Every finding on record at Superior Home Health LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/08/23. Standard level deficiency cited. Abbreviations: EP = 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 the review of the EP documents, personnel files and Staff interview, it was determined the Agency failed to ensure EP training was conducted and documented biannually. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. On 12/06/23 at 11:00 AM, the EP training was requested. As of 12/08/23, the requested training was not provided. 2. On 12/08/23 at 9:30 AM, the personnel files were reviewed and lacked documentation of the EP training. 3. The above findings were confirmed during interviews with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 12:30 PM and again with the Acting Director of Nursing on 12/08/23 at 9:50 AM.

Recertification survey completed. Standard level deficiencies cited. Abbreviations # = number > = greater than BP = blood pressure EP = Emergency Preparedness MSW = Medical Social Worker OT = Occupational Therapy/Therapist Pt./ Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse ST = Speech Therapy/Therapist

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical records review and Staff interview, it was determined the Agency failed to ensure that Staff provided services as ordered in the Plans of Care. This was found in 3 of 10 (Pts. #2, #6 and #9) clinical records reviewed. Findings include: 1. Patient #2, was admitted to Home Health services on 02/17/23 with Diagnoses: Multisystem Degeneration of the Autonomic Nervous System and Heart Failure. The clinical record was reviewed on 12/05/23. The signed Plans of care effective 08/16/23 and 10/15/23 which required: “SN to instruct patient on daily weight self-monitoring program…Report to SN weight gain….” The record lacked weight assessments for recertification assessment dated 10/11/23 and SN clinical notes dated 10/16/23, 10/27/23, 10/30/23, 11/06/23, 11/13/23, 11/20/23, 11/27/23 and 12/04/23, as ordered by the physician. 2. Patient #6, was admitted to Home Health services on 11/17/23 with Diagnoses: Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23. The signed Plan of care effective 11/17/23 required: “….Notify physician of:….Systolic BP greater than (>) 160 or less than()90 or less than ( The SN note dated 11/29/23 indicated only a systolic BP of 145, and lacked a diastolic BP assessment to report, as ordered by the physician. 3.Patient #9, was admitted to the Home Health Services on 01/23/23 with the Diagnoses: Hypertensive Heart and Chronic Kidney Disease without Heart Failure with Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 12/06/23. The Physician orders dated 05/17/23 included orders for the ST to evaluate the Patient. The ST frequency was 1 time a week for 6 weeks. The ST failed to assess the Patient, during the week of 05/29/23 ( week #4). 4.The findings were confirmed during the interview with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 11:30 AM. Findings include: 1. Patient #2 was admitted to Home Health services on 02/17/23 with Diagnoses of Multisystem Degeneration of the Autonomic Nervous System and Heart Failure. The clinical record was reviewed on 12/05/23. The signed Plans of care effective 08/16/23 and 10/15/23 required, “SN to instruct patient on daily weight self-monitoring program…Report to SN weight gain….” The record lacked weight assessments for recertification assessment dated 10/11/23 and SN clinical notes dated 10/16/23, 10/27/23, 10/30/23, 11/06/23, 11/13/23, 11/20/23, 11/27/23 and 12/04/23, as ordered by the physician. 2. Patient #6 was admitted to Home Health services on 11/17/23 with Diagnoses of Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23. The signed Plan of care effective 11/17/23 required, “….Notify physician of:….Systolic BP greater than (>) 160 or less than()90 or less than ( The SN note dated 11/29/23 indicated only a systolic BP of 145, and lacked a diastolic BP assessment to report, as ordered by the physician. 3. Patient #9 was admitted to the Home Health Services on 01/23/23 with the Diagnoses of Hypertensive Heart and Chronic Kidney Disease without Heart Failure with Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 12/06/23. The Physician orders dated 05/17/23 included orders for the ST to evaluate the Patient. The ST frequency was 1 time a week for 6 weeks. The ST failed to assess the Patient, during the week of 05/29/23 (week #4). 4. The findings were confirmed during interviews with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 11:30 AM.

