Every finding on record at South County Home Health

An emergency preparedness survey was conducted at this agency. Federal deficiencies were identified.

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 staff interview it has been determined that the agency failed to comply with all applicable Federal, State and local emergency preparedness requirements, relative to an all hazards risk assessment, individual written emergency preparedness plans, and testing of the emergency preparedness plan. Findings are as follows: 1. The agency failed to develop an emergency plan based on and including a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach. Refer to E0006 2. The agency failed to complete a written individual emergency preparedness plan for 17 of 17 patients that were reviewed, and failed to maintain a copy of the individual emergency plan in the patient's home and clinical record. Refer to E0017 3. The agency failed to participate in an emergency preparedness exercise to test the emergency plan. Refer to E0039

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to include a documented, facility-based and community-based risk assessment using an "all-hazards" approach. Findings are as follows: Review of the Emergency Preparedness Plan, last revised on 8/2021 was not developed based on and including a documented, facility-based, community-based risk assessment, utilizing an all-hazards approach. The plan failed to reveal evidence that a facility based/community-based risk assessment had been completed. During surveyor interview with the Agency Director on 4/21/2022 at approximately 11:15 AM, she was unable to produce evidence that the facility had completed a facility based and community-based risk assessment, that was used to develop the agencies Emergency Preparedness Plan.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure all patients have a written individualized emergency plan for 17 of 17 patients, ID#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11,12,13,14,15,16 and 17. Findings are as follows: Record review for Patients, ID #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17, failed to reveal a written individual emergency preparedness plan in the clinical records. During a surveyor home visit to Patients ID #'s 1, 2, 3, 4, 5, 6 and 7, a review of the patient records kept in the patients home failed to reveal an individual emergency preparedness plan for the patient to refer to in an emergency. During surveyor interview with the Nurse Clinical Team Leader, Staff A, on 4/21/2022 at approximately 10:30 AM, she was unable to provide evidence that the agency developed a written individual emergency preparedness plan for the above patients.

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 staff interview it has been determined that the agency failed to participate in an emergency preparedness exercise to test the emergency plan. Findings are as follows: Record review of the emergency preparedness documents and the Emergency Preparedness Plan, revision date 8/2021, failed to include any information relative to the agency participating in an annual emergency preparedness exercise to test the emergency plan. During an interview with the Director, Staff C on 4/21/2022 at approximately 11:30 AM, she was unable to provide evidence that the agency had participated in a full-scale community-based exercise, or that a individual agency-based exercise or a tabletop exercise was conducted.

A Federal Recertification Survey, Federal Infection Control Vaccination Survey, and State Licensure Survey have been conducted at this agency. State, standard and condition level deficiencies were identified.

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 staff interview it has been determined that the agency failed to ensure that the patient’s clinical record identifies all medications the patient is currently taking for 4 of 7 sample patients, Patient ID #’s 2, 3, 5, and 6. Findings area as follows: 1. Record review of the medications for Patient ID #2, during a home visit accompanied by the Physical Therapy Assistant, Staff E, on 4/14/2022 at 10:00 AM revealed an order on the plan of care certification dated 3/11/2022- 5/09/2022 for the patient to take Tylenol 2 tablets every 4-6 hours as needed for pain. Review of the medications while at the home with the patient, revealed that s/he had Tylenol 500 mg tablets that s/he reports taking 1-2 tablets for pain, not the 325 mg tablets as prescribed. During an Interview with Staff E, the Physical Therapist, during the above home visit, she was unaware that the Tylenol dose that the patient was taking was not the dose ordered by the physician. During surveyor interview on 4/19/2022 at approximately 10:20 AM, with the Nurse Clinical Team Leader, Staff A, she was unable to provide evidence that the medications had been reconciled. 