Every finding on record at Three Star Home Health Agency Inc

A recertification inspection survey was conducted on 05/16/2023. The licensed and certified home health services census was 7. Abbreviations/Acronyms: Adm-Administrator Alt/Adm/DON-Alternate Administrator/Director of Nursing Office Mgr.-Office Manager EP-Emergency Preparedness COO-Continuity of Operations

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: This is a continuing deficiency cited at E 0004 during survey dated 09/09/2020. Based on record review and interview, the agency failed to comply with all applicable Federal, State, and local emergency preparedness requirements, in that the agency failed to maintain a comprehensive emergency preparedness program that was reviewed and updated at least annually, per state regulations and agency policy, for the calendar years 2021 and 2022. The failure could place the agency’s patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan needed to be updated. FINDINGS INCLUDED: During the entrance conference on 05/16/2023 at 11:35 a.m., the Alt Adm/DON self-identified as the agency’s disaster coordinator and she identified the Adm as the alternate disaster coordinator. The surveyor requested all agency records (reports, documents, and binders) for the emergency preparedness and response plan. Review of the emergency preparedness plan binder, policies, and procedures did not identify any records to establish that the agency had conducted annual reviews and updates of the agency’s emergency preparedness and response plan for the years 2021 and 2022 (two of three years reviewed). Further record review of the emergency preparedness records provided by the Alt Adm/DON revealed the following: A “Continuity of Operations (COO) Business Plan.” The COO business plan was not completed (only the first page was completed), was not signed, and was not dated. The last completed COO business plan was dated 03/12/2020. There were yellow notes attached to the COO business plan that stated, “need update 2021 and 2022.” A risk assessment that was last updated on 03/12/2020. An emergency preparedness and response plan policy that was revised on 07/01/2020. An annual review dated 03/12/2020. There were also yellow notes that stated the annual review needed to be updated for 2021, 2022, and 2023. The Alt Adm/DON provided an additional binder that contained emergency preparedness policy, procedure, and staff training materials. Continued record review of the agency’s emergency preparedness and response plan records/binders did not reveal any records that indicated the agency had conducted an annual review and/or update of the emergency preparedness and response plan for 2021 and 2022. During an interview on 05/16/2023 with the Alt Adm/DON, at approximately 2:45 p.m., the surveyor asked what the agency’s processes for its emergency preparedness and response plan were. The Alt Adm/DON stated that it was outsourced to the agency’s consultant (Consultant A). She also stated that Consultant A would pull up the contract and would call back. The Alt Adm/DON stated that Consultant A reviewed the agency’s fire drills for 2021 and 2022. The surveyor also asked who was responsible for implementing the agency’s emergency preparedness and response plan. The Alt Adm/DON stated that she was responsible for the implementation of the plan. During an interview with the Alt Adm/DON on 05/23/2023 at 1:25 p.m. the surveyor asked why the agency’s emergency preparedness and response plan was not reviewed and updated for the years 2021 and 2022. The Alt Adm/DON replied, “It was an oversight.” The surveyor also asked how the oversight could adversely affect the agency’s patients. The Alt Adm/DON stated that if the agency “does not update the plan we won’t know what guidelines to follow if there is an emergency.” Review on 05/24/2023 of website, https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/emergency-preparedness/minimum-texas-administrative-code-tac-requirements-written-emergency-preparedness-response-plans, revealed the following: “Texas Administrative Code Title 26 Part 1 §558.256 (j)- Emergency Preparedness Planning and Implementation-An agency must complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.” Agency policy titled “Emergency Preparedness and Response Plan EC.8” revised 070120 read in part, “…Purpose I. To ensure the Agency complies with all applicable Federal, State, and local emergency preparedness requirements. II. To ensure the Agency develops…and implements emergency preparedness plan, which will be reviewed and updated at least annually…VI…The plan and related policies and procedures must be reviewed and updated at least annually…”