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 the clinical record review and Staff interview, it was determined the Agency failed to ensure the Aide Supervision was conducted in the patient’s home every 14 days. This was found for 2 of 5 Patients (Pt. #4 and 2) with Aide services. 2. Patient #2, was admitted to Home Health Services on 02/17/23 with Diagnosis: Multisystem Degeneration of the Autonomic Nervous System. The clinical record was reviewed on 12/05/23. The signed Plan of care effective 08/16/23 required Aide services 1 time a week for 9 weeks. The clinical record lacked an Aide's supervision between 09/04/23 and 10/30/23 (more than 14 days). 3. During interviews with the Acting Administrator and Acting Director of Nursing on 12/07/23 from 10:00 AM to 11:30 AM, both confirmed the above findings. Findings include: 1.Patient #4, was admitted to the Home Health Services on 11/18/22 with the Diagnoses: Unspecified Atrial Fibrillation and Alzheimer’s Disease. The clinical record was reviewed on 12/06/23 and lacked the Aide’s supervision every 2 weeks. As of 12/07/23, the last supervisory visit by the RN was dated 11/17/23 (more than 14 days).

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 the clinical record review and Staff interview, it was determined the Agency failed to ensure the clinical records included all the required items. This was found in 3 of 10 records reviewed (Pt. #3, 4 and 8). Findings include: 1.Patient #3 was admitted to Home Health Services on 11/18/22 with the Diagnoses of Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23 and lacked the signature of the SN on the supervisory notes dated 11/08/22 and 11/22/23. 2. Patient #4 was admitted to Home Health Services on 11/18/22 with the Diagnoses of Unspecified Atrial Fibrillation and Alzheimer’s Disease. The clinical record was reviewed on 12/06/23 and lacked an order for the Home Health Aide for the recertification period of 11/08/23 to 01/06/24. 3.Patient #8 was admitted to Home Health Services on 11/18/22 with the Diagnosis of Pressure Ulcer of Sacral Region, Stage 2. The clinical record was reviewed on 12/06/23 and lacked the frequency orders of the Aide, OT and MSW services assessed in the comprehensive assessment dated 05/01/23. 4. The findings were confirmed during the interview with the Acting Administrator and Acting Director of Nursing on 12/07/23, between 10:00 AM and 11:30 AM.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish a policy and plan relative to the use of volunteers during an emergency. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's Emergency Preparedness Plan last updated on 8/10/20 was reviewed on 1/5/21 at 12:45 PM. The Plan lacked a policy and documentation relative to the use of volunteers. 2. During an interview with the Administrator and the DON on 1/6/21 at 11:00 AM, the Administrator and the DON confirmed the Agency failed to incorporate volunteers into the Agency's Emergency Preparedness Plan.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Emergency Preparedness Plan, clinical record review and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's Emergency Preparedness Plan last updated on 8/10/20 was reviewed on 1/5/21 at 12:45 PM. The Plan lacked the names and contact information of the PT, OT and Speech Therapist. 2. The following clinical records were reviewed on 1/4/21 at 1:15 PM (Pt. #1) and 1/5/21 at 11:00 AM (Pt. #2): Pt. #1. SOC 10/22/20. OT and Speech therapy services were provided. Pt. #2. SOC 9/18/20. Medical Social Worker service was provided. 3. During an interview with the Administrator and the DON on 1/6/21 at 11:00 AM, the Administrator and DON confirmed the Agency failed to ensure the Agency's Emergency Preparedness communication plan was complete.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 1/7/21. Standard level deficiencies written. Abbreviations: Pt./Pts. = Patient/Patients SOC = start of care SN = Skilled Nurse DON = Director of Nursing MD = Medical Doctor POC = plan of care PsOC = plans of care AM = Morning PM = Evening, night E = employee # = number mg = milligrams ml = milliliters mcg = micrograms % = percent MDI = metered dose inhaler IU = international units BLE = bilateral lower extremities CMS = Centers for Medicare and Medicaid Services RN = Registered Nurse PT = Physical Therapist/Physical Therapy OT = Occupational Therapist/Occupational Therapy ADL = activities of daily living IADL = instrumental activities of daily living HHA = Home Health Aide COVID-19 = Coronavirus Disease 2019 eval. = evaluation treat. = treatment

