the visit, LPN #1 stated to the patient, "Can I come back Thursday between 1:00 p.m. and 3:00 p.m.? I'm already on the road seeing patients so that should be a good time for me." These findings were reviewed with and acknowledged by Adm #1 during an interview on 1/12/22 at 2:20 p.m.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the following: the initial assessment visit was held within 48 hours of referral; the comprehensive assessments accurately reflected the patient's current health status; a registered nurse conducted a review of the patients' medications; update or revise the comprehensive assessment within 48 hours of the patient's return home from the hospital; and update the comprehensive assessment at the time of discharge. These deficient practices affected the health and well-being of 10 patients (MR# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10). The cumulative effect of these systemic problems results in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.55, Comprehensive assessment of patients. Findings include: 1. The initial assessments were delayed for up to 7 days from receipt of the referral. (See G514) 2. The Initial Comprehensive Assessments listed the onset and exacerbations of all diagnoses as occurring on the same date as the admission to home care. (See G528) 3. A registered nurse did not conduct a review of the patients' medications for any potential side effects, drug interactions, and duplicate drug therapies. (See G536) 4. Home care was resumed 9-days after the patient returned home from the hospital. (See G548) 5. The patient's health status was not comprehensively assessed and updated at the time of discharge. (See G550)

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 record review and interview, the agency failed to ensure the initial assessment visit was held within 48 hours of referral for 1 of 2 (MR#10) records reviewed in which physical therapy completed the initial assessment visit, and 3 (MR's #1, 4, 5) records in which Registered Nurse was to completed the Initial Assessment, from a total of 10 sampled records reviewed, resulting in a delay in determining the immediate care and support needs. Findings include: MR#10: This patient was admitted to home care on 12/10/21 with a diagnosis of chronic inflammatory demyelinating polyneuritis (neurological disorder that targets the body's nerves). During record review on 1/11/22, it was noted that the referral for care was fax stamped on 12/6/21. The initial assessment visit was conducted four days later by CM#1 (clinical manager/physical therapist) on 12/10/21. Record review on 1/11/22, indicates the agency contacted the patient and left a message on 12/6/21 regarding home care services. There was no further documentation from 12/6/21 thru 12/9/21 to indicate why the initial assessment was delayed for 4 days. There was no documentation to indicate the physician was informed of the delay in services. During an interview on 1/11/22 at 3:30 p.m.,CM#1 explained that services are on hold while the agency waits for approval for therapy services from this patient's insurance and that the physician is aware of the issue. There was no documentation to indicate the physician was made aware of the 4-day delay in care until care was started on 12/10/21. MR #1: The patient's start of care (SOC) was 1/27/21 with diagnoses that included Right Lower Extremity Cellulitis, Congestive Heart Failure and Diabetes Mellitus. During the record review on 1/10/22 at 12:45 p.m., it was noted that the referral for home care was dated 1/21/21. The Registered Nurse (RN) conducted the Initial Comprehensive Assessment 6 days after the date of the referral. Further review revealed no documented rationale for the delay in needed services. MR #4: The patient's SOC was 12/27/21 with diagnoses that included CVA (stroke), Hemiplegia and Diabetes Mellitus. During the clinical record review on 1/11/22 at 9:55 a.m., it was noted that the referral for home care was dated 12/20/21. The RN conducted the Initial Comprehensive Assessment 7 days after the date of the referral. Further review revealed no documented rationale for the delay in needed services. MR #5: The patient's SOC was 11/24/21 with diagnoses that included Chest pain, Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 1/11/22 at 3:10 p.m., it was noted that the referral for home care was dated 11/18/21. The RN conducted the Initial Comprehensive Assessment 6 days after the date of the referral. Further review revealed no documented rationale for the delay in needed services. The Agency failed to ensure the Initial Comprehensive Assessment was conducted within 24 to 48 hours of the date of the referral. These findings were reviewed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/12/22. During the interview, CM #1 acknowledged acceptance of the patients and stated that the delay in beginning services for the above patients was due to pending insurances.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure the Comprehensive Assessments accurately reflected the patient's current health status, baseline data for future assessments, and ascertained the patient's immediate care needs in 10 (MR's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) of 10 records, from a total of 10 sampled records reviewed, resulting in incomplete and inaccurate clinical information to aid in determining the needs of the patient. Findings include: MR's #1-10: During a review of MR's 1 through 10, it was noted that in sections M1021 and M1023 of the Initial Comprehensive Assessments, listed all diagnoses (Onset and Exacerbation) as the same date of their admission to the Home Care Agency. The Assessments did not clearly identify the individual needs of the patients. Further, there was no clear indication if any of the listed diagnoses were treated and or resolved. The Agency failed to ensure the Comprehensive Assessments accurately reflected patients current health status and health care needs. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 2:38 p.m.