2. Record review of the medications during a home visit with the nurse, Staff K, on 4/14/2022 at 11:30 AM revealed that Patient ID #3' s, plan of care certification dated 3/11/2022- 5/09/2022, had an order for Valtrex 500 mg, to take one tablet, 2 times a day. Review of the patient medications during the above home visit, with the patient, in the presence of the nurse, Staff K, she/he informed the surveyor that the Valtrex 500 mg, is taken once a day, which was changed when the patient was seen by the physician on 3/31/2022. During interview with the nurse, Staff K at the time of the visit, she was unaware that the medication frequency had been changed to once a day by the physician on 3/31/2022 despite having been to the patients home. During an interview with the Nurse Clinical Team Leader, Staff A, on 4/19/2022, she was unable to produce evidence that the medications had been reconciled. 3. During a review of the medications during a home visit with the nurse, Staff G, on 4/14/2022 at 2:30 PM, Patient ID #5' s, plan of care certification dated 3/13/2022- 5/11/2022, revealed the following orders. -Cetirizine HCL 10 mg table one a day via gastrostomy tube -Ferrous Sulfate 325mg tablet one daily by mouth During an interview with the patient while reviewing the medications during the home visit, the patient stated that s/he was not taking the above medications because they had been previously discontinued by the physician. During a surveyor interview with the Nurse, Staff G, she was unaware that the patient was not taking the above medications as they had been discontinued, despite having been to the patients home for visits. During a surveyor interview with the Nurse Clinical Team Leader on 4/19/2022 at approximately 3:10 PM, she was unable to provide evidence that the medications had been reconciled. 4. During a review of the patients medications with the patients Social Worker, Staff F on 4/18/2022 at 1:00 PM, Patient ID #6' s, plan of care certification dated 3/20/2022- 5/18/2022, revealed the following orders. -"Synthroid 50 mg tablet one daily" -"Synthroid by mouth tablet 100 mcg (micrograms) tablet, prn (when necessary) , PO (by mouth) per PCP (primary care physician), 100 mcg [to be taken] two times a week added by PCP keep other dose as is" During a surveyor interview with the Nurse Clinical Team Leader, Staff A on 4/19/2022 at approximately 11:00 AM, she was unable to clarify the Synthroid 100 mcg order and contacted the patient's Case Manager, Staff I for clarification. During a surveyor interview with Staff Nurse I, on 4/20/2022 at approximately 11;30 AM, when asked by the surveyor to clarify the patient's medication Synthroid schedule, she stated that she was unaware that the physician had increased the patients medication dose to 100 mcg twice a week, and did not know what days the patient was scheduled to take the 100 mcg's. She was unable to produce evidence that the patient's medications had been reconciled. During an additional interview with the Nurse Team Leader, Staff A, on 4/20/2022 at approximately 11:45 AM, she stated that Staff I, should have been aware that the patient's medications had been changed and should have have clarified with the physician which days the patient was to take the 100 mcg.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure the patient's plan of care is signed by a physician, for 3 of 17 patients records reviewed, ID #'s 3, 5 and 12. Findings are as follows: 1. Record review for patient ID #3, reveals a certification and plan of care dated 3/11/2022-5/9/2022 completed by the nurse on 3/11/2022 after the initial visit and assessment. Review of this plan of care on 4/21/2022 fails to reveal a physician signature. 2. Record review for patient ID #5, reveals a certification and plan of care dated 3/13/2022-5/11/2022 completed by the nurse on 3/13/2022 after the initial visit and assessment. Review of this plan of care on 4/21/2022 fails to reveal a physician signature. 