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician- ordered start of care date. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the SOC assessment was conducted within 48 hours of the referral of the referral date. This was found in 2 of 10 (Pts. #7 and 9) clinical records reviewed. Findings include: 1. Pt. #7. SOC 9/3/20. Primary Diagnosis: Unspecified Hypothyroidism. The clinical record was reviewed on 1/4/21 at 12:50 PM. The record contained the SOC comprehensive assessment completed by the RN and dated 9/3/20. The assessment included documentation the Pt. was not discharged from an inpatient facility, or that the physician had ordered a specific SOC date. As of 1/4/21, the record lacked a referral form to include the referral date and source. It cannot be determined that the SOC was conducted within 48 hours of the referral date. 2. Pt. #9. SOC 4/19/20. Primary Diagnosis: COVID-19 Acute Respiratory Disease. The closed clinical record was reviewed on 1/5/21 at 2:30 PM. The record contained the SOC comprehensive assessment completed by the RN, and dated 4/19/20. Pt. #9 was discharged from an inpatient facility on 4/13/20, as indicated by the SOC comprehensive assessment. As of 1/5/21, the record lacked a referral form to include the referral date, and a Physician order for SOC on a specific date. It cannot be determined that the SOC was conducted within 48 hours of the referral date. 3. The Agency policy titled, "Medical Record Content" was reviewed on 1/6/20 at 2:30 PM. The policy required: "4. Each medical record will contain the following... Physician's name and referral source..." 4. During an interview with the Administrator and the DON on 1/6/20 at 11:00 AM, both confirmed the clinical records lacked a referral indicating the date of the referal and/or source. During the same interview, the Administrator and DON were unable to determine whether the SOC was conducted within 48 hours after receipt of a referral.

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 may choose to include. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, observations and interviews made during home visits, Agency policy review, and staff interview, it was determined the Agency failed to include all current medications in the POC. This was found in 2 of 4 (Pts. #2 and 3) home visits conducted. Findings include: 1. Pt. #2 SOC 12/5/20. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 1/4/21 at 3:00 PM. The record included a POC, effective 12/5/20, which included the following medications: Ergocalciferol (Vitamin D2) 1.25 mg/50,000 IU weekly; Ferrous Sulfate 325 mg, 1 tablet daily; Loratadine 10 mg, 1 tablet daily; and Dicylomine HCL 20 mg, 1 capsule every 6 hours. There were no subsequent Physician's orders during this recertification period for any new medications/medication changes. A home visit was conducted 1/5/21 at 10:00 AM, along with E#6. During this home visit, Pt. #2 presented his/her medications, and stated he/she does not take Ergocalciferol, but instead takes Vitamin D3 50,000 IU weekly. Pt. #2 no longer takes Ferrous sulfate, but instead takes Raw Iron 22 mg daily. Pt. #2 also stated he/she no longer takes Loratadine and Dicyclomine. Pt. #2 stated he/she takes the following medications, which are not included on the POC: Raw Iron 22 mg daily, Omeprazole 40 mg daily; Vitamin B12, 5,000 mcg daily; and Cod Liver Oil, one capsule daily. Pt. #2 stated he/she has been taking these medications "for awhile--at least several months." The POC was inaccurate. 