Every finding on record at Sunny Brook Home Care, LLC

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/5/24 through 2/8/24 and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements for the Establishment of Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan/policies and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for all staff. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: During an interview on 2/7/24 at 2:15 PM, Administrator reported inability to locate documentation of any emergency preparedness training for any staff since the last survey in 2021. No training has been completed over the past year. During an interview on 2/8/24 at 10:01 AM, Administrator confirmed no other information available. The agency failed to ensure all staff completed initial and biannual training in emergency preparedness as required by regulation. The surveyor reviewed the above stated findings with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/5/24 through 2/8/24. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 150 patients at the time of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, patient interview, and agency staff interview, the agency failed to ensure accurate and thorough completion of pertinent components of the initial comprehensive assessment for 1 of 2 sampled patients with wound care. (Patient #1) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to agency policy, titled Initial Assessments/Comprehensive Assessments, dated April 2023, each patient admitted will receive a comprehensive assessment. The comprehensive assessment will reflect the patient’s current health status. 1. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The comprehensive assessment, dated 12/19/23, contained documentation the integumentary system was within normal limits, and indicated no pressure ulcers. b. The skilled nurses visit note dated, 12/27/23, contained documentation the integumentary system was assessed with no documented skin issues or pressure ulcers. c. Two missed visits were recorded with physician notification, documented for the dates of 1/3/24, and 1/10/24. d. During a home observation visit, 2/6/24 at 9:30 AM, surveyor observed Staff C, Registered Nurse, (RN) providing wound care to the right buttock. e. During the home visit the patient reported they had sustained a fall outside prior to their December admission to home care, and reported they had to wait for help to get up off the ground for some time. Patient reported it was sore at the time, but that they had not noted any drainage or opening to the area. Patient reported in January the area became very painful and the patient was taken to the local emergency room and was transferred to the University of Iowa Hospital where the wound had to be surgically debrided and received antibiotics. f. Hospital records from the University of Iowa, dated 1/11/24, revealed that patient was brought into Washington County Hospital on 1/10/24, transferred to the University of Iowa hospital on 1/11/24. Admission diagnosis was an infected right buttock pressure ulcer with necrotizing fasciitis. (flesh eating disease) Hospital records indicated that patient had a fever of 101.4 Fahrenheit with mental confusion also documented. Patient required surgery to remove the infected tissue in the wound. Agency failed to identify a wound during the initial comprehensive assessment. The above stated findings were reviewed with the agency Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 3 sampled patients requiring a resumption of care assessment (Patient #4). The agency performed 29 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment, the comprehensive assessment for resumption of care must be completed within 48 hours after the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician/practitioner ordered resumption of care date. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed: a. The update to the comprehensive assessment at the time of resumption of care, dated 1/15/24, documented the patient had a physician ordered resumption of care date of 1/15/24 but lacked documentation of a date the agency was notified of the patient hospital discharge. b. Interim physician order, dated 1/15/24, included resumption of care orders that included the physician ordered resumption of care date as 1/15/24. c. The faxed paperwork from the hospital, dated 1/17/24, identified the patient admitted on 1/8/24 and discharged on 1/10/24. d. Home health aide visit note, dated 1/11/24, included documentation services were provided. Interview on 2/8/24 at 10:01 AM, the Administrator reported the registered nurse (RN) was scheduled to complete the resumption of care comprehensive assessment on 1/11/24 but was unable to complete the visit due to an ice storm. The home care aide was scheduled for a visit on 1/11/24 as well and was able to make it to the home prior to the ice storm. The nurse failed to obtain the physician ordered resumption of care date within 48 hours of the patient hospital discharge or to complete the update to the comprehensive assessment at the time of resumption of care within 48 hours of the patient hospital discharge. The update to the comprehensive assessment at the time of resumption of care was completed 5 days after the patient’s hospital discharge, and 3 days late as required by regulation and the agency’s own policy. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 3 sampled patients with surveyor home observation visits (Patients #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 2. Patient #3 had a start of care date of 9/23/20. Home visit observation, clinical record review, and accompanying patient interviews revealed the following: a. The Plan of Care, dated 1/6/24 through 3/5/24, included physician orders for skilled nursing services and medications: Spiriva Inhaler and Carboxymethylcellulose eye drops. b. The Medication Profile, dated 1/12/24, included medications: Spiriva Inhaler and Carboxymethylcellulose eye drops. c. During a home observation visit on 2/6/24, at 1:30PM, with Staff D, Licensed Practical Nurse (LPN), surveyor identified patient had medications on the medication profile that the patient no longer self-administered including a Spiriva Inhaler, and Carboxymethylcellulose eye drops. During an interview with Patient #3 during the home observation visit, Patient #3 reported they had not self-administered the two medications in a long time. Agency failed to identify and obtain orders to discontinue mediations patient no longer was self-administering including a Spiriva inhaler and Carboxymethylcellulose eye drops. The above findings were reviewed with the agency Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care – CMS #485 and Physician/Practitioners Orders, dated April 2023, the individualized plan of care must include all medications, supplies and equipment required. 1. Patient #2 had a start of care date of 12/24/2020. Clinical record review, home observation visit and accompanying interviews revealed the following: a. The Plan of Care, dated 12/9/23 to 2/6/23, identified tape, diabetic supplies, syringe, tub/shower bench, needles, walker, kerlix rolls, sharps container, alcohol pads, cpap (continuous positive airway pressure) machine, pill minder; and orders for medications. b. During a home visit observation on 2/6/24 at 12:05 PM, with Staff E, Registered Nurse (RN), Staff E set up medications in the pill minder and used a pill cutter to cut tablets in half prior to placing in the pill minder. Staff E questioned if the patient had checked their weight this morning. Staff E reported to the surveyor the patient received a scale and monitoring system from the VA (Veterans Administration), the patient checks their weight daily and the information is reported electronically to the VA. During the home visit observation on 2/6/24 at 12:05 PM, the patient reported using the scale and monitor daily to check weight. c .During an interview on 2/7/24 at 3:20 PM, the Clinical Manager reported agency practice is to list medication planners (pill minder), pill cutters, and scale and monitor as medical equipment used by the patient on the plan of care. This information may be listed under the DME (Durable Medical Equipment) and supplies section of the plan of care or in the narrative note. d. During the home visit observation on 2/6/24 at 12:05 PM, Staff E, RN, set up medications, including Tylenol 3 times a day and potassium daily. Staff E left a phone message for the VA case manager regarding the patient needing a refill on the lidocaine patches. Staff E reported these medications were long-term medications for patient, they had been on these for multiple years, unsure of exact start date. Staff E checked medication profile in electronic medical record and reported the medications were not on the current medication profile. The Plan of Care failed to identify the pill cutter, scale and monitor as medical equipment used by the patient and the Tylenol, potassium and lidocaine patches, medications used by the patient.

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 agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 4 of 4 sampled patients with new verbal/interim orders. (Patients #1, #2, #4 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. 4. Patient #1 had a start of care of 12/19/23. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/19/23 to 2/16/24, included orders for skilled nursing services, aide services, and medications for the patient. b. Resumption of care orders, dated 1/16/24 included physicians’ orders for change in skilled nursing frequency effective 1/22/24; skilled nurse to assess skin for breakdown every visit; and wound care orders to pack wound with Dakins soaked kerlix gauze, place in abdominal pad over wound and gauze, secure with tape, perform twice daily. The agency failed to ensure the POC was updated to include all patient care orders, including the resumption of care orders. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care – CMS #485 and Physician/Practitioners Orders, dated April 2023, all patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so all agency staff are working from a current plan. During an interview on 2/6/24 at 11:43 AM, the clinical manager reported the agency enters interim physician orders in the computer when taken and the plan of care is updated at every recertification period. 1. Patient #2 had a start of care date of 12/24/2020. Clinical record review revealed the following: a. The Plan of Care, dated 12/9/23 to 2/6/24, included physician orders for skilled nursing services one time a week. b. Interim physician order, dated 1/19/24, for an extra skilled nursing visit. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 2. Patient #2 had a start of care date of 2/17/2020. Clinical record review revealed the following: a. The Plan of Care, dated 11/28/23 to 1/26/24, included diagnosis E10.43 Type 1 diabetes with diabetic autonomic (poly)neuropathy and physician orders for skilled nursing services 1 time every other week, home care aide services 1 time every week. b. Interim physician order, dated 1/4/24, to resume home care services; add new diagnoses E10.10 Type 1 diabetes mellitus with ketoacidosis without coma and J18.9 pneumonia, unspecified organism; and increase skilled nursing services to 1 time a week and home care aide services to 2 times a week. c. Interim physician order, dated 1/15/24, to resume home care services and start levofloxacin 750 mg capsule, 1 capsule daily for 7 days. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 3. Patient #7 had a start of care date of 11/9/2020 and a discharge date of 12/22/23. Clinical record review revealed the following: a. The Plan of Care, dated 8/26/23 to 10/24/23, included physician orders for skilled nursing services and medications. b. Interim physician order, dated 10/23/23, to resume home care services and start new medications Nitrofurantin and Ciprofloxacin. The agency failed to ensure the Plan of Care was updated to include all patient care orders.