A recertification inspection survey was conducted on 05/16/2023. The licensed and certified home health services census was 7. Abbreviations/Acronyms: Adm-Administrator Alt/Adm/DON-Alternate Administrator/Director of Nursing Office Mgr.-Office Manager EHR- Electronic Health Record POC- Plan of Care SOC- Start of Care HHA- Home Health Agency PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement SN- Skilled Nursing

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: This is a continuing deficiency cited at G 0446 during survey dated 09/09/2020. Based on record review, observation and interviews, the agency denied the patients’ right to be advised of the names, addresses, and telephone numbers of federally funded and state-funded entities that serviced the area where the patient resided, in three (Patients # 5, # 6 and # 8) of three patients who received home visits. The failure could place the patients’ health and safety at risk if they were unable to access needed resources that were available for them in their service area. Findings included: On 05/16/2023 the surveyor reviewed the agency's sample "Medicare" admission packet. The sample packet did not include the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where the patients resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency, and Aging and Disability Resource Center. The packet included a document titled “Notice of Medicare Non-Coverage.” The notice had an area to insert the name and number of the Quality Improvement Organization. The area was not completed with the name and the contact number listed was not correct. The packet also included the name and correct contact information for the Quality Improvement Organization, on a document that listed patient rights, for the service area where the patients resided. Patient # 5 Review of the clinical record for Patient # 5 revealed a POC for the certification period of 03/07/2023 to 05/05/2023. The POC revealed a start of care date of 07/15/2021 and a primary diagnosis of chronic pain and other diagnosis of type 2 diabetes mellitus (Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 05/18/2023 at approximately 9:00 a.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where patient # 5 resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency, and Aging and Disability Resource Center. The home folder included all documents that were in the sample Medicare admission packet. Patient # 6 Review of the clinical record for Patient # 6 revealed a POC for the certification period of 03/26/2023 to 05/24/2023. The POC revealed a start of care date of 07/29/2022 and a primary diagnosis of bilateral osteoarthritis of knee and other diagnosis of chronic kidney disease. The POC contained an order for skilled nursing visits for one time per week for nine weeks: hha two times per week for eight weeks, and one time per week for eight weeks. During a home visit conducted on 05/18/2023 at approximately 10:00 a.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where patient # 6 resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency, and Aging and Disability Resource Center. The home folder included all documents that were in the sample Medicare admission packet. Patient # 8 Review of the clinical record for Patient # 8 revealed a POC for the certification period of 05/01/2023 to 06/29/2023. The POC revealed a start of care date of 05/01/2023 and a primary diagnosis of osteoarthritis, left knee. The POC contained an order for skilled nursing visits for one time per week for nine weeks; PT to evaluate and treat; hha two time per week for one week, three times per week for seven weeks, and two times per week for one week. During a home visit conducted on 05/18/2023 at approximately 12:00 p.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where patient # 8 resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency, and Aging and Disability Resource Center. The home folder included all documents that were in the sample Medicare admission packet. On 05/23/2023 at 1:30 p.m., the surveyor discussed the findings with the Alt Adm/DON and Office Mgr. of why the sample admission packet and home folders for Patients # 5, # 6 and # 8 did not include the names, addresses, and telephone numbers of the federally funded and state-funded entities that served the area where the patients resided. The Alt Adm/DON stated that she was not aware of the regulatory requirement. Review of agency policy titled “Patient/Client Rights and Responsibilities…RI.2” revised 011318 read in part: “…Procedure…VI. The patient/client has the right to…K. Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that service the area where the patient/client resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization...”

