Every finding on record at Sentry Home Health Care LLC

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Initial survey conducted at Sentry Home Health Care Agency (HHA) on January 5, 2023, resulted in a finding of noncompliance with the Emergency Preparedness Program Condition for Coverage of Participation (CoP) under 42 CFR 482.102 with the following condition level deficiency listed below.

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, §485.542, §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 facility failed to develop an Emergency Preparedness plan and conduct a community-based risk assessment along with identifying the continuity of business operations. This deficient practice has the potential to affect all patients receiving care from the home health agency. Findings include: The HHA failed to develop an Emergency Preparedness plan and conduct a community-based risk assessment along with identifying the continuity of business operations. (See findings in tag E0004)

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview the facility failed to develop an Emergency Preparedness Plan and conduct a community-based risk assessment along with identifying the continuity of business operations. This deficient practice can delay the ability to offer continuity of patient care by not being prepared in case of an emergent situation and can lead to inappropriate treatment to all patients. The findings are: A. Record review of the facilities policy titled; “Disaster/Emergency Preparedness” specific policy undated (policy binder has blanketed date 03/01/22 approved) showed the following: 1. “Procedure: a) 2. This agency shall coordinate with other area providers, when possible, promote cohesiveness and a more robust drill. 3. Once a Drill is conducted and an all clear has been called the Administrator shall complete a Disaster After Action Report and Improvement Plan.” Facility did not have an After-Action Report and Improvement Plan. b) 6. The Clinical Manager or designee classifies patients according to the acuity of the patient’s medical condition, nursing needs and caregiver availability. Patients will be classified into one of the following categories: Class I, Class II, Class III.” EPP also states patients will be given a priority code. Facility could not provide a list of priority codes used. c) 7. The Administrator/Clinical Manager will attempt to notify appropriate staff and the staff will contact the office as soon as possible by telephone to receive assignments or other instruction. 1) If phone service is not operating and roads are impassible for travel, staff should stay home or at another place until communications are restored. 2) If the Administrator/Clinical Manager cannot reach the office, the communication center will be his/her home. An alternate communication center must also be designated. 3) The Agency must inform the staff of a designated local/radio television status in the event of loss of telephone service for an extended time; these stations will be utilized to communicate the emergency plan. 4) The Administrator/Clinical Manager or designee will possess a list of local law enforcement offices, emergency centers and/or ambulance services for transport if necessary.” The facility could not provide a list of local law enforcement, emergency centers or ambulance services for transport. d) 11. If a home visit is not possible to those patients in Class I, the staff member will contact the Administrator/Clinical Manager who will then coordinate with local law enforcement offices, emergency operations center or local ambulance services to transport the patient(s) to an acute care facility.” The facility could not provide a list of local law enforcement, emergency centers or ambulance services for transport. e) 13. This agency shall inform State and local emergency preparedness officials about patients in need of evacuation of their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.” Facility could not identify who they would contact for evacuation. f) 16. In order to facilitate evacuation and transportation this agency shall maintain a patent roster containing at least the following information: Patient name, Age, DOB, Medications, Allergies, Diagnosis, The care and safety of patients with limited mobility, Those requiring evacuation due to medical or psychiatric conditions or their home environment, Emergency contact(s).” Facility could not provide a patient roster. B. Record review of the facilities Disaster Plan and Emergency Preparedness Packet (EPP) revealed the following: 1. A table of contents that does not coincide with the rest of the EPP. 2. Home Care Emergency Preparedness Assessment completed on 10/08/22, included areas that had not been completed such as Plans for transportation interruptions and Alternate transportation arranged. No coinciding documentation explaining what was done to complete action. 3. Facility Home Health Care Phone Tree with Key members showing as Local Representatives and Phone (RingCentral) with no corresponding information identifying who needs to be called. 4. Organizational Chart for Disaster Response Team only shows Incident Commander and Alternate Incident Commander. There are 8 roles left unassigned which include: Public Information, Safety & Security, Liaison Officer, Operations, Planning, Logistics, Finance, and Emergency Supervisor. Facility could not provide a list of staff for these roles. 5. The Assignment Sheet is an example form and when asked to provide an assignment sheet for facility, one could not be provided. 