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 record review and interview, the agency failed to ensure a review of all medications and failed to ensure a registered nurse conducted a review of the patients' medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 6 of 10 (MR# 2, 3, 4, 6, 8, 10) records reviewed, resulting in the potential for harmful medication effects for these patients. Findings include: MR # 2: The patient's start of care (SOC) was 12/29/21 with diagnoses that included Fractured Lumbar Vertebrae and Repeated Falls. During the clinical record review on 1/10/22 at 2:00 p.m., it was noted that section M2001 (Medication Review) of the Initial Comprehensive Assessment dated 12/29/21, completed by the Registered Nurse documented, "No issues found during review." The patient's 19 prescribed medications were entered in "Drugs.Com" (online drug interaction checker) and yielded the following: 7 Major drug to drug interactions, 15 Moderate drug to drug interactions, 8 drug to food interactions and 2 duplicate drugs. There was no evidence that the agency had conducted a review of all the patient's medications to identify untoward medication interactions. MR #3: The patient's SOC was 8/21/21 with diagnosed that included Covid-19, Weakness and Hypertension. During the record review on 1/10/22, it was noted that section M2001 of the Initial Comprehensive Assessment dated 8/21/21, completed by the Registered Nurse documented, "No issues found during review." The patient's 15 prescribed medications were entered in Drugs.Com and yielded the following: 6 Major drug to drug interactions, 19 moderate drug to drug interactions, 3 drug to food interactions, and 2 duplicate drugs. There was no evidence that the agency had conducted a review of all the patient's medications to identify untoward medication interactions. MR #4: The patient's SOC was 12/27/21 with diagnoses that included CVA (stroke), Hemiplegia and Diabetes Mellitus. During the record review on 1/11/22 at 9:55 a.m., it was noted that section M2001 of the Initial Comprehensive Assessment dated 12/27/21, completed by the Registered Nurse documented, "No issues found during review." The patient's 17 prescribed medications were entered in Drugs.Com and yielded the following: 1 Major drug to drug interaction, 16 Moderate drug to drug interactions, 7 drug to food interactions and 2 duplicate drugs. There was no evidence that the agency had conducted a review of all the patient's medications to identify untoward medication interactions. The deficiencies identified in the above records were reviewed with and Acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 2:20 p.m. MR#6: This patient was admitted to home care on 12/4/21 with diagnoses of post operative care for a left hip joint replacement and depression. The comprehensive assessment was conducted by CM#1 (clinical manager/physical therapist) on 12/4/21. Record review on 1/12/22, indicates the patient's medications were reviewed by CM#1. There was no documented evidence that the patient's medications had been reviewed by a registered nurse (RN). During an interview on 1/13/22 at 1:10 p.m., Adm#1 (administrator) confirmed that the list of medications was not reviewed by an RN. MR#8: This patient was admitted to home care on 12/2/21 with diagnoses of compression of the spinal cord in the neck with a post op cervical spinal fusion. During record review on 1/12/22, it was noted that the RN documented on the 12/2/21 patient medication record that there were no severe medication interactions. On 1/13/22 at 1:20 p.m., Adm#1 was interviewed regarding the medication interactions for this patient. During the interview, Adm#1 utilized the agency's electronic medical record system (EMR) and ran a medication interaction report which indicated that there was 1 "potential interaction suggested" for the patient's Hydrocodone and