3. Record review for patient ID #12 , reveals a certification and plan of care dated 3/25/2022-5/23/2022 that was completed by the nurse on 3/25/2022 after the initial visit and assessment. Review of this plan of care on 4/25/2022 fails to reveal a physician signature. During surveyor interview with the Clinical Nurse Team Leader, Staff A, on 4/25/2022, she was unable to explain why the plan of care for patient's ID #'s 3, 5 and 12 had not been signed by the physician. Additionally, she was unaware that the above plans of care had not been signed by the physicians until it was brought to her attention by the surveyor.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview the agency failed to ensure that all patient care orders, including verbal orders, are recorded in the plan of care for 3 of 17 records for patient's ID #'s 1, 3, and 5. Findings are as follows: 1. Record review for patient ID #1, revealed a start of care date 3/17/2021, and a certification and plan of care dated 3/12/2022- 5/10/2022. During a home visit conducted on 4/14/2022 at approximately 8:30 AM, Patient ID #1 was noted to have a Gastrostomy Tube (G-Tube). Surveyor review of the physicians’ orders and plan of care failed to include that the patient has a G-Tube (Gastrostomy tube) or a physician’s order for the treatment and assessment of the G-Tube which the patient had upon admission on 3/12/2022. During surveyor interview with the Nurse Clinical Team Leader, on 4/18/2022 at approximately 9:30 AM, she was unable to produce evidence of a physician’s order for the above. 2. Record review for Patient ID #3, revealed a certification and plan of care dated 3/11/2022- 5/09/2022, which failed to include orders relative to care and treatment of the PICC (Peripherally Inserted Central Catheter) that the patient had in his/her right arm. During surveyor interview with the Clinical Manager, Staff B on 4/20/2022 at 9:15 AM, she acknowledged that the certification lacked any orders relative to care and treatment for the PICC line, which is managed by an infusion company. 3. Record review for patient ID #5, reveals a certification and plan of care dated 3/13/2022-5/11/2022 completed by the nurse on 3/13/2022 which states; "Tube type (specify) date inserted..."PEG (Percutaneous endoscopic gastrostomy) The orders fail to include the type of tube or the date it was inserted. During a surveyor interview with the Nurse Team Leader, Staff A, and the Nurse Case Manager, Staff J, on 4/19/2022, at approximately 3:15 PM they acknowledged that the G-Tube orders were incomplete.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to provide services and treatments in accordance with physician's orders for 1 of 3 patient's, ID # 1, 5 & 12 relative to home health aide services, gastrostomy tube (G-Tube)/feedings, and services of a Social Worker. Findings are as follows: 1. Record review for Patient ID #1, revealed a start of care date 3/17/2021, and a certification and plan of care dated 3/12/2022- 5/10/2022. During surveyor home visit with the Home Health Aide, Staff L on 4/14/2022 at 8:30 AM, the surveyor observed that the patient had a gastrostomy tube (g-tube) and was receiving a nutritional supplement, Kate Farms (plant-based, organic nutrition) Standard 1.4, 325 ml per box. Review of the patients record reveals a physician order for a nutritional supplement: TwoCal HN [calorie and protein dense nutrition] 240 ml (milliliters) 1 can, 5 times a day. During the home visit the surveyor interviewed the patient's caregiver, who stated that the patient has been receiving Kate Farms for the nutritional g-tube feedings and has been consuming 4 boxes a day administered via the patient's gastrostomy tube. The caregiver informed the surveyor that the Kate Farms is the feeding which they has been receiving. During the surveyor interview with the Nurse Clinical Team Leader Staff A, on 4/15/2021, she was unable to explain why the patient was not getting the TwoCal as ordered by the physician. Additionally, she could not provide information as to who had ordered the Kate Farms nutritional supplements which the patient had been receiving. 2. Review of the calendar of visits for Patient ID #1, reveals that the week of 4/10/2022 through 4/16/2022 the patient had 3 Home Health Aide visits. Review of the physicians’ orders failed to reveal a physician’s order for the three Home Health Aide visits completed the week of 4/10/22 through 4/16/2022. During a surveyor interview with the Nurse Clinical Team Leader, on 4/18/2022 at approximately 9:30 AM, she was unable to produce evidence of a physician’s order for the health aide visits that were conducted the week of 4/10/2022-4/16/2022. She acknowledged that the staff did not contact the physician for approval of the additional health aide visits. 