Every finding on record at Southern Nevada Home Health Care, Inc.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from August 2, 2022 through August 10, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

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 ensure it reviewed and updated its emergency preparedness plan every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided an appendix A Hazard Vulnerability Assessment. The last review date for the assessment, along with the emergency preparedness program, was dated March 2020. The Clinical Manager verbalized taking over the oversight of the emergency preparedness recently.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures at least every 2 years. The Clinical Manager indicated the agency provided all the documents located.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying patients in need of home evacuation at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding identifying patients needing evacuation from their residences at least every 2 years. The Clinical Manager indicated the agency provided all the documents located.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying on duty staff or patients the agency was unable to contact at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding identifying on duty staff or patients the agency was unable to contact and report to state and local officials at least every 2 years. The Clinical Manager indicated the agency provided all the documents located.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing/maintaining availability of records at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing/maintaining availability of records at least every 2 years. The Clinical Manager indicated the agency provided all the documents located.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years. The Clinical Manager indicated the agency provided all the documents located.

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, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to 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. The Clinical Manager indicated the agency provided all the documents located.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. The Clinical Manager indicated the agency provided all the documents located.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Agency] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. The Clinical Manager indicated the agency provided all the documents located.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically to include all of the following: A method for sharing information and medical documentation for patients under the [agency's] care, as necessary, with other health providers to maintain the continuity of care, and the means for providing information about the general condition and location of patients under the [agency's] care as permitted under 45 CFR 164.510(b)(4). The Clinical Manager indicated the agency provided all the documents located.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: A means of providing information about the [agency's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The Clinical Manager indicated the agency provided all the documents located.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its emergency preparedness training and testing program at least every 2 years. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its emergency preparedness training and testing program. The [agency] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The Clinical Manager indicated the agency provided all the documents located.

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 ensure it conducted exercises to test the emergency plan at least annually. The agency 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. Findings include: On 8/10/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency conducted annual exercises or any type of exercise related to emergency preparedness after June 2018. A lone fire drill was documented with 6 employees attending dated 3/31/2022. The Clinical Manager indicated the agency provided all the documents located.

This Statement of Deficiencies was generated as a result of the Medicare Recertification survey and Healthcare Worker (HCW) Vaccine Mandate conducted at your agency from August 02, 2022 through August 10, 2022 , in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The census on the first day of the survey was 228 patients. Seventeen clinical records were reviewed. Seven home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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, interview and observation, the agency failed to ensure clinicians followed physician orders for 4 of 17 patients (Patient #5, #14, #16 and #17). Findings include: Patient #5 On 7/3/2022, the agency admitted Patient #5 with left revision/infection/inflammation. On 7/3/2022, the plan of care showed a physician ordered 4 skilled nursing visits for the first care week. On 7/4/2022, a physician order showed a physician ordered 5 skilled nursing visits for the first care week. The clinical record contained 4 documented skilled nursing visits dated 7/3/2022, 7/4/2022, 7/5/2022 and 7/9/2022. On 8/10/2022 in the afternoon, the Administrator confirmed an ordered fifth visit, but the clinical record lacked evidence of the same. Patient #14 On 6/18/2022, the agency admitted Patient #14 with encounter for fitting and adjustment of urinary device. On 6/18/2022, the plan of care showed a physician ordered a Foley catheter change monthly with a 16 french, 10 milliliter balloon catheter. On 8/4/2022 at 8:00 AM, a skilled nursing home visit was conducted with the nurse performing a Foley catheter change. The catheter inserted was observed to be an 18 french catheter. The patient's supply box was full of 18 french catheters as well. The family member present indicated the agency ordered and delivered the catheters. The nurse documented insertion of the 18 french catheter and contacted the physician regarding updating the monthly catheter change order and supplies delivered. On 8/10/2022 in the afternoon, the Administrator confirmed the findings. Patient #16 On 7/12/2022, the agency admitted Patient #16 with exacerbation of diabetes mellitus II and chronic kidney disease. On 7/12/2022, the plan of care showed a physician ordered a social worker visit effective the week of 7/17/2022. On 7/25/2022, a social worker documented a missed social worker visit dated 7/25/2022. On 8/3/2022, the patient was transferred to an acute care facility where the patient remained through the duration of the survey. The clinical record lacked documented evidence a physician discontinued or otherwise modified the order for a social worker visit. The clinical record showed seven other documented clinician visits occurred between 7/17/2022 and 8/3/2022, dated 7/18/2022 (therapy), 7/20/2022 (nursing), 7/21/2022 (therapy), 7/26/2022 (nursing), 7/27/2022 (therapy) and 2 on 8/2/2022 (therapy and nursing). The clinical record lacked documented evidence of any other attempts to conduct a social worker visit or why the visit was not made between 7/17/2022 and 8/3/2022. On 8/10/2022 in the afternoon, the Administrator confirmed there was no documentation or explanation as to what happened regarding the social worker visit. Patient #17 On 1/13/2022, the agency admitted Patient #17 with bed confinement and urinary tract infection. On 1/13/2022, the plan of care showed a physician ordered a Foley catheter change every 30 days with a 16 french, 10 milliliter balloon catheter. On 8/4/2022, a home health aide visit was conducted. During the visit, it was identified and confirmed by the patient the agency ordered Foley catheters and had them delivered to the patient's house, and those were the catheters used. The catheters in the box were sized at 18 french, 10 milliliter balloon catheters. On 8/10/2022 in the afternoon, the Administrator confirmed the size ordered should be used, or the order changed for a different size. There was no clarification as to why 18 french catheters were delivered.