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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 2 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #4). Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency's policy, titled Home Health Aide Supervision, dated April 2023, a registered nurse must make an onsite visit to the patient’s home no less frequently than every 14 days. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed: a. Plan of Care, dated 11/28/23 to 1/26/23, included physician orders for skilled nursing and home health aide services. b. A skilled nursing visit note, dated 12/11/23, included documentation of home health aide supervision. c. A skilled nursing visit note, dated 12/26/23, included documentation of home health aide supervision (exceeding aide supervision requirements by 1 day). The nurse failed to complete home health aide supervision every 14 days as required by agency policy. During an interview on 2/8/24 at 10:01 AM, the Administrator reported no other clinical findings to present to the surveyors. The surveyor reviewed the above stated findings with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure the clinical record included the patient's Patient Service Agreement form for 3 of 3 sampled patients admitted in 2022 or later (Patients #3, #5 and #6). Failure of the agency to ensure the clinical record included all required documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. 3. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 12/19/23, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. b. A skilled nursing visit note, dated 12/27/24, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. c. Missed visit notification notes for the dates of 1/3/24, and 1/10/224 were marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. The surveyor reviewed the above findings with the Administrator and Clinical Manager. No additional information provided prior to the end of the survey. Findings include: According to the agency policy, titled Medical Record Content, dated April 2023, the clinical record will contain evidence of consent for care on admission. During an interview on 2/7/24 at 11:58 AM, the Administrator reported the Patient Service Agreement form is completed on paper and scanned into the EMR, there is no paper chart. 1.Patient #6 had a start of care date of 12/22/23 and a discharge date of 1/19/24. Clinical record review revealed the following: a. Plan of Care, dated 12/22/23 to 2/19/24, included physician orders for skilled nursing services. b. Patient Service Agreement form was not identified in the electronic medical record (EMR). During an interview on 2/7/24 at 11:58 AM, the Administrator reported they were unable to locate the completed admission consent forms in the EMR. They contacted the admitting nurse who reported having the document but had been unable to scan into the EMR. On 2/7/24 at 2:34 PM, the Patient Service Agreement form was scanned and uploaded into the EMR. The agency failed to include the Patient Service Agreement in the clinical record as required by agency policy. 2.Patient #5 had a start of care date of 3/2/23. Clinical record review revealed the following: a. Plan of Care, dated 3/2/23 to 4/29/23, included physician orders for skilled nursing services. b. Patient Service Agreement form was not identified in the EMR. During an interview on 2/7/24 at 11:58 AM, the Administrator reported they were unable to locate the completed admission consent forms in the EMR. During an interview on 2/7/24 at 1:52 AM, Administrator reported the admitting nurse thought the patient had a signed copy in the home. On 2/7/24 at 3:34 PM, the Patient Service Agreement form was scanned and uploaded into the EMR. The agency failed to include the Patient Service Agreement in the clinical record as required by agency policy.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure electronic signatures included staff credentials for 3 of 7 sampled patients (Patients #1, #4 and #6). Failure to maintain appropriately authenticated electronic signatures risked patients receiving services from inappropriate staff. 3. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 12/19/23, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. b. A skilled nursing visit note, dated 12/27/24, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. c. Missed visit notification notes for the dates of 1/3/24, and 1/10/224 were marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. The surveyor reviewed the above findings with the Administrator and Clinical Manager. No additional information provided prior to the end of the survey. Findings include: During an interview on 2/7/24 at 3:10 PM, the Administrator reported she was responsible for adding staff credentials to the electronic medical record signature. She would review and see why credentials are not showing for the new staff. 1. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed the following: a. The Plans of Care, dated 9/29/23 to 11/27/23, 11/28/23 to 1/26/24 and 1/27/24 to 3/26/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. b. Interim physician order, dated 1/15/24, for resumption of care orders, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. c. Resumption of Care assessment note, dated 1/15/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. d. Skilled nursing visit notes, dated 12/11/23 and 12/26/23, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. e. Transfer assessments, dated 12/29/23 and 1/8/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. f. Transfer summaries, dated 12/29/23 and 1/824, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. 2. Patient #6 had a start of care date of 12/22/23 and a discharge date of 1/19/24. Clinical record review revealed the following: a. The Plan of Care, dated 12/22/23 to 2/19/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. b. Start of Care comprehensive assessment, dated 12/22/23, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. c. Skilled nursing visit notes, dated 12/29/23, 1/5/24 and 1/10/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. d. Discharge assessment, dated 1/19/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents.

The Iowa Department of Inspections and Appeals completed a complaint investigation for complaint #63014 on 5/16/22 to 5/17/22. The allegation related to 42 CFR 484.50 Patient Rights was substantiated with a standard level unrelated deficiency.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on agency policy review and agency staff interview, the agency failed to ensure that all patient clinical record documentation was maintained in a secure and confidential manner and was uploaded to the electronic medical record for 1 of 3 sampled patients who received home care services from the agency. The agency reported a current census of 173 patients at the time of the survey. Failure to maintain secured and accurate clinical record information increased the risk of a breach in confidentiality related to patient information and potential inappropriate services provided. Findings include: According to the agency policy, titled Consent for Treatment and Services, dated March 2018, the consent/release of information form will be placed in the medical record. According to the agency policy, titled Medical Record Content, dated February 2021, the agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations. Each medical record will contain documentation that patient received advanced directives information and receipt of rights and responsibilities. Patient #1 had a start of care date of 4/16/22. Clinical record review revealed the plan of care, dated 4/16/22 to 6/14/22, included interim physician orders for skilled nursing services one time a week. Clinical record review on 5/16/22 at 3:00PM, revealed no admission consent in the electronic medical record (EMR). During an interview on 5/16/22 at 3:30 PM, the Administrator reviewed the clinical record and confirmed with the surveyor no admission consent was uploaded in the EMR. The Administrator reported the agency does not keep paper charts, everything paper is scanned into the EMR. The Administrator will contact the admitting nurse and inquire about the consent. On 5/17/22 at 8:15 AM, the Administrator provided the surveyor with the original admission consent that had been sent by the admit nurse via text pictures and printed in the office. During an interview on 5/17/22 at 9:00 AM, the Administrator reported the agency expectation was for admit nurse to take pictures of the admit consent and send to the office. Office staff will print off the consent and scan/upload the document to the EMR. The agency expectation is for this process to be completed within the first week of services. Agency staff can hand deliver the signed paper consent to the home care office for office staff to scan to the EMR. On 5/17/22 at 1:20 PM, the Administrator reported the agency staff should bring all paper consents to the office and place them in a folder by the copy machine for office staff to scan to the EMR. The office staff responsible for scanning the documents to the EMR will shred paper documents after being scanned to the EMR. During an interview on 5/17/22 at 1:33 PM with Staff C, Registered Nurse (RN), Staff C reported having difficulty getting paper work into the office regularly. Staff C reported she works outside the city where the home care office is located and does not take the time to drive to the office to deliver paperwork. Staff C reported she should take pictures of admit consent within days of admit and send to the office but she is not very good at this without having someone to remind her. Staff C reported paper consents are kept in a folder in the car, under supplies and other items so the folder was not visible, not in the trunk, and car is always locked. All paper consents are eventually turned into the office and placed in a folder for office staff to scan into the EMR. Clinical record review on 5/17/22 at 2:20 PM, revealed the admit consent was scanned into the EMR on 5/17/22, 31 days after admission to home care services. The above stated findings were reviewed with the Administrator and the agency provided no additional information prior to the end of the survey.

The recertification survey, conducted from 2/1/21 through 2/3/21, identified the following deficiencies related to emergency preparedness.