Methocarbamol. Adm#1 acknowledged that the RN should have informed the doctor of the potential interaction. MR#10: This patient was admitted to home care on 12/10/21 with a diagnosis of chronic inflammatory demyelinating polyneuritis (neurological disorder that targets the body's nerves). The comprehensive assessment was completed by CM#1 on 12/10/21. Record review on 1/11/22, indicates the patient's medications were reviewed by CM#1. There was no documented evidence that the patient's medications had been reviewed by an RN. During a joint surveyor home visit with the occupational therapy assistant on 1/11/22 at 12 noon, the patient's medications were reviewed with the patient and spouse/caregiver. The spouse/caregiver indicated that the patient takes Tylenol two to three times each week to manage pain. The patient's list of medications failed to include Tylenol. There was no documentation to indicate that the patient's medications had been reviewed in total (including Tylenol) by an RN to determine any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy. During an interview on 1/13/22 at 1:10 p.m., Adm#1 confirmed that the list of medications was not reviewed by an RN and did not include Tylenol.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to update or revise the comprehensive assessment within 48 hours of the patient's return home from the hospital for 1 o1 (MR# 8) records reviewed in which care was resumed, resulting in no assessment of the health status and care needs for this one patient. Findings include: MR#8: This patient was admitted to home care on 12/2/21 with diagnoses of a recent cervical spinal fusion due to compression of the spinal cord in the neck. The 12/2/21 plan of care ordered weekly skilled nursing, physical therapy, and aide services for this patient. On 12/17/21, the licensed practical nurse (LPN#1) documented in the visit note that the patient was having diarrhea and increased blood pressure. LPN#1 noted that the patient agreed to go to the hospital and emergency medical services was called to transport the patient to the hospital. During record review on 1/12/22, it was noted that hospital documentation indicates the patient was in the emergency department on 12/17/21 and was discharged home the next day on 12/18/21 with a diagnosis of opiate withdrawal. There was no documentation to indicate the agency had corresponded with the hospital, the physician, or the patient to track the patient's return home status. Home care was resumed on 12/27/21, which is 9 days after the patient returned home from the hospital. The findings were reviewed with the administrator (Adm#1) on 1/13/22 at 1:20 p.m. Adm#1 acknowledged the findings and stated the agency needs to do better at tracking the patients when they go to the hospital.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to update the comprehensive assessment at the time of discharge, that included a summary of the patient's progress towards goals for 1 (MR #5) of 1 patient's record reviewed, who discharged from the agency's services, resulting in the potential for unaddressed health concerns and unmet care needs. Findings include: MR #5: The patient's start of care (SOC) was 11/24/21 with diagnoses that included Chest pain, congestive Heart Failure and Diabetes Mellitus. The plan of care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Medical social Work (MSW) services to be provided. During the clinical record review on 1/11/2 AT 3:10 p.m., it was noted that the patient discharged from the agency's services on 12/22/21. The Discharge Comprehensive Assessment had not been completed at the time of this review. These findings were reviewed with the Administrator (Adm #1) during an interview on 1/12/22 at 2:38 p.m. who responded, "We've had problems with this discipline. The discharge Oasis (Assessment) should have been completed at the time of discharge.