2. Pt. #3 SOC 8/21/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/5/21 at 12:15 PM. The record contained a POC for the recertification period effective 12/19/20. This POC included the following medications: Betamethasone 0.1 % apply topically to BLE two times a day; Triamcinolone 0.1 % apply to BLE two times a day; Gabapentin 300 mg three times a day; Ocean Nasal Spray 0.65 % 3 sprays each nostril as needed; Magnesium Oxide 400 mg 2 capsules daily; Furosemide 20 mg daily; Premarin Vaginal cream 0.625 mg twice weekly; Atorvastatin 20 mg daily at bedtime; Calcium Ascorbate 500 mg daily; Albuterol Sulfate inhalation 108 mcg 2 puffs daily; Apixban 5 mg every 12 hours; Semaglutide 2 mg/1.5 ml subcutaneous weekly on Thursdays; Diclofenac Transdermal 1 % topically to affected areas 4 times daily; Duloxetine 30 mg daily; and Hydrocortisone 1% to both legs twice daily. There were no subsequent Physician's orders during this recertification period for any new medications/medication changes. A home visit was conducted on 1/5/21 at 3:00 PM, along with E #7. During this home visit, Pt. #3's medications were reviewed. Pt. #3 stated he/she uses Bethamethasone cream "every other day--I rotate it with Biofreze cream (not listed on the POC)." Pt. #3 stated he/she has not taken Premarin cream for "at least a month." Pt. #3 stated he/she does not take Ocean Nasal Spray, and has not used Triamcinolone cream "for at least 3 months." Pt. #3 stated he/she has not taken Gabapentin, Atorvastatin, or used Diclofenec for "at least 6 months." Pt. #3 stated he/she has not taken Semaglutide injections or Duloxetine "for at least one year." Pt. #3 stated he/she has not used Albuterol "for years." Pt. #3 stated he/she takes Magnesium "twice a day." Pt. #3 stated he/she takes Furosemide "once or twice a week." Pt. #3 stated he/she has taken Calcium Ascorbate "every other day, for years." Pt. #3 states he/she takes Apixaban "daily, since last March." Pt. #3 stated he/she does not use Hydrocortisone cream, and "when I did, it was for a rash on my nose." Pt. #3 stated he/she uses Bactroban 1 gram ointment (not listed on the POC) to both nares every night at bedtime. The POC was inaccurate. 3. The Agency policy titled "Plan of Care - CMS # 485 and Physician Orders" was reviewed on 1/6/21 at 12:25 PM. The policy required: "...The individualized POC must include the following...All medications and treatments... 4. During an interview with the Administrator and DON on 1/6/21 at 1:00 PM, the DON confirmed the above findings, and stated the Nurse should reconcile the Patient's medications at the SOC, and at each SN visit thereafter. If the Pt. subsequently reports any new medications/changes in medications, the Nurse should call the Physician to obtain orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service and treatment, as indicated in the PsOC. This was found in 2 of 10 (Pts. #7 and 10) clinical records reviewed. Findings include: 1. Pt. #7. SOC 9/3/20. Primary Diagnosis: Unspecified Hypothyroidism. The clinical record was reviewed on 1/4/21 at 12:50 PM. The record included the POC for the certification period of 11/2/20 to 12/31/20 requiring, "SN: 1 week 9" (1 time a week for 9 weeks). The record lacked documentation the SN provided service during the week of 11/29/20 to 12/5/20. 2. Pt. #10. SOC 9/18/20. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 1/5/21 at 11:00 AM. The record contained the POC effective 11/17/20 requiring, "PT: eval and treat." The record lacked documentation the PT conducted an "eval and treat" on or after 11/17/20. The record contained the Physician order dated 9/16/20 requiring: "Occupational Therapy - for safety. ADL/IADL management, functional limitations and cognitive..." The record lacked documentation that "Occupational Therapy" was offered and/or provided on or after 9/16/20. 3. During an interview with the Administrator and the DON on 1/6/20 at 11:00 AM, both confirmed the staff failed to provide service and treatment, as indicated in the PsOC.