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 review of agency's emergency preparedness plan/policies, review of the agency's admission packet, clinical record review, and agency staff interview, the home health agency failed maintaining documentation of the plan in the patient's chart, for 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6 #7, #8, #9 and #10). The agency reported a current census of 283 patients at the time of the survey. Failure to ensure the agency completed an individualized emergency plans developed as part of the comprehensive assessment and failure to ensure the patient has knowledge of the identified Plan placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: According to the agency's policy, titled Emergency Operations Plan and Policies, mitigation activities will include developing an individual emergency preparedness plan for each patient as part of the comprehensive assessment. Interview on 2/3/21 at 11:37 AM with the Administrator and Clinical Manager reported the agency staff complete an individual emergency plan with the patient during the admission visit. The Plan is in the admission packet and is titled, Emergency Preparedness Checklist. The Administrator and Clinic Manager did reveal the agency does not keep a copy of the plan with the patient's clinical record, but does keep the original plan in the patient's home. 1. Patient #1 had a start of care date of 12/28/2020. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 2. Patient #5 had a start of care date of 1/19/21. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 3. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 4. Patient #8 had a start of care date of 9/14/2020 and a discharge from agency on 11/30/2020. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 5. Patient #9 had a start of care date of 3/28/19 and a discharge from the agency on 9/17/2020. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 6. Patient #2 had a start of care date of 9/15/2020. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 7. Patient #3 had a start of care date of 10/8/2018. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 8. Patient #6 had a start of care date of 1/2/2021. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 9. Patient #4 had a start of care date of 1/8/2021. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. 10. Patient #10 had a start of care date of 1/13/2021 and was discharged from home health 1/23/21. Clinical record review revealed a lack of a written copy of the emergency plan for the patient. The above findings for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 review of the agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 283 patients. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: During an interview on 2/3/21 at 10:15 AM, the Administrator verified the agency emergency preparedness plan failed to include a written policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of emergency preparedness plan and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles. At the time of the survey the agency reported 29 direct hired employees and 11 contracted. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: The agency failed to provide initial training for 2 of 2 contracted staff (Staff G and Staff I) in 2019 and 2 of 2 contracted staff in 2020 (Staff H and Staff K) during orientation and annual education for 1 of 1 direct hired employees (Staff F) and 2 of 2 contracted staff (Staff Staff E and Staff J) in 2019 or 2020. During interview on 2/3/21 at 10:50 AM, Administrator reported contracted staff have never received training on agency's emergency preparedness plan. Administrator further reported agency staff receive training of the plan during orientation and education is provided on 'emergency assessment' at inservices, but the agency emergency plan and policies have not been reviewed after the initial training at orientation. The agency failed to ensure all staff completed annual training in emergency preparedness. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

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 agency staff interview, agency policy review and review of training documentation, the agency failed to ensure participation in two emergency preparedness exercises (a full-scale exercise that is community based or actual event, and an additional exercise on the opposite year of the full-scale or functional exercise which may be full-scale, mock disaster drill, or tabletop exercise) in 2019 and 2020 with analysis of the exercises as required every two years. The agency reported a current census of 283 patients at the time of the survey. Failure to conduct or participate in emergency preparedness exercises placed agency patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: On 2/3/21, review of training exercises and actual event documentation provided by the agency, revealed agency staff failed to provide evidence of completion of any training exercises or actual event documentation for 2019 or 2020. During interview on 2/3/21 at 11:08 AM, Administrator reported the agency participated in a Bariatric training at the hospital in 2019, but no further training exercises were completed. No documentation of training was provided. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 2/1/21 through 2/3/21 . The agency was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the agency operating out of compliance with multiple standard level regulatory requirements.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 8 of 9 sampled patients (Patients #2, #4, #5, #6, #7, #8, #9 and #10). At the time of the survey, the agency reported a current census of 283 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Agency policy, titled Patient Bill of Rights and Responsibilities, dated January 2020, identified the agency will provide each patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before initiation of treatment. The policy further states the patients have the right to be advised of extent to which payment for services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the agency, be advised of the charges for services that may not be covered by Medicare, Medicaid or any other federally funded or federal aid program known to the agency, and be advised of the charges the individual may have to pay before care is initiated. Interview on 2/1/21 at 2:24 PM with the Administrator revealed the agency does not have hard charts and all documents are scanned into the Electronic Health Record (EHR). 1. Patient #5 had a start of care date of 1/19/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 1/19/21, included documentation the agency planned to bill Medicaid for agency services. b. The Admission Services Agreement form included a handwritten signature by the patient and agency staff, dated 1/19/21. The form failed to identify what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services. 2. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed the initial comprehensive assessment completed at start of care, dated 11/16/2020, included documentation the agency planned to bill Medicare for agency services. On 2/3/21, the surveyor informed the Clinical Manager the EHR was lacking the Admission Services Agreement form which is completed on admission and signed by the patient and staff. The agency form failed to identify what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services. Agency staff did not provide the surveyor with the requested patient signed form prior to the end of the survey. 3. Patient #8 had a start of care date of 9/14/2020 and a discharge from agency on 11/30/2020. Clinical record review revealed the initial comprehensive assessment completed at start of care, dated 9/14/2020, included documentation the agency planned to bill Medicare for agency services. On 2/3/21, the surveyor informed the Clinical Manager the EHR was lacking the Admission Services Agreement form which is completed on admission and signed by the patient and staff. The agency form failed to identify what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services. Agency staff failed to provide the surveyor with the requested patient signed form prior to the end of the survey. 4. Patient #9 had a start of care date of 3/28/19 and a discharge date of 9/17/2020. Clinical record review revealed the initial comprehensive assessment completed at start of care, dated 3/28/19, included documentation the agency planned to bill Medicaid for agency services. On 2/3/21, the surveyor informed the Clinical Manager the EHR was lacking the Admission Services Agreement form which is completed on admission and signed by the patient and staff. The agency form failed to identify what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services. Agency staff did not provide the surveyor with the requested patient signed form prior to the end of the survey. 5. Patient #2 had a start of care date of 9/15/2020. Clinical record review revealed the following: a. The patient's clinical record included lacked any documentation of an admission agreement. b. On 2/3/2021 at 3:00 PM, the Clinical Manager presented the surveyor with a copy of a Patient Service Agreement, dated 9/15/2020 and signed by the patient and the patient's primary registered nurse. The agreement documented the agency planned to bill VA Optum for the patient's services; however, the section available to document how much the patient could expect to pay out of pocket was left blank. 6. Patient #4 had a start of care date of 1/8/2021. Clinical record review revealed the following: a. The Admission Services Agreement, dated 1/8/21 and signed by the patient and the patient's primary registered nurse, documented the agency planned to bill Medicare for the patient's home health services. The form stated "I understand and agree to pay deductibles, co-payments and any amounts due after payments of benefits on my behalf by any and all third party payers."; however, the document failed to include identification of what out of pocket expense may be present after Medicare paid for the patient's services. 7. Patient #6 had a start of care date of 1/2/2021. Clinical record review revealed the following: a. The patient's clinical record included lacked any documentation of an admission agreement. b. The start of care comprehensive assessment, dated 1/4/2021, documented the agency planned to bill Medicare for the patient's home health services. c. The surveyor requested a copy of the patient's admission agreement; however, the agency failed to provide documentation of verbal and written notification of the third party payer the agency planned to bill for the patient's services or any expected out of pocket expenses the patient would be responsible for after payments were made on the patient's behalf. 