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 interview, the Agency failed to ensure that 4 (MR's #1, 3, 4 and 5) of 10 patients received care and services as written in the patient's individualized plan of care, from a total of 10 sampled records reviewed, resulting in the potential for poor grooming, physiological and psychological decline, lack of resources and unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 1/27/21 with diagnoses that included Right lower extremity Cellulitis, Congestive HEart Failure and Diabetes Mellitus. During the record review on 1/10/22 at 12:45 p.m., it was noted that the POC ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical Therapy (PT) services to be provided. During the period of review, HHa missed one of 7 schedule home visits and PT missed a total of 5 of 9 scheduled home visits. There was no documented justifiable rationale for the missed visits. Further, there was no indication that the patient declined/refused services. MR # 3: The patient's SOC was 8/21/21 with diagnoses that included Covid-19, Weakness and Hypertension. During the record review on 1/10/22, it was noted that the POC ordered SN, HHa, PT and Occupational Therapy (OT) services to be provided. During the period of review, HHa missed 4 of the 6 schedule home visits and PT missed 2 of the 7 scheduled home visits. There was no documentation of patient refusal or any justifiable rationale for the missed visits. MR #4: The patient's SOC was 12/7/21 with diagnoses that included CVA (stroke), Hemiplegia and diabetes Mellitus. During the record review on 1/11/22 at 9:55 a.m., it was noted that the POC ordered SN, PT and OT services to be provided. During the period of review, PT missed one of 3 scheduled visits and SN missed 3 of 5 scheduled home visits. There was no documentation of patient refusal. MR #5: The patient's SOC was 11/24/21 with diagnoses that included Chest Pain, Congestive HEart Failure and Diabetes Mellitus. During the record review on 1/11/22 at 3:10 p.m., it was noted that the POC ordered SN, HHa, PT, OT and Medical Social Work (MSW) services to be provided. During the period of review, the HHa missed 4 of 8 scheduled home visits. MSW was to see the patient 2x/M (month) x 1 month. During the review, it was noted that MSW only made one of the 2 ordered home visits. There was no documentation of patient refusal or any other documentation for the missed visits. During the review, there was no evidence that the above disciplines made effort to honor the ordered visit frequencies. Further, there was no documented evidence that the Physician had been made aware of the missed visits. The above findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 2:38 p.m.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure that the Physician was promptly notified of 1 (MR #3) of 1 patient who sustained a fall with a head injury and a subsequent accident resultant from hot liquid burns to bilateral thighs, resulting in the potential for unidentified health concerns, delayed treatment and unmet care needs. Findings include: MR #3: The patient's start of care (SOC) was 8/21/21 with diagnoses that included covid-19, Weakness, Hypertension and COPD (Chronic Obstructive Pulmonary Disease). The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Medical social work (MSW) services to be provided. During the clinical record review on 1/10/22, a SN visit note dated 8/24/21 written by the Licensed Practical Nurse (LPN #2) documented,"Patient had burns on both thighs after spilling coffee on himself..., Patient [sic] was advised to take his father to the hospital for burns in his thigh and a contusion on his for-head [sic]. I did report to supervisor (Administrator)..." Another Nurse will f/u (follow up) care..." The 8/24/21 SN visit note documented that LPN #2 had notified the Administrator (Adm #1). A Skilled Nursing visit Note dated 9/3/21 documented, "Wound Care Sheet completed..., Wound 1 Location: Bilateral thighs, open partial thickness..., Treatment: (Antibiotic ointment)..., Patient has a raised scab to his right knee from his fall. He also has a contusion to his forehead. Noted 2nd degree burns to his anterior bilateral thighs..., pt (patient) had a telehealth visit with MD (doctor) on 9/1/21..., The record indicated the Physician became aware of the patient's burns during a telehealth visit on 9/1/21 (This was 8 days after the patient sustained burns and forehead contusion). There was no documented evidence that the Doctor had been made aware of the patient's injuries prior to 9/1/21. These findings were reviewed with the Administrator (Adm #1) during an interview on 1/12/22 at 1:57 p.m. During the interview, Adm #1 was queried about the patient's injuries. when asked if she had been made aware, Adm #1 alleged no knowledge of being made aware. Adm #1 then stated, "The doctor should have been notified. LPN #2 should have called the doctor."