3. Review of the patients record during a home visit with nurse, Staff G, on 4/14/2022 at 2:30 PM, revealed Patient ID #5' s, plan of care certification dated 3/13/2022- 5/11/2022, which revealed the following orders. Nutritional Requirements: "Bolus Jevity 1.5, 360 ml (milliliters) 4x/day. Free water flushes". Review of the nurses assessment on the plan of care states; "... takes 8 jugs Jevity, 1.5 with 200 ml H2O each feed". During surveyor interview with the nurse,Staff G, at the time of the visit, she was unable to explain the discrepancy or clarify the Jevity order as she was not the staff who had admitted the patient and wrote the assessment. During surveyor interview with the nurse who admitted the patient and completed the assessment, Staff J, on 4/19/2022 at 3:10 PM, she acknowledged the physicians order was for jevity, 4 boxes of 360ml a day. She was unable to produce evidence that she had notified the physician that the patient was not taking the 4 boxes as ordered. 4. Record review for Patient ID #12, reveals a start of care date of 3/25/2022, and a certification and plan of care dated 3/25/2022-5/23/2022. The physician order states; MSS (medical social service) evaluate and treat. Review of the record and the calendar of visits failed to reveal that the social services evaluation ordered on 3/25/2022 was completed. During surveyor interview with Nurse Clinical Team Leader, Staff A on 4/25/2022 at 9:20 AM, she was unable to provide evidence that the Social Service evaluation that was ordered on 3/25/2022 was completed. Additionally she was unable to explain why the visit was not scheduled by the schedulers as is the agency practice.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to revise the plan of care to reflect current information from the patient's updated comprehensive assessment, for 2 of 12 patient' s records reviewed, ID #'s 6 and 7. Findings are as follows: 1. Record review for Patient ID # 6's plan of care certification dated 3/20/2022- 5/18/2022, revealed the following orders; OT (Occupational Therapy), week of 3-20-2022, 1-2 times a week for 1 week, week of 3/27/2022, 1-2 times a week for 3 weeks. Nursing Assistant, (CNA) to provide personal care and ADL (activities of daily living) assistance. Review of the patients calendar of visits revealed that the patient has not received any OT visits since the week of 3/27/2022, and has not had any Home Health Aide visits as ordered on the above plan of care. During surveyor interview with the Nurse Clinical Team Leader, Staff A, on 4/19/2022 at approximately 1:00 PM, after reviewing the record, she informed the surveyor that the patient had refused the Home Health Aide services and refused OT visits after the week of 3/27/2022. Staff A was unable to provide evidence that the care plan had been updated to reflect the current services the patient was receiving. 2. Record review for patient ID #7, revealed a start of care on 3/19/2022, and a certification and plan of care dated 3/19/2022- 5/17/2022, that included orders for nursing, PT (physical therapy) & OT. The patient was admitted after a stay at an acute rehab, and his/her diagnosis cerebral infarct affecting right dominant side and seizures. The patient's medications included Keppra (for seizures). The record reveals that nursing had discontinued visits the week of 4/3/2022. The patient continued to receive visits by the Physical Therapist. On 4/14/2022, during a PT home visit the patient experienced a seizure, 911 was called and the patient sent to the ER for evaluation and returned home. During a surveyor home visit with the PT present on 4/18/2022, the patient complained of dizziness and stated she/he had vomited earlier in the day. Review of the home medication list at the patients house revealed that the patient had been taking Meclizine (for dizziness). According to the patients caregiver this medication had been discontinued. During surveyor interview with the Clinical Nurse Team Leader, Staff A, on 4/19/2022 at approximately 1:30 PM, she acknowledged that the care plan should have been updated after the patient was evaluated in the ER for the seizure on 4/14/2022, and that a skilled nursing visit should have been scheduled per agency policy.