8. Patient #10 had a start of care date of 1/13/2021 and was discharged from agency services on 1/23/2021. Clinical record review revealed the following: a. The Admission Services Agreement, dated 1/13/21 and signed by the patient and the patient's primary registered nurse, documented the agency planned to bill VA Optum for the patient's home health services. The form stated "I understand and agree to pay deductibles, co-payments and any amounts due after payments of benefits on my behalf by any and all third party payers."; however, the document failed to include identification of what out of pocket expense may be present after VA Optum paid for the patient's services. The agency did not advise Patients #2, #4, #5, #6, #7, #8, #9 and #10 of which federally funded program would pay for services during the episode of care and/or how much the patient could expect to pay out of pocket. The above stated findings for Patients #2, #4, #5, #6, #7, #8, #9 and #10 were reviewed with the agency's Administrator and Clinical Manager. The agency presented no additional information prior to the end of the survey.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered for 1 of 1 patients with private insurance (Patient #1). At the time of the survey, the agency reported a current census of 283 patients. Failure to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered, placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Agency policy, titled Patient Bill of Rights and Responsibilities, dated January 2020, identified the agency will provide each patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before initiation of treatment. The policy further states the patients have the right to be advised of extent to which payment for services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the agency, be advised of the charges for services that may not be covered by Medicare, Medicaid or any other federally funded or federal aid program known to the agency, and be advised of the charges the individual may have to pay before care is initiated. Interview on 2/1/21 at 2:24 PM with the Administrator revealed the agency does not have hard charts and all documents are scanned into the Electronic Health Record (EHR). Patient #1 had a start of care date of 12/28/2020. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 12/28/2020, included documentation the agency planned to bill private HMO (Health Maintenance Organization)/managed care for agency services. b. The Admission Services agreement form included a handwritten signature by the patient and agency staff, dated 12/28/2020. The form failed to identify what services the agency planned to provide and bill the responsible party and how much the agency planned to bill the responsible party for services. The agency did not advise the patient how much the patient could expect to pay out of pocket beginning on 12/28/2020. The above findings for Patient #1 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 4 of 6 sampled patients requiring a recertification assessment (Patients #3, #7, #9 and #11). The agency reported a census of 283 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment and dated 1/2020, an update to the comprehensive assessment for recertification will be completed within the last five days (days 56-60 of the current period) of every 60 day episode, beginning with the start of care. According to the agency policy, titled OASIS Assessment Reference Sheet and dated 10/2017, the update to the comprehensive assessment at the time of recertification must be completed in the last 5 days of every 60 day period (days 56-60 of the current 60 day period). 1. Patient #3 had a start of care date of 10/8/18. Clinical record revealed the following: a. The Plans of Care, dated 9/27/2020 to 11/25/2020 and 11/26/2020 to 1/24/2021, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 11/23/2020 (day 58 of the certification period) but was not completed until 11/28/2020, 3 days into the new certification period. The certification period ended on 11/25/2020. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. 2. Patient #11 had a start of care date of 1/16/2019. Clinical record revealed the following: a. The Plan of Care, dated 9/7/2020 to 11/5/2020, included physician orders for skilled nursing and home health aide services. The Plans of Care, dated 11/6/2020 to 1/4/2021 and 1/5/2021 to 3/5/2021, included physician orders for home health aide services without the provision of skilled services. b. The update to the comprehensive assessment at the time of recertification, dated as initiated on 11/3/2020 (day 58 of the certification period) but was not completed until 11/6/2020, 1 day into the new certification period. The certification period ended on 11/5/2020. The assessment was not completed by day 60 as required by regulation and agency policy. c. The update to the comprehensive assessment at the time of recertification, dated as initiated on 1/5/2021 (day 1 of the next certification period) and completed on 1/13/2021 (day 9 of the next certification period). The certification period ended on 1/4/2021. The assessment was not completed by day 60 as required by regulation and agency policy. The agency failed to update the comprehensive assessments in the last 5 days of each 60 day episode. 3. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed an update to the comprehensive assessment for recertification, dated as initiated on 1/13/21 (day 55 of the certification period) was not electronically signed as completed until 1/29/21, day 15 into the new certification period. The certification period ended on 1/14/21. The assessment was not completed by day 60 as required by regulation and agency policy, which was 15 days late. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. 4. Patient #9 had a start of care date of 3/28/19 and a discharge date of 9/17/2020. Clinical record review revealed: a. An update to the comprehensive assessment for recertification, dated as initiated on 5/20/2020 (day 60 of the certification period) was not electronically signed as completed until 5/21/2020, day 1 into the new certification period. The certification period ended on 5/20/2020. The assessment was not completed by day 60 as required by regulation and agency policy, which was 1 day late. b. An update to the comprehensive assessment for recertification, dated as initiated on 7/16/2020 (day 55 of the certification period) was not electronically signed as completed until 7/22/2020, day 3 into the new certification period. The certification period ended 7/19/2020. The assessment was not completed by day 60 as required by regulation and agency policy, which was 3 days late. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The above findings for Patients #3, #7, #9, and #11 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #13). The agency provided services to 283 patients at the time of the survey and performed 23 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment and dated 1/2020, an update to the comprehensive assessment for resumption of care following a hospital inpatient admission will be completed within 48 hours of the patient's return home from the facility or on the physician ordered resumption of care date. According to the agency policy, titled OASIS Assessment Reference Sheet and dated 10/2017, an update to the comprehensive assessment for resumption of care following a hospital inpatient admission will be completed within 48 hours of the patient's return home from the facility or on the physician ordered resumption of care date. Patient #13 had a start of care date of 6/23/2020. Clinical record review revealed the following: a. The transfer assessment, dated 10/16/2020, documented the patient was hospitalized for shortness of breath and acute mental/behavioral issues. b. The update to the comprehensive assessment at the time of resumption of care, dated 10/20/2020, documented the patient was discharged from the hospital on 10/19/2020. The nurse initiated the update to the assessment on 10/20/2020 but did not complete the assessment until 11/8/2020, 19 days after the patient's return home from the inpatient stay. The assessment was completed 17 days late as required by regulation and the agency's own policy. The above stated findings for Patient #3 were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy and clinical record review, the agency failed to ensure completion of all required components of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 1 of 2 sampled patients requiring a discharge comprehensive assessment (Patient #8). The agency reported a census of 283 patients at the time of the survey and discharged 209 patients in the previous 6 months. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: Agency policy titled, Reassessments/Update of the Comprehensive Assessment, dated 1/2020, the comprehensive assessment must be updated and revised if discharged from agency within 2 calendar days of the discharge/transfer/death date. Agency policy titled, Initial Assessments/Comprehensive Assessment, dated 1/2020, identified a Drug Regimen Review should be completed with each patient's comprehensive assessment and includes a review of all medications the patient is currently taking as well as times of medication administration and routes. The agency nurse must consider and document each medication the patient is taking to identify significant side effects, significant drug interactions, noncompliance with medications, duplicate therapy, potential adverse effects, medication reactions, significant medication issues, and management of oral and injectable medications. In rehabilitation therapy only cases, the patient's therapist must submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an agency nurse for review. The nurse should contact the physician if indicated. Interview with the Clinical Manager on 2/1/21 at 3:17 PM stated, the therapist notes what medications the patient is taking and takes it to the Registered Nurse (RN) for input into the computer in the physical therapy only cases. Patient #8 had a start of care date of 9/14/2020 and a discharge date of 11/30/2020. The Plan of Care, dated 9/14/2020 to 11/12/2020, included orders for skilled nursing for one time a month for one month starting 10/1/2020 to discharge the patient and orders for physical therapy to evaluate and treat between 9/14/2020 to 9/18/2020. The agency billed Veteran's Affairs for the patient's home care services; thereby, not requiring the collection of OASIS data as part of the comprehensive assessments. Clinical record review revealed a physical therapy evaluation and discharge summary, dated 11/30/2020, documented discharge of the patient from physical therapy visits, but failed to include documentation of physician notification of the discharge. The physical therapy discharge visit failed to include a drug regimen review, therefore making the discharge assessment incomplete. The above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 4 of 10 sampled patients (Patients #3, #6, #7 and #8). The agency reported a census of 283 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Physician Orders- Verbal Orders and dated 3/2018, drugs and treatments are administered by the agency staff only as ordered by the physician. The physician order will be obtained prior to the provision of care, including changes in the plan of care. According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, home health services will be in accordance with the Plan of Care based on the diagnosis and assessment of needs and resources. Drugs, services, treatments and all clinical services are administered by staff only as ordered by the physician. Clinicians must promptly alert the physician to any changes in the patient's condition or the need to alter the Plan of Care. During agency staff interview on 2/1/2021 at 11:13 AM, the Clinical Manager reported if visit frequency differs from the Plan of Care, a missed visit note is completed by the clinician, documenting why the visit was missed and then sent to the physician by facsimile. If an extra visit occurs, the physician is contacted to obtain an order for an as needed visit. 