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 record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all staff employed by this agency, including who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 37 current patients (G684); and, failed to provide documented evidence that Covid-19 infection control education was provided to all staff employed by this Agency staff, including all contracted staff and those who were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 37 patients currently serviced by this agency (G686). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.

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 record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all staff employed by this agency, including who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 37 current patients. Findings include: On 1/10/22 at 8:41 a.m., upon arrival to the agency, it was noted that there were no signage posted on the Agency's door that instructed visitors on the protocol for entrance into the agency's suite. Upon entry, it was noted that there was no tool used for screening visitors upon entrance into the agency. This writer was escorted to a conference room without being screened for covid-19. On 1/10/22 at 10:09 a.m., an interview was conducted with the Administrator (Adm #1). When asked if there was a process in place for screening office staff for potential COVID-19 infections, Adm #1 reported, "There is a thermometer on the wall. There is no screening form currently used." When asked if the field staff were screened for exposure to anyone with Covid-19 or recent travel, prior to the provision of care, Adm #1 reported, "No. I wasn't aware that staff had to be screened." There was no evidence that visitors and office staff had been screened upon entrance into the agency. Further, there was no documented evidence that field staff had been thoroughly screened for Covid-19 prior to providing care and services. Additionally, a request was made to review the agency's infection control surveillance logs for all patients and staff, and the infection control committee meeting minutes. The requested documents had not been provided by the end of the survey.

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: Based on interview and record review, it was determined the Agency failed to provide documented evidence that Covid-19 infection control education was provided to all staff employed by this Agency staff, including all contracted staff and those who were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 37 patients currently serviced by this agency. Findings include: On 1/10/22 at 10:10 a.m., the Administrator (Adm #1) was queried about documentation of staff training, education, and in-services' regarding the Covid-19 virus. Adm #1 provided a binder with documents that covered topics such as, Donning and Doffing PPE (Personal Protective Equipment), and printouts from CDC related to Covid-19. The documents had an attached sign in sheet which revealed only minimal staff had received information and training on Covid-19. When asked if there was documented evidence that the remaining staff members had completed training on Covid-19, Adm #1 was unable to provide the requested information. There was no documented evidence that all staff received nor completed the required training on Covid-19 protocol. The Agency failed to provide infection control education to all staff, including contracted staff, to prevent the probability of the development and spread of the Covid-19 virus. The above findings were reviewed with and acknowledged by Adm #1 at the time of discovery.

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 record review and interview, the Agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 2 (MR #5, 9) of 9 records reviewed with multiple disciplines, from a total of 10 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes (G706); failed to ensure the Occupational Therapist assisted the Physician in evaluating the patient's level of function and helped to develop the plan of care for 2 (MR's #4, 5) of 4 records in which Occupational Therapy services were ordered, from a total sample of 10 records reviewed resulting in the potential for decline in physical functioning and unmet care needs (G708); failed to ensure skilled professionals were responsible for preparing clinical notes for 2 of 10 (MR# 3 and 6) records reviewed, resulting in a lack of information regarding the health status of these patients and the potential for unmet care needs (G716). The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.75 Skilled Professional Services.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 2 (MR #5, 9) of 9 records reviewed with multiple disciplines, from a total of 10 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings included: MR #5: The patient's Start of Care (SOC) was 11/24/21 with diagnoses that included Hypertensive Heart Disease with Heart Failure, Systolic Congestive Heart Failure (CHF), Cardiomyopathy and Diabetes Mellitus. During the clinical record review on 1/11/22 at 3:10 p.