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 record review and staff interview it has been determined that the agency failed to provide infection control education to patients and or the patient's caregivers, for 2 of 2 patients with infections, patient's ID #'s 5 & 10. Findings are as follows: 1. Record review for Patient ID #5, revealed the patient was admitted on 3/13/2022, after being discharged from an acute care hospital where h/she was treated for a non- pressure chronic ulcer of the lower extremities. Review of the patient referral form notes reveal that while in the hospital the patient was diagnosed with MRSA (Methicillin-resistant Staphylococcus aureus) infection in the nares on 3/8/2022 and placed on contact precautions. Review of the plan of care reveals that the patient was receiving, skilled nursing services, physical therapy, and occupational therapy. Additionally, the patient resides in a second floor apartment and has a roommate. Review of the initial nursing assessment visit note and certification and plan of care failed to reveal any documentation of the MRSA infection. Additionally, the record failed to provide documentation of education provided relative to the care and management of the MRSA infection control practices for the patient and or the caregivers. During an interview with the Clinical Nurse Team Leader, Staff A on 4/19/2022 at 3:15 PM, along with the nurse, Staff J who completed the initial assessment on 3/13/2022 relative to the MRSA. Staff J stated that she was unaware of the MRSA diagnoses, and did not know if the patient was treated for the MRSA while in the hospital. She acknowledged that she had not provided any infection control education to the patient or the roommate relative to the MRSA. The Nurse Team Leader, Staff A, stated that the nurse in her admission note or assessment, should have addressed the MRSA, contacted the physician relative to the status of the infection, and provided educated to the patient and caregivers relative to handwashing and cleaning of the environment to prevent spread of the infection. 2. Record review for Patient ID #10, reveals the patient was admitted to the agency on 11/16/2021, with diagnoses of malignant neoplasm of bladder and ESBL ( extended spectrum beta-lactamase) in the urine. Record review failed to reveal evidence that a care plan was initiated for the ESBL infection or that any infection control education was provided to the patient or caregiver relative to the risk of transmission and importance of handwashing. During surveyor interview with the Nurse Clinical Manager, Staff A, on 4/25/2022 at approximately 9:45 AM, she was unable to produce evidence that the staff had provided the patient or caregivers, infection control education relative to the ESBL, and nursing had not created a care plan to address the infection. Staff A stated that the nurse who completed the initial assessment and plan of care should have included a plan of care for the ESBL that included infection control education.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and staff interview the facility failed to conduct on-site supervisory visits no less frequently than every 14 days for 1 of 1 Patient, ID #1 receiving Home Health Aid services. Findings are as follows: Record review for Patient ID # 1, reveals a start of care date, 3/17/2021, and a certification and plan of care dated 3/12/2022 to 5/10/2022. Review of the calendar of visits, revealed that the patient had one Home health Aide visit the first week, and continued to receive health aide visits three times a week. Record review failed to reveal evidence that the Home Health Aide supervisory visits were conducted. During surveyor interview with the Nurse Clinical Team Leader, Staff A, on 4/18/2022 at approximately 9:30 AM, she was unable to to provide evidence that supervisory visits are conducted no less frequently than every 14 days as required.

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 staff interview it was determined that the agency failed to send a discharge and or transfer summary to the appropriate health care professional when patients are discharged for 3 of 5 Patient's, ID #'s 13,16 and 17. Findings are as follows: 1. Record review for Patient ID # 13, reveals he/she was admitted to the agency on 8/25/2020 with a primary diagnosis of chronic venous ulcers of the lower extremities. The record reveals that the patient's caregiver contacted the agency on 3/10/2022 to inform them that she had made arrangements for the patient to be admitted to a skilled nursing facility for one month for daily wound care. The record for the patient reveals a discharge/transfer date of 3/10/2022 but failed to document that a discharge summary or transfer summary was sent to the skilled nursing facility or the patient's physician. During surveyor interview with the Nurse Team Leader Staff A, on 4/25/2022 at approximately 11:30 AM, she was unable to provide evidence that the discharge summary or transfer summary had been sent to skilled nursing facility or physician. 2. Record review for Patient ID #16, reveals the patient was admitted to the agency on 2/9/2022, with a primary diagnoses of hypertensive heart disease, chronic kidney disease, and heart failure. The record reveals the patient was admitted to the agency for evaluation of a decline and recent falls. Review of the assessment note reveals that the patient and spouse do not want to the patient to be sent to the emergency room any more and will explore comfort measures. The record notes that the patient was discharged from the agency on 2/11/2022 and was admitted to Hospice. The record lacked evidence of a discharge or transfer note/summary. During a surveyor interview with the Nurse Team Leader Staff A, on 4/25/2022 at approximately 11:30 AM, she was unable to produce evidence of a discharge summary or transfer summary. 3. Record review for patient ID # 17, reveals the patient was admitted to the agency on 10/18/2021, after a left leg angioplasty and left carotid endarterectomy for skilled nursing and physical therapy. The record reveals that the patient improved and goals were met and the patient was discharged from the agency on 1/10/2022. Further review of the record failed to reveal evidence that a discharge summary was sent to the patients physician upon discharge from the agency . During a surveyor interview with the Nurse Team Leader Staff A, on 4/25/2022 at approximately 11:30 AM, she was unable to provide evidence that the patients physician was sent a copy of the discharge summary.