1. Patient #3 had a start of care date of 10/8/2018. Clinical record review revealed the following: The Plan of Care, dated 11/26/2020 to 1/24/2021, included physician orders for home health aide visits once weekly for one week; three times weekly for three weeks; twice weekly for two weeks; then three times weekly for three weeks. The clinical record included documentation of only one home health aide visit during the weeks of 12/20/2020 to 12/26/2020 and 12/27/2020 to 1/2/2021, the fifth and sixth week of service. The physician ordered 2 home health aide visits to occur during both weeks. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. 2. Patient #6 had a start of care date of 1/2/2021. Clinical record review revealed the following: The Plan of Care, dated 1/2/2021 to 3/2/2021, included physician orders for home health aide visits three times weekly for three weeks; then twice weekly for four weeks beginning during the week of 1/5/2021. The clinical record included documentation of only one home health aide visit during the weeks of 1/3/2021 to 1/9/2021, the first week of service. The physician ordered 3 home health aide visits to occur during the first week. The clinical record lacked documentation of why the visits were not made and lacked any communication with the physician to discuss that inability to follow the Plan of Care. The clinical record lacked any missed visit notification to the physician sent by facsimile. The clinical record lacked any interim physician orders for a change in home health aide visit frequency. 3. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed: a. The Plan of Care, dated 11/16/2020 to 1/14/2020 and 1/15/2020 to 3/15/2020, included physician orders for skilled nursing visits 3 times per week for 8 weeks to assess the patient's hypertension, venous insufficiency, diabetes mellitus, chronic pain, and chronic skin ulcers and report the following: pulse greater than 100 or less than 60, fasting or random blood sugars greater than 250 or less than 60 and systolic blood pressures greater than 150 or less than 90 and diastolic blood pressures greater than 90 or less than 50. b. The skilled nurse visit note, dated 12/2/2020, included documentation of an apical pulse of 58. The clinical record failed to include documentation of physician notification of the pulse. c. The skilled nurse visit note, dated 12/4/2020, included documentation of an apical pulse of 57. The clinical record failed to include documentation of physician notification of the pulse. d. The skilled nurse visit note, dated 1/4/21, included documentation of an blood pressure of 155/82. The clinical record failed to include documentation of physician notification of the systolic blood pressure. The clinical record lacked any documentation of physician notification for the variance in the tasks ordered on the Plan of Care. 4. Patient #8 had a start of care date of 9/14/2020 and a discharge date of 11/30/2020. Clinical record review revealed: a. The Plan of Care, dated 9/14/2020 to 11/12/2020, included physician orders for physical therapy to evaluate and treat. b. The skilled nurse visit note, dated 12/2/2020, included documentation of an apical pulse of 58. The clinical record failed to include documentation of physician notification of the pulse. c. The physical therapy evaluation, dated 9/18/2020, included a signed physician's order for physical therapy visits twice per week for 4 weeks and then 1 time per week for one week for the period of 9/14/2020 to 11/12/2020. d. The physical therapy reevaluation, dated 11/9/2020, included a signed physician's order for physical therapy visits twice per week for 3 weeks. e. A physical therapy visit noted, dated 10/19/2020. The clinical record review failed to include documentation of a second physical therapy visit for the week of 10/18/2020 as ordered by the physician. f. No documentation of any physical therapy visits for the week of 10/25/2020 or 11/1/2020 as ordered by the physician. The clinical record lacked documentation of communication with the physician to discuss that inability to follow the Plan of Care. The above findings were reviewed for Patients #3, #6, #7, and #8 with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication orders for 7 of 10 sampled patients (Patients #1, #2, #3, #5, #6, #7, and #9). The agency reported a current census of 283 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Plan of Care-CMS #485 and Physician Orders, dated 3/2019, the individualized plan of care must include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, the types of services, supplies and equipment required, the frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, all medications and treatments, safety measures to protect against injury, a description of the patient's risk for emergency hospitalization and hospital readmission, discharge planning, patient-specific interventions and education and measurable outcomes and goals, information related to advance directives, and all patient care orders, including verbal orders. 1. Patient #1 had a start of care date of 12/28/2020. Clinical record review revealed: a. The Plan of Care, dated 12/28/2020 to 2/25/21, included physician orders for skilled nursing visits 1 times per week for five weeks, for PICC (Peripherally Inserted Central Catheter) line management and lab and included orders for Daptomycin to be given IV push via the PICC line every 24 hours. b. The Plan of Case failed to identify supplies needed for IV therapy to be received by the patient, including PICC dressing change supplies. c. The Plan of Care dated 12/28/2020 to 2/25/21, failed to identify the patient's mental status, prognosis, safety measures, nutritional requirements, functional limitations and activities permitted and left all these field blank. The agency failed to include all the required elements of the individualized plan of care per regulation. 2. Patient #5 had a start of care date of 1/19/21. Clinical record review revealed: a. The Plan of Care, dated 1/19/21/ to 3/19/21, identified the following equipment and supplies used to meet the patient's needs: cane, walker, nebulizer, dressing supplies, sharps container, alcohol pads, PICC line, and incentive spirometer. b. On 2/2/21 at 8:20 AM, the surveyor accompanied Staff O, Registered Nurse (RN) to Patient #5's home. During the home visit the surveyor reviewed supplies and equipment used by the patient. The patient reported use of a shower chair located in the patient's bathroom for safety while showering. The patient verified use of the ramp for "a long time and at least over one year". c. During the same home visit, the surveyor noted the bathroom used by the patient for bathing had a hand held showerhead. The patient reported use of the hand held showerhead for "a couple of years". The Plans of Care, dated 1/19/21/ to 3/19/21, lacked identification of the shower chair and hand held showerhead as equipment used to meet the safety and bathing needs of the patient. d. The Plans of Care, dated 1/19/21 to 3/19/21, included an order for Ginko biloba one capsule two times per day and Caltrate 600 mg daily. e. During the same home visit, the surveyor reviewed the medications used by the patient in the home. The patient's medications were stored in the kitchen. The surveyor observed a bottle of Ginko biloba 120 mg and a bottle of Citracal 630/12.5 mg. The patient verified both medications were taken by the patient. The Plans of Care, dated 1/19/21 to 3/19/21, failed to include the dosage of Ginko biloba used by the patient and identified the incorrect type of Calcium used by the patient. 3. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed: a. The Plan of Care, dated 11/16/2020 to 1/14/2021, identified the following equipment and supplies used to meet the patient's needs: cane, probe covers, ace wrap, diabetic supplies, exam gloves, tub/shower bench, walker, alcohol pads, hospital bed, and CPAP (Continuous Positive Airway Pressure) machine. b. A skilled nursing visit note, dated 12/2/2020, 12/4/2020, 12/28/2020, 1/4/21, and 1/8/21, included documentation of Oxygen use at 4 liters per minute via nasal cannula at bedtime. c. A skilled nursing visit note, dated 12/2/2020, 12/4/2020, 12/28/2020, 1/4/21, and 1/8/21, included documentation of a wheelchair used as an assistive device by the patient. The Plan of Care, dated 11/16/2020 to 1/14/2021, lacked identification of the oxygen and wheelchair as equipment used to meet the needs of the patient. 4. Patient #9 had a start of care date of 3/28/19 and a discharge from agency date of 9/17/2020. Clinical record review revealed: a. The Plan of Care, dated 7/20/2020 to 9/17/2020, identified the following equipment and supplies used to meet the patient's needs: cane, tub/shower bench, and walker. b. Skilled nursing visit notes, dated 7/31/2020, 8/13/2020, 8/27/2020 and 9/10/2020, included documentation of the patient's use of a nebulizer for respiratory issues. The Plan of Care, dated 7/20/2020 to 9/17/2020, lacked identification of a nebulizer as equipment used to meet the needs of the patient. 5. Patient #2 had a start of care date of 9/15/2020. Clinical record review, home visit observation and accompanying interviews revealed the following: a. On 2/2/2021 at 11:00 AM, the surveyor accompanied Staff C, Registered Nurse (RN) to Patient #2's home. During the home visit the surveyor noted the patient had a rolling walker, cane, glucometer and nebulizer in the home. Patient interview while in the home revealed he/she used all of the above stated equipment on a regular basis. The rolling walker was reportedly used whenever the patient went outside of the apartment and the cane as needed when in the apartment. b. The skilled nurse visit notes, dated 12/1, 12/8, 12/15, 12/22, 12/29/2020, 1/5/21 and 1/12/2021, documented the patient's use of a glucometer, nebulizer, cane as needed and icepacks for non-pharmaceutical pain relief. The Plan of Care, dated 11/14/2020 to 1/12/2021, lacked identification of the glucometer, nebulizer, rolling walker or cane as equipment used by the patient to meet his/her needs. c. The skilled nurse visit notes, dated 1/19 and 1/28/2021, documented the patient's use of a glucometer, nebulizer, rolling walker or cane as needed and icepacks for non-pharmaceutical pain relief. The Plan of Care, dated 1/13/2021 to 3/13/2021, lacked identification of the glucometer, nebulizer or cane as equipment used by the patient to meet his/her needs. d. During the same home visit, the surveyor observed Staff C, RN, filling a weekly medication planner with the patient's medications. The surveyor noted the bottle being used to fill the planner with Cholcalciferol included the directions "take 25 micrograms take three tablets by mouth daily. The prescription label on the bottle indicated the pharmacy had filled the Cholecalciferol in October 2020. The Plans of Care, dated 11/14/2020 to 1/12/2021 and 1/13/2021 to 3/13/2021, documented the patient took Cholecalciferol 25 micrograms one tablet by mouth daily. 