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN) at a frequency of 1x/wk. x 1 wk., 2x/wk. x 2 wks., 1x/wk. x 1 wk. for "Assessment of patient with Hypertensive Heart Disease with Heart Failure, unspecified Systolic (Congestive) Heart Failure..., SN to instruct patient on daily weight..., report to SN weight gain of 1 lb (pounds)/1 day, 5 lb/1 week..., SN to assess patient's weight log every visit." During the review, it was noted that SN made 6 visits to the patient's home. Of the SN visits dated 11/28/21, 11/30/21, 12/5/21, 12/7/21 and 12/17/21, there was no documented evidence that the SN assessed the patient's weights. The SN made no mention of the patient's weights in the above visit notes. The SN failed to assess the patient's weight as an indicator of CHF exacerbation. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 2:38 p.m. MR#9: This 72-year-old patient was admitted to home care on 3/8/21 with diagnoses of a recent fall resulting in a left arm fracture and back injury. The 3/8/21 plan of care orders skilled nursing, physical therapy, occupational therapy (OT), and medical social work (MSW) services for this patient. During record review on 1/11/22, it was noted that the MSW completed an assessment of the patient on 3/18/21, which is 10 days after MSW services were ordered. The OT completed an assessment of this patient on 3/25/21, which is 18 days after OT services were ordered. There was no documentation to indicate the patient had declined or delayed these services. Both the OT and the MSW failed to provide timely interdisciplinary assessments of the patient's health status and care needs. The findings were reviewed with and acknowledged by the administrator (Adm#1) during an interview on 1/13/22 at 1:35 p.m.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Occupational Therapist assisted the Physician in evaluating the patient's level of function and helped to develop the plan of care for 2 (MR's #4, 5) of 4 records in which Occupational Therapy services were ordered, from a total sample of 10 records reviewed resulting in the potential for decline in physical functioning and unmet care needs. Findings include: MR #4: The patient's start of care (SOC) was 12/27/21 with diagnoses that included CVA (stroke), Hemiplegia and Diabetes Mellitus. The referral for home care dated 12/20/21 ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy services to be provided. At the time of this clinical clinical record review on 1/11/22 at 9:55 a.m., OT services had not been provided as ordered. These findings were reviewed with the Administrator (Adm #1) during interview on 1/12/22 at 2:20 p.m. who confirmed, "OT didn't do the Eval (evaluation)." MR #5: The patient's SOC was 11/24/21 with diagnoses that included Congestive Heart Failure, Chest Pain, and Diabetes Mellitus. During the record review on 1/11/22 at 3:10 p.m., it was noted that the referral for home care dated 11/18/21 ordered SN, PT, Home Health Aide, Medical Social work and OT services to be provided. It was further noted that the patient discharged from the agency's services on 12/22/21. OT services had not been provided at the time of this record review. These findings were reviewed with and acknowledged by Adm #1 during an interview on 1/12/22 at 2:38 p.m.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals were responsible for preparing clinical notes for 2 of 10 (MR# 3 and 6) records reviewed, resulting in a lack of information regarding the health status of these patients and the potential for unmet care needs. Findings include: MR #3: The patient's start of care (SOC) was 8/21/21 with diagnoses that included covid-19, Weakness, Hypertension and COPD (Chronic Obstructive Pulmonary Disease). The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Medical social work (MSW) services to be provided. During the clinical record review on 1/10/22, a SN visit note dated 8/24/21 written by the Licensed Practical Nurse (LPN #2) documented,"Patient had burns on both thighs after spilling coffee on himself..., Patient [sic] was advised to take his father to the hospital for burns in his thigh and a contusion on his for-head [sic]. I did report to supervisor (Administrator)..." Another Nurse will f/u (follow up) care..." The 8/24/21 SN visit note documented that LPN #2 had notified the Administrator (Adm #1). During the review, it was noted that 2 visit notes (8/28/21 and 8/31/21) were blank and documented "Not Started." The author of the blank visit notes was documented as the Administrator (Adm #1). There were no visit notes/documentation of the follow up regarding the identification of the patient's burns and forehead contusion upon notification from LPN #2. These findings were reviewed with and acknowledged by Adm #1 during an interview on 1/12/22 at 1:57 p.m. who reported, "It must have been an oversight. I didn't document. MR#6: This patient was admitted to home care on 12/4/21 with diagnoses of post operative care for a left hip joint replacement and depression. The 12/4/21 plan of care orders the physical therapist to provide one visit the first week, three visits the second week, and then two visits each week for 5 weeks. Record review on 1/12/22, indicates there was no documented second visit in week 5 (week of 12/26/21) and no documented visits in week 6 (week of 1/2/22). There was no documentation to indicate the patient had declined or delayed these visits. The agency's policy titled, Timely Submission of Patient Documentation (not dated), details that all documentation must be turned in every Monday by 5 p.m. During an interview on 1/13/22 at 1:10 p.m., the findings were reviewed with Adm#1 (administrator). Adm#1 acknowledged the findings and stated that staff are expected to have their documentation in the clinical record within 24-48 hours of the visit.