6. Disaster Command Center, Administration: a) 1. Each office will keep and maintain a current list of contact information for all staff, staff family members, vendors, emergency services, hospitals and other appropriate community resources. A list of contact information was requested, and facility could not provide. b) 2. The Director will ensure the existence of a Disaster Command System and team to respond to an emergency system. When asked for the Disaster Command System procedure and Disaster Team Roster the facility was unable to provide documentation. c) Patient Care & Planning, on admission, the admitting nurse will assign each patient with a priority code. When asked to show priority code in patient charts, none was present. 7. EPP states, “If phones are not available, the information officer will contact two (2) prearranged radio stations (K216BJ, KEND) with an announcement for staff and patients. When asked to provide contracts with local radio stations, facility could not provide any. 8. Security: a) The Security Officer will make assessments regarding the security of the command center, the safety and travel conditions for staff and make arrangements for relocation of the command center, transportation and/or safety escorts as needed. The Security Officer will also ensure all staff has identifying badges and/or uniforms which will allow them access to their agency. Security Officer on facility Organizational chart is unassigned. 9. Public Information: The Public Information Officer (PIO) will confer with the Disaster Command Officer and other members of the Disaster Response Team to reach a joint decision regarding the information, in any, to be released to the media. The PIO will also be in charge of determining alternate means of contacting staff. Public Information Officer on facility Organizational chart is unassigned. 10. Emergency Supply Storage Area: An emergency supplies storage area will be maintained at the Agency office for employees during the time period that they are working in the event of an emergency and will be maintained by Office Manager. When asked to see the supply storage, facility stated they did not have one. 11. Emergency Supervisor Task: a) “Each month, all Emergency Supervisors will get an updated copy of the emergency list and keep it at home for reference if an emergency occurs after hours, or if the Agency office is damaged or destroyed. When Director gets a call asking for assistance with an emergency, she will call Assistant Director and Office Manager. Both will then go to the Agency office immediately.” Emergency Supervisor on facility Organizational chart is unassigned and facility could not provide a copy of the emergency list. b) “While this is being determined, calls will be made to nursing homes and residential care facilities to determine the number of rooms which will be available for temporary placement of displaced patients to local authorities to determine shelter options and locations.” When asked to provide a list and contract with nursing homes and residential facilities, facility could not provide any information or contracts. c) “Calls will be made to prearranged transportation of patients in need of evacuation.” When asked to provide a copy of contract and list of names for prearranged transportation, facility could not provide the information. 12. EPP states, “Office Manager will notify Secretary, and then each will notify persons listed below on the calling list. If they are unable to reach an employee on the telephone, they will proceed to the next listed person on the list. The Office Manager and Secretary will call the office and list the employees available for assistance then come to the office. Upon arriving, every five (5) minutes, Office Manager and Secretary will try those employees not found with the first call attempt and notify the Disaster Supervisor(s) of any other employees found to be available to be on standby. They will also manage calls upon arrival at the office. If the Office Manager is not able to reach the Secretary, Office Manager will notify all persons under Secretary on the calling list.” “Assignments: After Office Manager and Secretary have called and put a staff member on alert, that staff member will wait for an Emergency Supervisor to call back with their assignment and where to meet their partner or security escort.” When asked to provide the name of the secretary, facility stated they do not currently have one. 13. Emergency During Working Hours: “The emergency supply packet will consist of various supplies that may be needed, as well as emergency worksheets.” “Each emergency assessment team will fill out the emergency worksheet and turn them in to the Emergency Supervisors at least hourly with a report on the condition of patients they have assessed during that time frame. This emergency worksheet will enable the Emergency Supervisor to maintain a tracking list for identification of those patients assessed their status and what location they were moved to.” When asked to see a supply packet and emergency worksheet, facility could not provide. 14. In the EPP under Drills, Emergency Contacts, Organization type, 6 of 9 organizations listed have phone numbers with no names or email addresses listed. Department of Health (DOH) has phone number and when called for verification it is for the DOH Community Clinic. Hospital has phone number and no name. City had multiple hospitals. 15. Essential Vendors, entire chart was left blank, when facility was asked to provide vendors, they stated they did not have any. 16. Emergency Plan by Event: Civil Disturbance and Workplace Violence, Fire Emergency at Office Location, Hurricane. Events listed are not state specific to the community population being served by agency. 