6. Patient #3 had a start of care date of 10/8/2018. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The agency's medication list documented Patient #3 took Docusate Sodium 100 milligrams every morning, Levothyroxine 88 micrograms daily and Potassium Chloride 20 mEq once daily, all dated as initiated on 10/11/2020. b. The Plans of Care, dated Plans of Care, dated 11/26/2020 to 1/24/2021 and 1/25/2021 to 3/25/2021, included physician orders for Docusate Sodium 100 milligrams every morning, Levothyroxine 88 micrograms daily and Potassium Chloride 20 mEq once daily. c. On 2/2/2021 at 8:00 AM, the surveyor accompanied Staff D, RN, to Patient #3's home. During the home visit the surveyor noted the patient's medication list included Levothyroxine 75 micrograms daily and did not include Potassium Chloride or Docusate sodium. Agency staff interview during the visit revealed Staff D, RN, reported the patient's mother came to the group home where the patient resided and set up the medications into a medication planner for the patient. The medications were given by the HCBS (home and community based services) staff who cared for the patient in the home. The HCBS staff followed the medication list in the patient's home. 7. Patient #6 had a start of care date of 1/2/2021. Clinical record review, home visit observation and accompanying interviews revealed the following: a. On 2/3/2021 at 1:30 PM, the surveyor accompanied Staff E, Physical Therapist (PT) to Patient #6's home. During the home visit the surveyor noted the patient had a reacher (claw like stick used to pick items up from the floor or out of arms reach); a CPAP (continuous positive airway pressure) machine used when sleeping to assist with sleep apnea; a toilet riser with rails and a gait belt used to assist with ambulation for safety reasons. The home health aide assignment, dated 1/4/2021, directed the home health aide to use the gait belt when ambulating the patient. The Plan of Care, dated 1/2/2021 to 3/2/2021, lacked inclusion of the reacher, the CPAP, the toilet riser with rails and the gait belt as equipment used to meet the patient's needs. b. During the same home visit, the surveyor noted a medication list, completed by the agency nurse and left in the patient's home. The list included 12 medications taken by the patient. The Plan of Care, dated 1/2/2021 to 3/2/2021, lacked inclusion of any medications. The above findings for Patients #1, #2, #3, #5, #6, #7 and #9 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 5 of 5 sampled patients with new verbal/interim orders. (Patients #1, #2, #5, #7, and #8) The agency reported a current census of 283 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Plan of Care-CMS #485 and Physician Orders, dated 3/2019, all patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all agency staff are working from a current plan. It is not necessary for the physician to sign an updated plan of care until the patient is recertified to continue care and the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60 day period. Interview on 2/3/21, beginning at 11:40 AM, with the Administrator reported the agency does have a Plan of Care update the clinician can run that includes all changes to the Plan of Care. The surveyors reviewed with the Administrator in the past this EHR software has not had a Plan of Care Update and simply attached all orders to the end of the generated update. No further information was provided by agency staff prior to the end of the survey. 1. Patient #1 had a start of care date of 12/28/2020. Clinical record review revealed an interim physician order, dated 1/5/21, discontinued use of Daptomycin 550 milligram (mg) and ordered Cefazolin in Sodium Chloride intravenous solution 2-0.9 grams (g) per 20 milliliters (ml) with a frequency of 2 g, 20 ml intravenous push over 3-5 minutes three times per day. The Plan of Care, dated 12/28/2020 to 2/25/21, failed to include an update with the changes of the added/changed medication orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 2. Patient #5 had a start of care date of 1/19/21. Clinical record review revealed: a A verbal physician order, dated 1/19/21, ordered skilled nursing to assess and evaluate the patient for services. b. The Plan of Care dated 1/19/21 to 3/19/21, failed to include any orders for treatment and frequency of services ordered. c. The initial comprehensive assessment at start of care, dated 1/19/21, documented skilled nursing visits effective 1/26/21 weekly for 8 weeks for assessment and education of PICC (Peripherally Inserted Central Catheter) line dressing change and labs as ordered. Interview with the clinical manager revealed, orders were present from hospital discharge instructions on 1/12/21 for weekly Complete Blood Count with differential, Blood Urea Nitrogen, Creatinine, Liver Function Tests, and C Reactive Protein test to be faxed weekly to the physician and the discharge orders were provided to the surveyor. d. Discharge Instructions, dated 1/12/21, included orders for weekly Complete Blood Count with differential, Blood Urea Nitrogen, Creatinine, Liver Function Tests, and C Reactive Protein test to be faxed weekly to the physician. e. A physician's order, dated 1/22/21, included an order for the weekly Complete Blood Count with differential, Blood Urea Nitrogen, Creatinine, Liver Function Tests, and C Reactive Protein test to be faxed weekly to the physician. The Plan of Care, dated 1/19/21 to 3/19/21, failed to include an update with the changes of the added/changed orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 3. Patient #7 had a start of care date of 11/16/2020. Clinical record review revealed: a. A physician's order, dated 12/3/2020, reporting the patient requests home health aide services be placed on hold. b. A physician's order, dated 12/14/2020, discontinued Warfarin 10 mg on Monday, Wednesday, and Friday and 7.5 mg on Sunday, Tuesday, Thursday and Saturday reporting the patient took self off of the medication and the doctor was aware. c. A physician's order, dated 1/22/21, resumed home health aide services starting 1/25/21 three times per week for 7 weeks and 1 time per week for 1 week for safety and assistance with activities of daily living, patient fall risk, risk for skin breakdown, and skin care prior to skilled nursing wound care. d. A faxed order from dermatology ordering the patient to take a bath with nursing staff assistance at least every Monday, Wednesday, and Friday. If able to get into bath/shower, use chlorhexidine soap and thoroughly rinse when complete. If unable to get in bath or shower, recommend using a 5 gallon bucket filled with warm water and Dawn dish soap and do a bedside sponge bath. After bedside bath, wipe all rash areas with chlorhexidine wipes. After bath, soak gauze in 0.25% sodium hydrochloride wash (Dakin's solution) and apply to all rash areas of ulceration containing purulent debris. Let gauze sit on skin for 10-15 minutes prior to removal. After gauze soaks, apply a mixture of clotrimazole 1 % cream and pimecroliumus 1% cream to all rash areas. Next apply polysporin ointment to all open ulcerations, try to avoid application to areas of intact skin. After applying topical medications, apply Interdry fabrics, cut to length in all skin folds. The Plans of Care, dated 11/16/2020 to 1/14/21 and 1/15/21 to 3/15/21, failed to include an update with the new/changed orders. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 4. Patient #8 had a start of care date of 9/14/2020 and a discharge date from the agency on 11/30/2020. Clinical record review revealed: a. The initial Plan of Care, dated 9/14/2020 to 11/12/2020, included orders for physical therapy to evaluate and treat from 9/14/2020 to 9/18/2020. b. The initial physical therapy evaluation, dated 9/18/2020, included signed physician's orders for physical therapy visits twice per week for four weeks and once per week for one week for the time period of 9/14/2020 to 11/12/2020. c. The physical therapy re-evaluation, dated 10/09/2020, included signed physician's orders for physical therapy visits twice per week for four weeks and once per week for one week for the time period of 9/14/2020 to 11/12/2020. d. The physical therapy re-evaluation, dated 11/9/2020, included signed physician's orders for physical therapy visits twice per week for three weeks starting 11/16/2020. The Plan of Care, dated 9/14/2020 to 11/12/2020 and 11/13/2020 to 1/12/22, failed to include an update with the changes of the ordered physical therapy visits. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 5. Patient #2 had a start of care date of 9/15/2020. Clinical record review revealed the following: a. The Plan of Care, dated 9/15/2020 to 11/13/2020, included physician orders for physician orders for Ascorbic Acid and Iron Sulfate. The physician's interim order, dated 10/16/2020, discontinued the Ascorbic Acid and Iron Sulfate. The Plan was not updated with the new interim order. b. The Plan of Care, dated 11/14/2020 to 1/12/2021, included a physician's order for Alogliptine Benzoate 12.5 milligrams once daily. The physician's interim order, dated 12/22/2020, increased the dosage of Alogliptine from 12.5 milligrams daily to 25 milligrams daily. The Plan was not updated with the new interim order. The above stated findings for Patients #1, #2, #5, #7 and #8 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 2 of 10 sampled patients (Patients #6 and #9). The agency reported a current patient census of 283 patients. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, home health services will be in accordance with the Plan of Care based on the diagnosis and assessment of needs and resources. The individualized Plan of Care must specify the care and services necessary to meet the needs of the patient, including identification of the responsible discipline(s) responsible for the task. The physician must approve the Plan of Care. Drugs, services, treatments and all clinical services are administered by staff only as ordered by the physician. According to the agency policy, titled Medication Orders and dated 3/2018, orders for medication related devices must include the device and any specific rates and settings. According to the agency policy, titled Medication Administration and dated 3/2018, medications and treatments are administered by agency staff only as ordered by the physician. 1. Patient #6 had a start of care date of 1/2/2021. Clinical record review revealed: a. The Plan of Care, dated 1/2/2021 to 3/2/2021, included orders for physical therapy, occupational therapy and home health aide services. The Plan lacked orders for skilled nursing services. b. The clinical record lacked any physician interim orders initiating skilled nursing services. c. The clinical record included documentation of skilled nursing visits occurring on 1/6, 1/8, 1/11, 1/15, 1/21 and 1/26/2021. The visit notes documented patient assessment and medication set up in a weekly planner. 