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 observation, interview and record review, it was determined the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the Home Health Aide regarding client needs, and safety precautions prior to the provision of care in 3 (MR#'s 1, 3, 5) of 4 records in which Home Health Aide services were ordered, from a total of 10 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #1: The patient's start of care (SOC) was 1/27/21 with diagnoses that included Cellulitis right lower limb, Atrial fibrillation and diabetes Mellitus. During the record review on 1/10/22 at 12:45 p.m., it was noted that the Plan of Care (POC) indicated the following Safety Measures: Slow position change, support during transfer and ambulation, Fall precautions and Anticoagulant (bleeding) precautions. The "Aide Care Plan" was dated 1/27/21 and completed by the Registered Nurse (RN). The RN failed to include any of the above safety precautions on the Aide Care Plan. Further, during the record review, it was noted that the patient required wound care to her lower right extremity. There was no instruction or guidance on the Aide Care Plan on measures to take if the dressing should become soiled or removed. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 1/12/22 at 1:28 p.m. MR #3: The patient's SOC was 8/21/21 with diagnoses that included Covid-19, Weakness and Hypertension. The POC ordered Home Health Aide (HHa) services to be provided at a frequency of 3x/wk. x 2 wks., 2x/wk. x 3 wks., 1x/wk. x 4 weeks. During a review the clinical record on 1/10/22, it was noted that the RN (Adm #1) had not generated an Aide Care Plan with guidance and instructions on the types of services to be provided. These findings were reviewed with Adm #1 during an interview on 1/12/22 at 1:57 p.m. who acknowledged the findings and reported, "I opened that case. I guess I just missed it." MR #5: The patient's SOC was 11/24/21 with diagnoses that included Chest Pain, congestive Heart Failure (CHF) and Diabetes Mellitus. The POC ordered HHa services to be provided at a frequency of 1x/wk x 1 wk., 2x/wk. x 3 wks. During the record review on 1/11/22 at 3:10 p.m., it was noted that the POC indicated the following Safety Measures: Slow position change, proper position during meals, Fall precautions and bleeding precautions. The "Aide Care Plan" was dated 1/24/21 and completed by the Registered Nurse (RN). The RN failed to include any of the above safety precautions on the Aide Care Plan. These findings were reviewed with and acknowledged by Adm #1 during an interview on 1/12/22 at 2:38 p.m.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the home health aide provided services at the frequency ordered by the physician and failed to provide services as indicated in the aide care plan for 1 of 4 (MR# 8) records reviewed in which aide services where provided, resulting in a lack of personal care services for this patient. Findings include: MR#8: This patient was admitted to home care on 12/2/21 with diagnoses of compression of the spinal cord in the neck with a post op cervical spinal fusion. The 12/8/21 aide care plan ordered the aide to provide 2 visits each week for 3 weeks to assist the patient with personal hygiene and other activities of daily living. During an interview on 1/11/22 at 2:15 p.m., the administrator (Adm#1) explained that the agency is using a licensed practical nurse (LPN#1) to provide aide services. During record review on 1/12/22, it was noted that LPN#1 documented that aide care was declined on 12/7/21 and on 12/9/21, LPN#1 documented there was no answer to a phone call resulting in a missed aide visit note. However, on 12/7/21 and 12/9/21, LPN#1 documented skilled nursing visits. It was unclear how LPN#1 was unable to provide aide care on 12/7/21 and 12/9/21 yet was able to provide skilled nursing visits on those same dates. The aide visit note dated 12/12/21, documents that LPN#1 completed a set of vital sign measurements for this patient and no other personal hygiene tasks