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 record review and interview the agency failed to ensure the individualized plan of care included all required elements, for seven (Patients # 1, #2, # 3, # 5, # 6, # 7 and # 8) of seven active records reviewed and for one (Patient # 11) of one inactive record reviewed. The POC(s) for the patients did not include 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. The failure placed the patients at increased risk for emergency room visits and re-hospitalizations if they did not receive the necessary assessments, interventions, and treatments to address the risk factors. Findings included: Patient # 1: Record review of the hard copy clinical record and EHR for Patient # 1 revealed a POC with a SOC date of 05/01/2023. The POC had a certification period 05/01/2023 thru 06/29/2023 and a primary diagnosis of bilateral osteoarthritis of hip. The POC was signed by the Alt Adm/DON and dated 05/01/2023. The POC did not include 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. Patient # 2: Record review of the hard copy clinical record and EHR for Patient # 2 revealed a POC with a SOC date of 11/25/2020. The POC had a certification period 03/15/2023 thru 05/13/2023 and a primary diagnosis of chronic kidney disease. The POC was signed by the Alt Adm/DON and dated 03/10/2023. The POC did not include 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. Patient # 3: Record review of the hard copy clinical record and EHR for Patient # 3 revealed a POC with a certification period of 03/29/2023 to 05/27/2023. The POC had a SOC date of 04/19/2019, dated 03/28/2023 and signed by the Alt Adm/DON. The POC included diagnoses of hypertension (is when the pressure in the blood vessels is too high, 140/90 mmHg or higher). The POC did not include 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. Patient # 5: Review of the hard copy clinical record and EHR for Patient # 5 revealed a POC for the certification period of 03/07/2023 to 05/05/2023. The POC revealed a start of care date of 07/15/2021 and a primary diagnosis of chronic pain and other diagnosis of type 2 diabetes mellitus (Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). The POC was dated 03/03/2023 and signed by the Alt Adm/DON. The POC did not include 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. Patient # 6: Review of the hard copy clinical record and EHR for Patient # 6 revealed a POC for the certification period of 03/26/2023 to 05/24/2023. The POC revealed a start of care date of 07/29/2022 and a primary diagnosis of bilateral osteoarthritis of knee. The POC was dated 03/21/2023 and signed by the Alt Adm/DON. The POC did not include 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. Patient # 7: Review of the hard copy clinical record and EHR for Patient # 7 revealed a POC for certification period of 04/14/2023 to 06/21/2023. The POC had a SOC date of 08/17/2022 and a primary diagnosis of chronic pain. The POC was dated 04/11/2023 and signed by the Alt Adm/DON. The POC did not include 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. Patient # 8 Review of the hard copy clinical record and EHR for Patient # 8 revealed a POC for the certification period of 05/01/2023 to 06/29/2023. The POC revealed a start of care date of 05/01/2023 and a primary diagnosis of osteoarthritis, left knee. The POC was dated 05/01/2023 and signed by the Alt Adm/DON. The POC did not include 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. Patient # 11: Review of the inactive hard copy clinical record and EHR for Patient # 11 revealed a POC for the certification period of 03/23/2023 to 05/21/2023. The POC revealed a start of care date of 02/07/2020 and a primary diagnosis of hyperlipidemia (means there is too many lipids (fats) in the blood). The POC was dated 03/21/2023 and signed by the Alt Adm/DON. The POC did not include 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. During an interview on 05/23/2023 at 2:05 p.m. with the Alt Adm/DON, the surveyor discussed the findings and asked why Patients # 1, #2, # 3, # 5, # 6, # 7, # 8, and # 11’s did not include the required description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The Alt Adm/DON stated, “Because I wasn’t aware that I had to specifically describe” the patients’ risk for emergency department visits and re-hospital admissions. Review of agency policy titled “Plan of Care PC.8” revised 030119 read in part: “…Procedure…III. Each patient/client must receive an individualized written plan of care…A. The individualized plan of care must include the following: 1. All pertinent diagnoses; 2. The patient's/client’s mental, psychosocial, and cognitive status; 3. The types of services, supplies, and equipment required; 4. The frequency and duration of visits to be made; 5. Prognosis; 6. Rehabilitation potential; 7. Functional limitations; 8. Activities permitted; 9. Nutritional requirements; 10. All medications and treatments; 11. Safety measures to protect against injury; 12. A description of the patient's/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. 