2. Patient #9 had a start of care date of 3/28/19 and was discharged from the agency on 9/17/2020. Clinical record review revealed the skilled nursing visit notes, dated 7/31/2020, 8/13/2020, 8/27/2020, and 9/10/2020, documented in the narrative portion the patient using the nebulizer as needed. The Plan of Care, dated 7/20/2020 to 9/17/2020, included a diagnosis of chronic obstructive pulmonary disease. The Plans lacked any orders for use of a nebulizer or medication to be administered via a nebulizer. The above findings for Patients#6, and #9 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on agency policy review, personnel file review and agency staff interview, the agency failed to ensure 2 of 4 sampled home health aides (Staff L and M), demonstrated completion of all of the required basic skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently. The agency reported a current census of 283, including 28 who received home health aide services at the time of the survey. The agency employed 14 home health aides at the time of the survey. Findings include: According to the agency policy, titled Home Health Aide Services and Training Program and dated 1/2020, all home health aides employed or contracted by the agency will satisfactorily complete a training program and competency evaluation program prior to performing patient care. The policy defined a qualified home health aide as a person who had successfully completed a training and competency evaluation program; completed a competency evaluation program that meets regulatory requirements; or is registered as a nurse aide after having successfully competed a training and competency program. The policy directed aide training requirements of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse. The policy further defined the competency evaluation program to address reading and recording temperature,pulse and respirations; appropriate and safe techniques in performing bed bath, sponge, tub and shower bath; hair shampooing in the sink, tub and bed; nail care; skin care; oral hygiene; toileting; transfer techniques; positioning; ambulation; and range of motion. The policy documented an individual may furnish home health services only after successfully completing a competency evaluation program evaluated by a registered nurse. Review of personnel file documents revealed the following: 1. Staff L, Home Health Aide, had a hire date of 3/9/2020. The personnel file included: a. The Initial Competency Assessment Skills Checklist, dated as completed 3/18/2020, documented Staff N, Registered Nurse (RN) evaluated the competency of Staff L, Home Health Aide. The Checklist documented temperature, pulse, respiration blood pressure, transfers and ambulation were evaluated using the method "Actual" and bed bath, tub bath, shower, nail care, skin care, oral hygiene, shampoo, positioning and toileting were evaluated using the method "Demo". The Checklist did not document any evaluation of range of motion. b. The personnel file also included a Home Health Aide Skills Assessment, dated 12/19/2020. The Assessment documented the tasks of temperature, pulse, respiration blood pressure, transfers; ambulation; bed bath, tub bath, shower, nail care, skin care, oral hygiene, shampoo and toileting were "met" but the document lacked identification of whether the competency was determined by observation in a lab setting using a pseudo patient, on an actual patient or just verbalized/simulated. 2. Staff M, Home Health Aide, had a hire date of 12/1/2020. The personnel file included: The Initial Competency Assessment Skills Checklist, dated as completed 12/7/2020, documented Staff N, Registered Nurse (RN) evaluated the competency of Staff M, Home Health Aide. The Checklist documented temperature, pulse, respiration blood pressure, transfers, toileting and ambulation were evaluated using the method "Actual" and bed bath, tub bath, shower, nail care, skin care, oral hygiene, positioning and shampoo were evaluated using the method "Demo". The Checklist did not document any evaluation of range of motion. b. The personnel file lacked any Home Health Aide Skills Assessment after the initial testing. 3. During agency staff interview on 2/3/2021 at 2:10 PM, Staff N, RN, reported she performs competency evaluation for new agency home health aides. The RN reported she documents "Demo" as the evaluation method when she verbally reviews tasks with the aide but the aide does not actually perform a demonstration of the task. The RN reported she documents "Actual" when she observed the actual performance of the task performed by the home health aide. "During Covid I had the aides verbally tell me how they would do the tasks and then our education was built on that. No actual performance by the aide was done if it states 'demo'." 4. During agency staff interview on 2/3/2021 at 2:30 PM, the Administrator reported prior to Covid the home health agency had a contract with the nursing home owned by the same entity. Staff N, RN, took patients over to the nursing home to have the aides perform the competencies. During Covid all competencies were being done in the lab setting in the home health office. On 12/19/2020 all home health aides attended a 5 hour refresher in the home health office. No patients were present and "to my knowledge each task was reviewed so everyone was on the same page and not performed by the aides." The Administrator verified Staff L and Staff M were both home health aides and were not registered certified nurse aides. Staff L and M, Home Health Aides, did not successfully demonstrate all of the tasks required by regulation and agency policy before a registered nurse and deemed competent in all of the tasks before being allowed to provide care to agency patient's independently. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 5 sampled patients receiving home health aide services (Patients #6 and #7). The agency reported a census of 283 patients, including 28 who received care provided by a home health aide. Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: According to agency policy, titled Home Health Aide Services and Training Program, dated 1/2020, the home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional. A home health aide provides services that are ordered by the physician, included in the plan of care, permitted to be performed under state law, and consistent with the home health aide training. 1. Patient #7 had a start of date of 11/16/20. Clinical record review revealed: a. The Plan of Care, dated 1/15/21 to 3/15/21 included orders for skilled nursing services 3 times a week and home health aide 2 times a week. b. The home health aide assignment, dated 1/15/2021 for the period of 1/15/2021 through 3/15/2021, directed the following: "Foot Care-"- The assignment did not describe what "foot care" meant. "Nail Care"- The assignment did not describe what "nail care" meant. "Skin Care"- The assignment did not describe what "skin care" meant. The home health aide assignment did not give clear, specific directions for the aides to follow when assigning foot care, nail care and skin care.2. Patient #6 had a start of care date of 1/2/2021. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 1/2/2021 to 3/2/2021, included orders for physical therapy, occupational therapy and home health aide services. The Plan lacked physician orders for skilled nursing visits; however, skilled nursing visits were made. b. The home health aide assignment, dated 1/4/2021 for the period of 1/2/2021 through 3/2/2021, directed the following: "Foot Care-"- The assignment did not describe what "foot care" meant. "Nail Care"- The assignment did not describe what "nail care" meant. "Skin Care"- The assignment did not describe what "skin care" meant. The home health aide assignment did not give clear, specific directions for the aides to follow when assigning foot care, nail care and skin care. The above findings for Patients #6 and #7 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 5 sampled patients receiving home health aide services (Patients #3, #6 and #7). The agency reported a current census of 283 patients at the time of the survey, including 28 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the agency policy, titled Care Planning Process and dated 3/2018, the registered nurse will develop a home health aide assignment describing the type of service/procedure to be provided, including specific procedure to be performed and frequency/duration. According to the agency policy, titled Physician Orders- Verbal Orders and dated 3/2018, drugs and treatments are administered by the agency staff only as ordered by the physician. The physician order will be obtained prior to the provision of care, including changes in the plan of care. According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 3/2019, home health services will be in accordance with the Plan of Care based on the diagnosis and assessment of needs and resources. The individualized Plan of Care must specify the care and services necessary to meet the needs of the patient, including identification of the responsible discipline(s) responsible for the task. The physician must approve the Plan of Care. Drugs, services, treatments and all clinical services are administered by staff only as ordered by the physician. 1. Patient #3 had a start of care date of 10/8/2018. Clinical record review, home visit observation and associated agency staff interviews revealed the following: a. During the home visit to Patient #3's home while accompanied by Staff D, Registered Nurse (RN), the surveyor observed the RN apply Triamcinolone cream to the patient's buttocks. During agency staff interview while in the patient's home, Staff D, RN, reported the nurse applied the Triamcinolone cream to the patient's buttocks on Tuesday, Thursday and Saturday. The RN reported the home health aide applied the Triamcinolone cream to the patient's buttocks on Monday, Wednesday and Friday. HCBS (Home and Community Based Services) staff applied on Sundays and the second dose each day. Applying a topical cream is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 11/26/2020 to 1/24/2021 and 1/25/2021 to 3/25/2021, included physician orders for home health aide visits 3 times weekly to assist with bathing and activities of daily living. The Plans included orders for Triamcinolone cream to the buttocks twice daily. The Plans lacked physician approval for the home health aide to assist with the application of the Triamcinolone cream to the buttocks as an extension of nursing services. b. The home health aide assignment, dated 11/26/2020, included direction to the aide to monitor the patient's blood pressure each visit. Monitoring blood pressure is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 11/26/2020 to 1/24/2021 and 1/25/2021 to 3/25/2021, lacked physician approval for the home health aide to monitor the patient's blood pressure as an extension of nursing services. c. The home health aide assignments, dated 11/26/2020 and 1/25/2021, included RN direction for the home heath aide to monitor the patient's temperature, pulse, respirations and blood pressure every visit. The home health aide visit notes, dated 12/4/2020, 12/11/2020 and 1/6/2021, lacked documentation of the aide performing monitoring of the temperature, pulse, respirations and blood pressure as assigned by the RN. 2. Patient #6 had a start of care date of 1/2/2021. Clinical record review revealed the following: The home health aide assignment, dated 1/2/2021, included direction to the aide to monitor the patient's blood pressure each visit. Monitoring blood pressure is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 1/2/2021 to 3/2/2021, lacked physician approval for the home health aide to monitor the patient's blood pressure as an extension of nursing services. 