17. Business Continuity Plan: A business continuity plan will enable the organization to plan for continuing operations after a disaster. The Business Continuity Plan is an example form and was not completely filled out by agency. C. Interview with Staff (S)1, Office Manager and S2, Administrative Assistant on 01/05/23 at 9:15 am 1. When asked who the local representatives are was told by S2, “They can be the fire department, EMS, I will call I believe her name is [name of contact] at the city of [name of city] and find out what they need and what they need us to do.” 2. When asked if there was a Disaster Response Team list in the binder, S2 said, “No. The only 2 people on the team is [Administrator name] and myself.” 3. When asked if there was an assignment sheet completed and filled out, S2 responded, “No, I don’t have one filled out.” 4. When asked for a current list of contact information for all staff, staff family members, vendors, emergency services, hospitals and other appropriate community resources facility could not provide one with the information listed. 5. When asked who the director of the facility was, S2 answered “We do not have a director, the administrator is [administrators name].” 6. When asked to provide contracts with radio stations, S2 said, “We just haven’t got it done. That is on our list to do.” 7. When asked who the secretary is and why there is not one listed on the phone tree, S1 answered, “We have no secretary at the moment. It is just the 3 of us.” 8. When asked where the emergency supply packets and emergency worksheets are kept and if the surveyor could see them, S1 answered, “We have none, no.” 9. When asked if the facility had any essential vendors, S2 answered, “No vendors, the only person we deal with is the fire extinguisher service.” 10. When asked who the emergency supervisor is, how often they are given the emergency list and if copies are available for December, S2 answered, “[Administrator name] is our only supervisor and [DON name]. As often as they want to print it. No, because we run the report online and can run it instantaneously.” 11. When asked what nursing homes and residential care facilities contracts are held with and to provide a copy of the contract, S2 stated, “None, we don’t have any contracts.” 12. When asked who prearranged transportation is arranged with and to provide contracts, S2 answered, “We don’t have a contract for transportation, we call 911.”

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site initial survey conducted at Sentry Home Health Agency (HHA) on January 5th, 2023 resulted in noncompliance under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited:

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to obtain a signature to show that patients received written notice of patient’s rights and responsibilities for 3 (P[patients] 2, P6, P7) out of 7 home health patients reviewed. This deficient practice could result in patient’s not being involved in their own care and lead to poor outcomes. The findings are: A. Record review of the facility’s undated policy titled, “Patient Conduct, Responsibility and Rights” on page 9 under “Procedure” it states, “1. The Agency staff will obtain written consent/Service Agreement that specifies the type of care and services that may be provided by the Agency on every patient, either by patient or legal representative. The patient or the legal representative must sign or mark the consent form. 2. The Service Agreement will contain a signature line for the Patient/representative and Agency staff indicating compliance with State and Federal regulatory mandates including Patient Rights and Advanced Directives.” B. Record review of the facility’s “New Admission Packet”, page 38 and 39 is a document titled, “Consent & Verification of Receipt of Information” this document reveals a list of documents and the second page (page 39 of the packet) states, “By signing this consent, I acknowledge receipt of the admission booklet and confirm my understanding and agreement with its contents. I understand a copy of this consent shall be as valid as the original and shall remain in effect until I am discharged from the agency. I also understand that I may revoke this consent in writing at anytime [sic].” Below this statement is a signature line for the patient or legal guardian and agency staff. C. Record review of P2’s undated document titled; “Consent & [and] Verification of Receipt of Information” does not reveal any patient acknowledgement. There is second page of this document is blank page. D. Record review of P6’s undated document titled; “Consent & Verification of Receipt of Information” does not reveal any patient acknowledgement. On the second page of this document the signature lines are blank. E. Record review of P7’s undated document titled, “Consent & Verification of Receipt of Information” does not reveal any patient acknowledgement and there is no second page to this document. F. In an interview with S(staff)1 and S4 on 01/05/2023 at 11:00 AM it was asked if patients sign a consent and receipt of their rights on admission. It was confirmed that patients do sign for these, and it is scanned into their chart. It was then asked if there is any reason a signature would not be obtained. S1 stated, “I can speak to everything after 11/20/2023. I know there are issues prior to November, there are several missing consents.” S4 added that they have gone through charts and made recent improvements.