or activities of daily living tasks were completed as ordered in the aide care plan. The 12/8/21 aide care plan did not order the aide/LPN#1 to take a set of vital signs for this patient. There was no indication that the patient had declined the aide/LPN#1 assistance with personal hygiene tasks or the activities of daily living tasks on 12/12/21. During a joint surveyor home visit with LPN#1 providing home health aide services on 1/12/22 at 2:00 p.m., it was observed that LPN#1 provided foot care for this patient. The 12/27/21 aide care plan did not list this task to be completed. After the joint surveyor home visit, LPN#1 was interviewed at 2:45 p.m. regarding the lack of aide care on 12/7/21 and 12/9/21, yet skilled nursing services were provided. LPN#1 stated aide services were declined and that should have been documented within the aide visit notes and not as missed visits.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 1/10/22 during the entrance conference, the Clinical Manager (CM #1) was asked what services were currently provided by the agency and reported, "We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), Home Health Aide (HHa) and Registered Dietician services (RD)." When asked if they utilized contract personnel, CM #1 said "Yes." When asked which services were provided by the contract agency, Adm #1 stated, "We contract all the disciplines just in case we run into a problem." Upon review of the Agency's contracts, it was noted that the agency listed"contracted employees." The agency failed to ensure that at least one qualifying service was provided directly by agency employees. These findings were discussed and acknowledged at the time of discovery.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the transfer/discharge summaries were complete, provided the patient's current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 3 of 4 (MR# 3, 7 and 9) records reviewed in which the patient was discharged/transferred from the agency's services, from a total of 10 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#7: This patient was admitted to the agency on 2/22/21 and received skilled nursing, physical therapy, and medical social work services. During record review on 1/12/22, it was noted that the physical therapist discharged the patient from home health services on 4/17/21. There was no documented evidence the agency ensured a discharge summary was sent to the physician within 5 business days of being discharged from the agency. The findings were reviewed with Adm#1 (administrator) during an interview on 1/13/22 at 1:15 p.m. Adm#1 acknowledged the findings and stated the office staff fax the discharge summary to the physician however there is no documentation or tracking system in place for review. The agency's policy titled, Discharge Policy & Summary (no date), states a copy of the discharge summary will be sent to the physician upon request. The policy fails to align with the regulation. MR#9: This patient was admitted to the agency on 3/8/21 and received skilled nursing, physical therapy, occupational therapy, and medical social work services. During record review on 1/11/22, it was noted that the occupational therapist discharged the patient from home health services on 4/14/21. There was no documented evidence the agency ensured a discharge summary was sent to the physician within 5 business days of being discharged from the agency. The findings were reviewed with and acknowledged by Adm#1 during an interview on 1/13/22 at 1:35 p.m. MR #3: The patient's start of care was 8/21/21 with diagnoses that included Covid-19, Weakness and Hypertension. During the record review on 1/10/22, it was noted that the plan of care (POC) ordered Skilled Nursing, Home Health Aide, Physical Therapy and Medical social Work services to be provided. The patient discharged from Physical Therapy services on 9/15/21. There was no discharge summary available for review. These findings were reviewed with the Administrator (Adm #1) during an interview on 1/12/22 at 1:57 p.m.