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 interview, the agency failed to ensure drugs and treatments were administered only as ordered by a physician for 2 of 17 patients (Patient #5 and #12). Findings include: Patient #5 On 7/3/2022, the agency admitted Patient #5 with left knee revision/infection/inflammation. On 7/3/2022, the plan of care reflected a physician ordered Cefapime 2 grams intravenous via PICC line in right upper arm using sterile technique every 12 hours. The plan of care also reflected 5 skilled nursing visits the first care week and then weekly skilled nursing visits after the first care week. Skilled nursing visit narrative documentation and page 5 of the plan of care illustrated the visiting nurse flushed the PICC line with 10 milliliters of flush before and after medication administration. The flush was never identified on the plan of care or the medication profile. Skilled nurses mentioned flushing with normal saline in narrative notes of visits as well. The clinical record lacked documented evidence a physician ordered PICC line flushes or normal saline to flush with the Cefapime administration. The clinical record showed skilled nurses documented weekly PICC line dressing changes on 7/5/2022, 7/13/2022, 7/20/2022, 7/26/2022 and 8/2/2022. The clinical record lacked documented evidence a physician ordered PICC line dressing changes. On 8/10/2022 in the afternoon, a Clinical Manager confirmed there should have been orders for flushing the PICC line and dressing changes. The agency lacked a PICC line care policy. Patient #12 On 11/18/2021, the agency admitted Patient #12 with encounter for fitting and adjustment of urinary device. On 11/18/2021, the plan of care showed a physician ordered skilled nurses to assess the genitourinary system and to insert/change/maintain (indwelling catheter). Change every 4 weeks and as needed for dislodgement/stoppage using sterile technique. Skilled nurses documented Foley catheter changes during the skilled nursing visits dated 11/24/2021 and 12/23/2021. The clinical record lacked documented evidence in the plan of care, physician orders and the skilled nursing visits of the Foley catheter size used. On 11/30/2021 and 12/9/2021, a registered nurse documented flushing the Foley catheter with 60 milliliters of normal saline. The clinical record lacked documented evidence in the plan of care and physician orders of an order and directives for flushing a Foley catheter, including the use of normal saline. The agency lacked a policy governing the irrigation of Foley catheters with or without orders. On 8/10/2022 in the afternoon, the Administrator confirmed the findings and indicated the nurse should obtain an order for irrigating a Foley catheter.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, interview and observation, the agency failed to ensure clinicians followed physician orders for 2 of 17 patients (Patient #5 and #12). Findings include: Patient #5 On 7/3/2022, the agency admitted Patient #5 with left knee revision/infection/inflammation. On 7/3/2022, the plan of care reflected a physician ordered Cefapime 2 grams intravenous via PICC line in right upper arm using sterile technique every 12 hours. The plan of care also reflected 5 skilled nursing visits the first care week and then weekly skilled nursing visits after the first care week. Skilled nursing visit narrative documentation and page 5 of the plan of care illustrated the visiting nurse flushed the PICC line with 10 milliliters of flush before and after medication administration. The flush was never identified on the plan of care or the medication profile. Skilled nurses mentioned flushing with normal saline in narrative notes of visits as well. The clinical record lacked documented evidence a physician ordered PICC line flushes or normal saline to flush with the Cefapime administration. The clinical record showed skilled nurses documented weekly PICC line dressing changes on 7/5/2022, 7/13/2022, 7/20/2022, 7/26/2022 and 8/2/2022. The clinical record lacked documented evidence a physician ordered PICC line dressing changes. On 8/10/2022 in the afternoon, a Clinical Manager confirmed there should have been orders for flushing the PICC line and dressing changes. The agency lacked a PICC line care policy. Patient #12 On 11/18/2021, the