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 facility failed to conduct an initial assessment within 48 hours of receiving the referral for services for 3 (P[patient]3, P5, and P7) out of 7 home health patients reviewed. This deficient practice could lead to patients being left at risk for injury and/or illness while waiting for an assessment. The findings are: A. Record review of the facility’s undated policy titled, “Admission Criteria” on page 3 number 8 states, “Upon referral, the decision regarding acceptance of and initiation of service by licensed staff will be made within 48 hours of the referral or within 48 hours of the patients return home or knowledge of return home or on the physicians ordered start of care date.” B. Record review of P3’s document titled, “OASIS Assessment Details” completed on 12/27/2022 on page 1 under “Clinical Record Items” states that the assessment is being completed as a start of care, the date for the start of care is 12/27/2022. There is a box checked that indicates no specific start of care date was ordered by the physician. The date the referral was received by the facility is 12/22/2022. C. Record review of P5’s document titled, “OASIS Assessment Details” completed on 09/06/2022 on page 1 under “Clinical Record Items” states that the assessment is being completed as a start of care, the date for the start of care is 09/06/2022. There is a box checked that indicates no specific start of care date was ordered by the physician. The date the referral was received by the facility is 09/01/2022. D. Record review of P7’s document titled, “OASIS Assessment Details” completed on 10/10/2022 on page 1 under “Clinical Record Items” states that the assessment is being completed as a start of care, the date for the start of care is 10/10/2022. There is a box checked that indicates no specific start of care date was ordered by the physician. The date the referral was received by the facility is 10/06/2022. E. In an interview with S(staff)1 and S4 on 01/05/2022 at 11:00 AM regarding the referral process and an initial assessment being done. S1 explained they receive referrals via fax; the referrals are uploaded, and an initial assessment is conducted within 48-72 hours. It was asked if the agency is aware of any issues in their process and what they do if patients are not seen within the required 48-hour window. They explained that the only time they do not see patients within that window is when the patient does not want to schedule a visit. In these cases, they let the provider know and place a communication note. When asked if they get a new order or a new start of care date from the provider in these cases S1 stated, “No, we weren’t aware of that requirement.”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to follow physician’s orders for 1 (P[patient]5) out of 7 home health patients reviewed. This deficient practice could result in patient’s not receiving care as ordered and being left at risk for injury and/or illness. The findings are: A. Record review of P5’s orders revealed a verbal order dated 09/28/2022 and signed by the physician on 10/11/2023 requesting Skilled Nursing. The order states, “Patient having elevated HR [heart rate] over 100 BPM [beats per minute] and decreasing SaO2 [oxygen saturation] over the 4 session [sic]. Requesting skilled nursing for further assessment and management of vitals.” B. Record review of P5’s electronic health record did not reveal any evidence that Skilled Nursing was scheduled for the patient and there was no evidence of the order being discontinued. C. In an interview with S(staff)1 and S4 on 01/05/2023 at 11:00 AM staff was asked to explain why the order for Skilled Nursing was not done for P5 and to show the documentation in the electronic health record. The electronic health record for P5 was reviewed again with S1. S1 stated that they could not find why this order was not completed, and there was no documentation in the communication notes.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to maintain an effective, ongoing data driven Quality Assessment and Performance Improvement (QAPI) program to ensure adequate and effective operation in areas of clinical care. This deficient practice increases the likelihood of the facility not having a process for improving and identifying areas in quality and performance of patient practices for all patients. The findings are: A. Record review of the facilities policy titled; “Quality Assessment & Performance Improvement” specific policy undated (policy binder has blanketed date 03/01/22 approved) states the following: 1) Focus: 5. This agency shall use the data collected to – a. Monitor the effectiveness and safety of services and quality of care; b. Determine and define problematic areas for the purpose of conducting performance improvement projects; and c. Identify opportunities for improvement. 2) Program: “This QAPI program shall show measurable improvement in indicators for which there is evidence that the improvement in those indicators will improve health outcomes, patient safety, and quality of care. The following measures (at a minimum) will be used to capture significant outcomes that are essential to optimal care and will be used in care planning and coordination of services and events. (Assessment of these measures will be through data collection, which at a minimum will consist of clinical record review, patient interviews, and patient satisfaction reports.) 2. The QAPI committee will review at least the following: x. Quality indicator data, including measures derived from Outcome and Assessment Information Set (OASIS) and other relevant data to ensure a data driven program.” B. Record review of facilities QAPI Plan (undated), shows, “Identify and use data to monitor our performance, Establish goals and thresholds for our performance measurement, Identify and prioritize problems and opportunities for improvement. The QAPI committee will review data from areas the organization believes it needs to monitor monthly to assure systems are being monitored and maintained to achieve the highest level of quality for our organization. C. Interview with Staff (S)2, Administrative Assistant at 11:30 am on 01/04/2023 When asked what quality indicators were being tracked, S2 answered, Falls and infection control.” When asked, where is the data you are reviewing in the QAPI binder, S2 answered, “I don’t have any.” When asked if any other data was being tracked, S2 answered, “No.” When asked where adverse events were being tracked, S2 answered, I keep reports on my laptop. Looking at falls, infections, and anything that has been entered wrong in the online patient charts.