13. Patient/Client and caregiver education and training to facilitate timely discharge; 14. Patient/client-specific interventions and education; 15. measurable outcomes and goals identified by the Agency and the patient/client; 16. Information related to any advanced directives...”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to promptly alert the relevant physician of changes in the patient's needs that suggested outcomes were not being achieved and/or that the plan of care should be altered: in that two (Patients # 2 and # 3) of three active patients whose records were reviewed, with physician’s orders for weekly weights and were unable to be weighed. The failure could place the patients’ health at risk of an acute increase in the severity of their disease processes if their plan of care needed to be altered. Patient # 2: Record review of Patient # 2’s clinical records revealed a POC with a certification period of 03/15/2023 to 05/13/2023. The POC had a SOC date of 11/25/2020, was dated 03/10/2023 and was signed by the Alt Adm/DON. The POC included diagnoses of chronic kidney disease and chronic congestive heart disease (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply. Blood and fluids collect in the lungs and legs over time). The POC contained an order for SN to perform weekly weights and report weight gain/loss of 3 pounds in one week to physician. The POC also contained an order for SN visits one time per week for nine weeks. Further record review of Patient # 2’s clinical records revealed SN visit notes dated: 03/15/2023; 03/23/2023; 03/28/2023; 04/04/2023; 04/13/2023; 04/18/2023; 04/27/2023; and 05/02/2023. Review of the SN visit notes read in part: “…Weight Actual[:] unable…” The SN notes did not specify why Patient # 2’s was unable to be weighed. The SN notes also revealed that Patient # 2 had 2-3 + pitting edema (swelling) in both lower legs (pitting edema is assessed by applying pressure on the affected area and then measuring the depth of the pit (depression) and how long it lasts (rebound time). Grade +2: 3–4mm of depression, rebounding in 15 seconds or less). The Alt Adm/DON signed the SN visit notes. Patient # 2’s record did not reveal that the Alt Adm/DON had promptly alerted the physician who signed the POC (Identifier 100) of being unable to weigh the patient and the presence of the swelling in the lower legs, for the certification period of 03/15/2023 to 05/13/2023. Patient # 3: Record review of Patient # 3’s clinical records revealed a POC with a certification period of 03/29/2023 to 05/27/2023. The POC had a SOC date of 04/19/2019, was dated 03/28/2023 and was signed by the Alt Adm/DON. The POC included diagnoses of hypertension (is when the pressure in the blood vessels is too high, 140/90 mmHg or higher), atherosclerotic (atherosclerosis is thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) heart disease, and abnormal weight loss. The POC contained an order for SN to perform weekly weights and report weight gain/loss of 3 pounds in one week to physician. The POC also contained an order for SN visits one time per week for eight weeks. Further record review of Patient # 3’s clinical records revealed SN visit notes dated: 04/05/2023; 04/11/2023; 04/18/2023; 04/27/2023; 05/02/2023; and 05/09/2023. Review of the SN visit notes read in part: “…Weight Actual[:] unable…” The SN notes did not specify why Patient # 3 was unable to be weighed. The Alt Adm/DON signed the SN visit notes. Patient # 3’s record did not reveal that the Alt Adm/DON had promptly alerted the physician who signed the POC (Identifier 100) of being unable to weigh the patient, for the certification period of 03/29/2023 to 05/27/2023. During an interview on 05/23/2023 at approximately 2:05 p.m. with the Alt Adm/DON the surveyor discussed the findings and asked why Patient # 2 and # 3’s physician was not promptly alerted to the SN being unable to weigh the patients in accordance with their POC. The Alt Adm/DON stated that she “did it at the end of the certification period.” Review of agency policy titled “Monitoring Patient Care/Coordination of Care PC.10” revised 050119 read in part: “…Policy I. The Agency will monitor, evaluate, and report to the patient’s/client’s physician regarding the patient’s/client’s progress toward achieving goals established on the plan of care…Procedure I. The Agency will…Ensure communication with all physicians involved in the plan of care…” Review of American Heart Association website, https://www.ahajournals.org/doi/10.1161/circulationaha.107.690768, on 05/26/2023 revealed: “…Increases in body weight are associated with hospitalization for heart failure and begin at least 1 week before admission. Daily information about patients’ body weight identifies a high-risk period during which interventions to avert decompensated [inability of the heart to maintain adequate circulation] heart failure that necessitates hospitalization may be beneficial...” Review of American Family Physician’s website, https://www.aafp.org/pubs/afp/issues/2002/0215/p640.html, on 05/26/2023 revealed: “…The evaluation of unexplained weight loss in