3. Patient #7 had a start of care date of 11/16/2020. The Plans of Care, dated 1/15/21 to 3/15/21, included physician orders for skilled nursing services three times per week and home health aide services 2 times per week to assist with personal care. Clinical record review revealed: a. The Aide Care Plan for the time period 1/15/21 to 3/15/21, included direction to the aide to assess blood pressure every visit and shave the patient per patient request. b. The Plan of Care failed to include orders from the doctor for the aide to assess blood pressure and shave the patient which are extensions to nursing services. The home health aide provided services that lacked an order by the physician on the Plan of Care. The above findings for Patients #3, #6, and #7 were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure agency staff completed documentation in a timely manner and according to the agency policy for 3 of 10 sampled patients (Patients #3, #6 and #7). At the time of the survey, the agency reported a current census of 283 patients. Failure of the agency to ensure the clinical record included timely, up-to-date documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. Findings include: According to the agency policy, titled Timely Submission of Patient Documentation and dated 10/2017, all visit reports must be submitted the next scheduled work day, not exceeding 3 business days. All patient visit reports from contract personnel must be submitted within 3 business days from the date of the visit. During agency staff interview on 2/1/2021 at 4:20 PM, the Administrator reported all staff have the day of the visit and 2 additional days or 72 hours to complete all documentation related to patient visits. 1. Patient #3 had a start of care date of 10/8/18. The Plan of Care, dated 1/25/2021 to 3/25/21, included orders for skilled nursing and home health aide services. Clinical record review revealed the skilled nursing visit note, dated 1/27/2021, was not completed in the agency's electronic system until 2/2/2021, 4 business days (6 calendar days) following the visit, making the documentation 2 days late according to agency policy. 2. Patient #6 had a start of care date of 1/2/2021. The Plan of Care, dated 1/2/2021 to 3/2/2021, included orders for physical therapy, occupational therapy and home health aide services. The Plan lacked orders for skilled nursing services; however, skilled nursing visits were made. Clinical record review revealed: a. The skilled nursing visit note, dated 1/8/2021, was not completed in the agency's electronic system until 1/13/2021, making the documentation 1 day late according to agency policy. b. The skilled nursing visit note, dated 1/11/2021, was not completed in the agency's electronic system until 1/18/2021, making the documentation 3 days late according to agency policy. c. The home health aide visit note, dated 1/8/2021, was not completed in the agency's electronic system until 1/13/2021, making the documentation 1 day late according to agency policy. 3. Patient #7 had a start of care date of 11/19/2020. The Plans of Care, dated 11/16/2020 to 1/14/21 and 1/15/21 to 3/15/21, included orders for skilled nursing and home health aide services. Clinical record review revealed: a. A skilled nursing visit note, included documentation the visit occurred on 12/4/2020, with an electronic signature indicating completion on 12/19/2020, 10 days late according to agency policy. b. A skilled nursing visit note, included documentation the visit occurred on 12/9/2020, with an electronic signature indicating completion on 12/29/2020, 15 days late according to agency policy. c. A skilled nursing visit note, included documentation the visit occurred on 12/11/2020, with an electronic signature indicating completion on 12/29/2020, 13 days late according to agency policy. d. A skilled nursing visit note, included documentation the visit occurred on 12/18/2020, with an electronic signature indicating completion on 12/29/2020, 6 days late according to agency policy. e. A skilled nursing visit note, included documentation the visit occurred on 12/21/2020, with an electronic signature indicating completion on 12/30/2020, 7 days late according to agency policy. f. A skilled nursing visit note, included documentation the visit occurred on 12/23/2020, with an electronic signature indicating completion on 12/30/2020, 1 day late according to agency policy. g. A skilled nursing visit note, included documentation the visit occurred on 12/30/2020, with an electronic signature indicating completion on 1/7/21, 2 days late according to agency policy. h. A skilled nursing visit note, included documentation the visit occurred on 1/11/21, with an electronic signature indicating completion on 1/20/21, 6 days late according to agency policy. i. A skilled nursing visit note, included documentation the visit occurred on 1/18/21, with an electronic signature indicating completion on 1/28/21, 7 days late according to agency policy. j. A skilled nursing visit note, included documentation the visit occurred on 1/20/21, with an electronic signature indicating completion on 1/28/21, 3 days late according to agency policy. k. A skilled nursing visit note, included documentation the visit occurred on 1/22/21, with an electronic signature indicating completion on 1/28/21, 1 day late according to agency policy. The above findings for Patients #3, #6, and #7 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 5 of 5 sampled patients with transfers/ discharges (Patients #8, #9, #10, #12 and #13). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy, titled Timely Submission of Patient Documentation and dated 10/2017, discharge summaries must be submitted within 5 business days. According to the agency policy, titled Discharge Summary and dated 3/2018, the discharge summary will be completed and sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient within 5 business days of the patient's discharge. During agency staff interview on 2/2/2021 at 4:00 PM, the Clinical Manager reported the clinician completes the transfer and discharge summaries. The clinician generally will then send the summary to the physician by facsimile. 1. Patient #10 had a start of care date of 1/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 1/13/2021 to 3/13/2021, documented the patient's diagnoses as occlusion/stenosis of the carotid arteries, peripheral vascular disease and rectal cancer resulting in the use of a bowel ostomy. b. The transfer assessment, dated 1/22/2021, documented the patient was admitted to the hospital on 1/21/2021 with a diagnosis of bowel obstruction. The patient was subsequently admitted by hospice upon discharge from the hospital and was thereby discharged from the agency without ever returning to services. c. The transfer summary, dated 1/22/2021, included a check box to indicate the summary was sent to the physician. The box remained unchecked. During agency staff interview on 2/3/2021 at 3:00 PM, the Clinical Manager concurred the transfer summary was completed but did not appear sent to the physician caring for the patient at the time of the transfer. The surveyor requested documentation of the facsimile verification if available. The agency did not provide any such document prior to the end of the survey. 2. Patient #12 had a start of care date of 8/21/2020. Clinical record review revealed the following: a. The transfer assessment, dated 12/4/2020, documented the patient was admitted to the hospital with pneumonia on 12/4/2020. The update to the comprehensive assessment at the time of resumption of care, dated 12/18/2020, documented the patient remained hospitalized through 12/18/2020. The transfer summary, dated 12/4/2020, included a check box to indicate the summary was sent to the physician. The box remained unchecked. During agency staff interview on 2/2/2021 at 12:00 PM, the Clinical Manager concurred the transfer summary was completed but did not appear sent to the physician caring for the patient at the time of the transfer. The surveyor requested documentation of the facsimile verification if available. The agency did not provide any such document prior to the end of the survey. b. The transfer assessment, dated 12/24/2020, documented the patient was admitted to the hospital with weakness and a fall on 12/24/2020. The update to the comprehensive assessment at the time of resumption of care, dated 1/22/2021, documented the patient remained hospitalized through 1/14/2021. The transfer summary, dated 12/24/2020, included a check box to indicate the summary was sent to the physician. The box remained unchecked. During agency staff interview on 2/2/2021 at 12:00 PM, the Clinical Manager concurred the transfer summary was completed but did not appear sent to the physician caring for the patient at the time of the transfer. The surveyor requested documentation of the facsimile verification if available. The agency did not provide any such document prior to the end of the survey. 3. Patient #13 had a start of care date of 6/23/2020. Clinical record review revealed the following: a. The transfer assessment, dated 10/16/2020, documented the patient was admitted to the hospital with shortness of breath and acute mental/behavioral issues on 10/16/2020. The update to the comprehensive assessment at the time of resumption of care, dated 10/20/2020, documented the patient remained hospitalized through 10/19/2020. The transfer summary, dated 10/16/2020, included a check box to indicate the summary was sent to the physician. The box remained unchecked. During agency staff interview on 2/2/2021 at 12:00 PM, the Clinical Manager concurred the transfer summary was completed but did not appear sent to the physician caring for the patient at the time of the transfer. The surveyor requested documentation of the facsimile verification if available. The agency did not provide any such document prior to the end of the survey. 4. Patient #8 had a start of care date of 9/14/2020 and was discharged from the agency on 11/30/2020. Clinical record review revealed a physical therapy visit note for discharge with discharge summary, completed 11/30/2020, documented the discharge date of 11/30/2020. The discharge summary did not include physician notification of discharge summary or date the discharge summary was sent to the physician. Agency staff failed to send a completed discharge summary to the physician within 5 business days of the patient's discharge. 5. Patient #9 had a start of care date of 3/28/19 and was discharged from the agency on 9/17/2020. Clinical record review revealed: a. An OASIS assessment for discharge from agency, dated 9/17/2020, was completed on 9/18/2020. The discharge summary included documentation the physician was notified of discharge prior to discharge date and and agency summary availability policy and timeline. b. Task details from the electronic health record (EHR) showed the discharge summary was sent to the physician on 12/21/2020, 87 days after the requirement to send the summary within 5 business days. The agency failed to complete a discharge summary within 5 business days of the patient's discharge. The above findings for Patients #8, #9, #10, #12, and #13 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.