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 4 of 10 (Pts. #5, 6, 1, and 4) clinical records reviewed. Findings include: 1. Pt. #5. SOC 12/1/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Foot Ulcer. The clinical record was reviewed on 1/6/21 at 10:00 AM. The record contained PT visit notes dated 12/3/20, 12/9/20, 12/11/20, 12/21/20, and 12/23/20, indicating the PT provided service. The record lacked documentation the PT screened the Pt./family for COVID-19 symptoms prior to these visits. 2. Pt. #6. SOC 11/17/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/4/21 at 12:55 PM. The record contained Home Health Aide visit notes dated 12/10/20, 12/12/20, 12/17/20, 12/19/20, 12/23/20, and 12/31/20, indicating the Home Health Aide provided service. The record lacked documentation the Home Health Aide screened the Pt./family for COVID-19 symptoms prior to these visits 3. Pt. #1. SOC 10/22/20. Primary Diagnosis: Hemiplegia following Cerebrovascular Accident. The clinical record was reviewed on 1/4/21 at 1:15PM. The record contained SN visit note dated 11/20/20 and recertification comprehensive assessment dated 12/17/20, indicating that service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. The record contained Home Health Aide visit notes 3 times a week from 11/9/20 to 1/4/21, indicating service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. The record contained PT visit notes dated 11/11/20, 11/13/20, 11/20/20 and 11/27/20, indicating service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. The record also contained OT visit notes dated 11/14/20, 11/21/20 and 12/3/20, indicating service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. 4. Pt. #4 SOC 5/29/20. Primary Diagnosis: Tinea Cruris. The clinical record was reviewed on 1/5/21 at 10:15 AM. The record contained recertification comprehensive assessment dated 11/23/20 and SN visit notes dated 11/30/20, 12/7/20, 12/14/20, 12/21/20 and 12/29/20, indicating that service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. The record also contained the PT visit notes 2 times a week from 11/30/20 to 12/29/20, indicating service was provided. The record lacked documentation that COVID-19 screening was conducted prior to the visits. 5. During interview with the Administrator on 1/5/21 at 1:00 PM, the Administrator stated that COVID screening for Pts. are done by filling out a COVID Screening questionnaire by staff every 2 weeks. Staff are expected to screen Pts. before every visit and should document on their visit notes. During an interview with the Administrator and DON on 1/6/21 at 10:40 AM, the Administrator stated staff are required to submit and complete documentation to Agency within 7 days. 6. During the same interview with Administrator and DON on 1/6/21 at 10:40 AM and 1:00 PM, the DON confirmed the records lacked documentation of COVID-19 screening prior to the visits.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Infection logs and staff interview, it was determined that the Agency failed to ensure the Infection surveillance program related to COVID-19 for Pts. and employees was complete and/or accurate. This was found in 2 out of 2 (Pts. #7 and 9) Pts. identified as COVID-19 posiitive, and 2 out of 2 (E #2 and 8) employees reviewed for exposure to COVID-19. Findings include: 1. The Agency's log #1 titled, "Infection log: COVID POSITIVE (PATIENTS)" was reviewed on 1/14/21 at 1:00 PM and lacked documentation of Pt. #9. (Primary Diagnosis: COVID 19). 2. The Agency's log #2 titled, "Infection control date range: 1/01/2020 - 12/31/2020" was reviewed on 1/5/21 at 1:20 PM and lacked documentation of Pt. #9. 3. The Agency's log #3 titled, "Infection control date range: 1/01/2020- 12/31/2020" was reviewed on 1/5/21 at 1:25 PM. The log contained documentation that Pt. #7's COVID status was "unknown". However, Pt.#7 tested positive for COVID-19. Log #3 also lacked documentation of surveillance pertaining to Pt. #9. 4. The Agency's log #4 titled, "Infection Log: COVID POSITIVE (Staff)" was reviewed on 1/4/21 at 1:00PM and lacked documentation of surveillance of E #2 (Date of Hire 6/24/19) and #8 (Date of Hire 2/13/17) that tested positive for COVID-19. 