the elderly sometimes yields no cause other than “unexplained.” If a physical cause for the weight loss exists, it usually becomes evident within six months. Consequently, continued weight loss should be monitored, even when the initial evaluation does not supply a diagnosis…”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: This is a continuing deficiency cited at G 0612 during survey date 09/09/2020. Based on record review, observations, and interviews the agency failed to provide the patient and caregiver written instruction outlining visit schedules with frequency and medication schedule/instructions. Three (Patients # 5, # 6, and # 8) of three patients who received a home visit did not receive the required written instructions. The failure could place the patient’s health and safety at risk if the patient and caregiver did not understand what services to expect from the HHA, the purpose of each service and when to expect the services. Findings included: On 05/16/2023 the surveyor reviewed the agency's sample "Medicare" admission packet. The sample packet did not include a form for medication schedule/instructions. The sample packet did include a form for visit schedules. Patient # 5 Review of the clinical record for Patient # 5 revealed POC for the certification period of 03/07/2023 to 05/05/2023. The POC revealed a start of care date of 07/15/2021 and a primary diagnosis of chronic pain and other diagnosis of type 2 diabetes mellitus (Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). The POC contained an order for skilled nursing visits for one time per week for nine weeks. During a home visit conducted on 05/18/2023 at approximately 9:00 a.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. Continued review of the folder also revealed that it did not contain a patient medication schedule/instruction that included: medication name, dosage and frequency and which medications would be administered by HHA personnel and personnel acting on behalf of the HHA. The home folder included all documents that were in the sample Medicare admission packet. Patient # 6 Review of the clinical record for Patient # 6 revealed POC for the certification period of 03/26/2023 to 05/24/2023. The POC revealed a start of care date of 07/29/2022 and a primary diagnosis of bilateral osteoarthritis of knee and other diagnosis of chronic kidney disease. The POC contained an order for skilled nursing visits for one time per week for nine weeks: hha two times per week for eight weeks, and one time per week for eight weeks. During a home visit conducted on 05/18/2023 at approximately 10:00 a.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. Continued review of the folder also revealed that it did not contain a patient medication schedule/instruction that included: medication name, dosage and frequency and which medications would be administered by HHA personnel and personnel acting on behalf of the HHA. The home folder included all documents that were in the sample Medicare admission packet. Patient # 8 Review of the clinical record for Patient # 8 revealed POC for the certification period of 05/01/2023 to 06/29/2023. The POC revealed a start of care date of 05/01/2023 and a primary diagnosis of osteoarthritis, left knee. The POC contained an order for skilled nursing visits for one time per week for nine weeks; PT to evaluate and treat; hha two time per week for one week, three times per week for seven weeks, and two times per week for one week. During a home visit conducted on 05/18/2023 at approximately 12:00 p.m., the surveyor observed and reviewed the agency folder provided to the patient. The review revealed it did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. Continued review of the folder also revealed that it did not contain a patient medication schedule/instruction that included: medication name, dosage and frequency and which medications would be administered by HHA personnel and personnel acting on behalf of the HHA. The home folder included all documents that were in the sample Medicare admission packet. During an interview on 05/23/2023 at 1:30 p.m., the surveyor discussed the findings with the Alt Adm/DON and Office Mgr. of why the home folders for Patients # 5, # 6 and # 8 did not include a visit schedule that included frequency of visits and did not contain a patient medication schedule/instruction in accordance with regulatory requirements. The Alt Adm/DON stated for the visit schedule, “Because they know my visit schedule. I’m not sure that I’m aware of the requirement;” For the medication schedule/instructions, the Alt Adm/DON replied, “I don’t do that.” Review of agency policy titled “Implementing Care and Treatment PC.9” revised 120118 read in part: Procedure…VI. The Agency must provide the patient/client and caregiver with a copy of written instructions outlining: 1. Visit schedule, that included frequency of visits by Agency personnel and personnel acting on behalf of the Agency 2. Patient/Client medication schedule/instructions, including: medication name, dosage, time of medication administration, frequency and which medications will be administered by Agency personnel and personnel acting on behalf of the Agency...”