agency admitted Patient #12 with encounter for fitting and adjustment of urinary device. On 11/18/2021, the plan of care showed a physician ordered skilled nurses to assess the genitourinary system and to insert/change/maintain (indwelling catheter). Change every 4 weeks and as needed for dislodgement/stoppage using sterile technique. Skilled nurses documented Foley catheter changes during the skilled nursing visits dated 11/24/2021 and 12/23/2021. The clinical record lacked documented evidence in the plan of care, physician orders and the skilled nursing visits of the Foley catheter size used. On 11/30/2021 and 12/9/2021, a registered nurse documented flushing the Foley catheter with 60 milliliters of normal saline. The clinical record lacked documented evidence in the plan of care and physician orders of an order and directives for flushing a Foley catheter, including the use of normal saline. The agency lacked a policy governing the irrigation of Foley catheters with or without orders. On 8/10/2022 in the afternoon, the Administrator confirmed the findings and indicated the nurse should obtain an order for irrigating a Foley catheter.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a wound care provider was informed of, assessed and treated open areas for 1 of 17 patients (Patient #3). Findings include: Patient #3 On 1/18/2022, the agency admitted Patient #3 with exacerbation of lymphedema. On 1/18/2022, the plan of care showed a physician ordered skilled nursing visits twice the first week, three times the second week and then twice weekly the rest of the care episode. On 2/1/2022, a registered nurse documented identification of open areas on the bilateral buttocks but could not assess completely due to patient endurance. Three open areas were identified on the right lower buttock as stage III. A large unstageable pressure injury was identified on the left lower buttock. A wound specialist visit was noted for 2/3/2022. On 2/10/2022, the wound care physician documented the patient's wounds were not able to be assessed last visit due to bed complications. Additional wound care physician visits were documented on 2/18/2022, 2/25/2022, 3/4/2022 and 3/11/2022. The wound care physician's notes lacked documented awareness and treatment orders for the open areas on the buttocks. The clinical record lacked documented evidence of a physician order for treatment for any of the open areas on the buttocks for the agency nurses. On 2/28/2022, a registered nurse documented redressing the open areas of the buttocks without an order. Clinicians repeatedly documented the uncooperativeness of the patient throughout the care episode, but the agency failed to ensure the open areas of the buttocks were assessed and treated either by the wound care physician or the agency nurses. The agency discharged the patient due to failure to cooperate with the plan of care on 3/16/2022. On 8/10/2022 in the afternoon, the Administrator confirmed the findings.

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, interview and policy review, the agency failed to ensure its nurses documented home health aide supervision every 14 days for 1 of 17 patients (Patient #12). Findings include: Patient #12 On 11/18/2021, the agency admitted Patient #12 with aftercare following organ transplant and change/removal of surgical wound dressing. On 11/18/2021, the plan of care showed a physician ordered ordered twice weekly skilled nursing visits. throughout the care episode, dated 11/18/2021 and then later twice weekly for the remaining four weeks of the care episode. On 11/21/2021, a physician ordered home health aide visits once the first week, then twice weekly for six weeks and finally once the last care week starting the week of 11/21/2021. The clinical record lacked documented evidence of home health aide supervision every 14 days between the skilled nursing visits dated 11/30/2021 and 12/21/2021. On 8/10/2022 in the afternoon, the Administrator confirmed the finding. The Assignment and Supervision of Home Health Aides section of the Patient Care Supervision policy (03-17), last reviewed 6/2021, revealed when the patient received skilled nursing services, a registered nurse would make on-site supervisory visits to each patient receiving home health aide services at least every 14 days.