5. The Agency's log #5 titled, "Infection Control log: Employee Infections" was reviewed on 1/5/21 at 12:00 PM. The log contained 2 dates indicating 2 different employees that had COVID-19. The log lacked an identifier (name, date of hire or #) indicating which employee and follow up regarding their status. 6. During an interview with E #2 (Date of Hire: 6/24/19) on 1/5/21 at 9:00 AM, E #2 confirmed that he/she was positive for COVID-19 in April 2020. Neither the employee/staff logs contained documentation that E #2 tested positive for COVID-19. 7. During an interview with the Administrator on 1/5/21 at 2:00 PM, the Administrator confirmed the Agency's surveillance plan for Pts. and staff related to COVID-19 was incomplete and/or inaccurate.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (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: . A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure Home Health Aides provided services as ordered by a Physician, and included in the POC. This was found in 1 of 2 (Pt. #6) clinical records reviewed, wherein Home Health Aide services were provided. Findings include: 1. Pt. #6 SOC 11/17/20. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 1/4/21 at 12:55 PM. The record included a POC for the certification period effective 11/17/20. This POC did not include a Physician's order for topical Nystatin. There were no subsequent Physician's orders for topical Nystatin. The Home Health Aide visit note dated 12/17/20 contained "Client complained about his/her peri area hurting, so I said I have to see and clean his/her peri area, he/she said OK, his/her area was so irritated, the sides of his/her legs, and smelled very bad..." The Home Health Aide visit note dated 12/23/20 contained "Saw his/her peri area much clearer with the Nystatin powder...applied more." The Home Health Aide visit note dated 12/31/20 contained "Peri area clear, applied Nystatin." The Home Health Aide Care Plan dated 11/17/20 lacked instructions for the Home Health Aide to apply the "Nystatin powder." 2. The Agency policy titled "Home Health Aide Services and Training Program" was reviewed on 1/6/21 at 10:45 AM. The policy required: "A Home Health Aide training program must address each of the following subject areas...Recognizing and reporting changes in skin condition...A Home Health Aide provides services that are: Ordered by the Physician. Included in the POC...Home Health Aides must be members of the interdisciplinary team, and must report changes in the Patient's condition to a Registered Nurse or other appropriate skilled professional..." 3. The Agency's "Job Description: Home Health Aide (HHA)" was reviewed on 1/6/20 at 11:00 AM. This job description required: "...Responsibilities: Reports changes in the Patient's condition and needs to the RN." 4. During an interview with the Administrator and the DON on 1/6/21 at 1:00 PM, the DON confirmed the above findings.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that documentation entered into the clinical record was thorough. This was found in 2 of 7 (Pts. #7 and 9) clinical records reviewed. Findings include: 1. Pt. #7. SOC 9/3/20. Primary Diagnosis: Unspecified Hypothyroidism. The clinical record was reviewed on 1/4/21 at 12:50 PM. The record contained the "Beneficiary Elected Transfer" form completed by the RN, signed by the Pt., RN and dated 9/3/20. The form was not completed thoroughly, it lacked the name of the Agency the Pt. no longer received service, as required by the Agency's form. 2. Pt. #9. SOC 4/19/20. Primary Diagnosis: COVID-19 Acute Respiratory Disease. The closed clinical record was reviewed on 1/5/21 at 2:30 PM. The record contained the "Patent's Service Agreement" form completed by the RN, signed by the Pt., RN and dated 4/19/20. The form was not completed thoroughly, it lacked the services to be provide and the payment source. The "Notice of Payment Responsibility" form completed by the RN and dated 4/19/20 lacked the payment source, services ordered by the Physician and the frequency of those services, as required by the Agency's forms. 3. During an interview with the Administrator and the DON on 1/6/20 at 11:00 AM, the Administrator and DON confirmed clinical documentation was not completed thoroughly.