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: This is a continuing deficiency cited at G 0658 during survey dated 09/09/2020. Based on record review and interview, the agency failed to conduct and document Performance Improvement Projects for the calendar years 2020, 2021 and 2022 (three of three years reviewed), that reflected the scope, complexity, and past performance of the agency's services and operations. The failure could place patients’ health and safety at risk if the agency did not identify health and safety concerns and develop improvement projects to address the concerns. Findings included: During the entrance conference on 05/16/2023 at 11:35 a.m., the surveyor requested all agency QAPI binders/reports/documents. Record review of the QAPI binder revealed the following records: The last QAPI report in the binder was titled “…QAPI 2nd Quarter” and dated 07/09/2020. The 2nd Quarter report read in part: “…PIP not yet implemented.” The binder did not include any documentation that showed the agency had any performance improvement project(s) either in development, on-going or completed for the years 2020, 2021, and 2022. During an interview with the Alt Adm/DON at 2:28 p.m. the surveyor asked if the agency had any additional QAPI records. She provided the following: An emergency preparedness binder that included policy, procedure, and training material for emergency preparedness. A Licensed and Certified orientation manual, which contained the following cover page: “Replacement sheets and covers reflecting name change for the following manuals inside…QAPI Manual…Business Profile…upon receipt, please remove these documents from this binder and place in the appropriate manual…” The orientation manual contained a QAPI quarterly report titled, “…Review Quarterly Report Quarter: 2nd/3rd” dated 10/07/2021. The binders did not include any documentation that showed the agency had any performance improvement project(s) either in development, on-going or completed for the years 2020, 2021, and 2022. The surveyor requested and reviewed the agency’s business profile manual. The manual contained a “Govering Body…Minutes of Meeting” dated 02/21/2019. The binder did not include any documentation that showed the agency had any performance improvement project(s) either in development, on-going or completed for the years 2020, 2021, and 2022. During an interview on 05/16/2023 with the Alt Adm/DON, at approximately 2:45 p.m., the surveyor asked what the agency’s processes for its QAPI program were. The Alt Adm/DON stated that it was contracted with the agency’s consultant (Consultant A). The surveyor also asked who was responsible for ensuring the agency’s QAPI program was conducted according to agency processes and according to regulations. The Alt Adm/DON stated that it was “outsourced now” (to Consultant A). The surveyor asked who at the agency was responsible for implementing the agency’s QAPI program. The Alt Adm/DON stated that she was responsible for the implementation of the agency’s QAPI program. During a telephone interview with Consultant A at approximately 3:00 p.m. on 05/16/2023, the surveyor discussed Consultant A’s role in the agency’s QAPI processes. Consultant A stated that she went “in and monitor/audit what the agency has already been monitoring.” She also stated that two to three years ago the agency was doing their own monitoring/audits but “in 2021 I came back. I did two quarters in one [year] for 2021.” She also stated that she did the 4th quarter of 2022 on 01/22/2023. Consultant A provided the 4th quarter report for 2022. The report was dated 01/30/2023. Record review of the 2022 4th quarter QAPI report (dated 01/30/2023) read in part: “Agency has chosen to do PIP in-house. Consultant provided information regarding PIP and Star Ratings. Sample left with Agency. Recommendation: Administrator and Clinical Manager to become familiar with Performance Improvement Project (PIP).” The report did not include any documentation that showed the agency had any performance improvement project(s) either in development, on-going or completed for the years 2020, 2021, and 2022. During an interview on 05/23/2023 at 1:35 p.m. the surveyor reviewed the above findings with the Alt Adm/DON and Office Mgr. and asked why the agency had not conducted performance improvement projects in the QAPI program that reflected the scope, complexity, and past performance of the agency's services and operations, as required by federal regulations, for the years 2020, 2021 and 2022. The Adm/DON replied, “It’s an oversight.” The Alt Adm/DON also stated that she was not aware of the requirement Review of agency policy titled "Quality Assessment Performance Improvement Program QAPI.1" reviewed 011318 read in part: "PROCEDURE...III...D...Performance Improvement Projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity and past performance of the Agency's services and operations. 2. The agency will document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects..."