Every finding on record at Uchange Inc.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/22/2023. Standard level deficiencies were cited. Abbreviations: POC = Plan of Care Pts. = Patients RN = Registered Nurse SN = Skilled Nurse

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan contained an updated community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/21/23 at 9:30 AM. The plan lacked documentation of an updated facility-based and or community-based risk assessment, utilizing an all-hazards approach. The last risk assessment was from 2019. 2. Findings of the Agency's Emergency Preparedness Plan lacking documentation of an updated risk assessment was confirmed during an interview with the Alternate Administrator on 12/21/2023 at 12:30 PM.

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), §485.542(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, REHs at §485.542, 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 a review of the Agency's Emergency Preparedness Plan, and Staff interview, it was determined that the Agency failed to ensure that the Agency conducted / participated in a full-scale Community Based Exercise or Facility Based Exercise since 2018. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/21/23 at 9:30 AM. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted / participated in any testing exercise or drills since 2018. 2. Findings of the Agency's Emergency Preparedness Plan lacking documentation of any testing was confirmed during an interview with the Alternate Administrator on 12/21/2023 at 12:30 PM.

A recertification survey was conducted on 12/22/2023. Standard level deficiencies cited. Abbreviations: POC = Plan of Care Pts. = Patients RN = Registered Nurse SN = Skilled Nurse

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 Physicians' orders were followed for 3 of 7 records reviewed (Pt. #1, 5 and 3). 4. Patient #3 was admitted to Home Health Services on 03/09/23 with Diagnosis of Heart Failure Unspecified. The clinical record was reviewed on 12/19/23 at 11:50 AM. The clinical record included a POC for the certification period of 11/4/23 to 01/02/24 requiring, "Notify Physician of Respirations: Greater than (>) 22 less Than ( The SN visit note dated 12/05/23 lacked weight assessment. 5. During interviews with the Alternate Administrator and Office Support Staff on 12/20/23 at 2:00 PM and on 12/21/23 at 10:30 AM, the above findings were confirmed. Findings include: 1.Patient #1, was admitted to the Home Health Services on 02/01/23 with the Diagnoses: Bilateral Primary Osteoarthritis of Hip and pressure Ulcer of Sacral region, Stage 1. The clinical record was reviewed on 12/19/23. The Physician orders dated 09/29/23 included orders for the SN frequency: 2 times a week for 2 weeks, 1 time a week for 5 weeks and 2 times a week for 1 week plus 2 as needed visits. The SN visit was not conducted on 11/01/23 (week #6). 2. Patient #5, was admitted to the Home Health Services on 11/20/23 with the Diagnoses: Encounter for Change or Removal of Surgical Wound dressing. The clinical record was reviewed on 12/20/23. The Physician orders dated 11/20/23 included orders for the SN frequency: 3 times a week for 1 week, 2 times a week for 7 weeks plus 2 as needed visits. The second SN visit was not conducted on 12/07/23 (week #3).

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 records review, policy 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 in 1 of 3 Patients (Pt. # 4) receiving Home Health Aide services. Findings include: 1. Patient #4 was admitted to the Home Health Services on 10/02/23 with diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/20/23 and included weekly Aide visits from 10/05/23 through 12/17/23. The record lacked documentation of Aide supervision by the RN on 12/16/23 (more than 14 days). 2. The Agency’s policy titled “Home Health Aide Supervision,” was reviewed on 12/21/23 at 12:30 PM and required “SPECIAL INSTRUCTIONS… 3…a. When skilled services are being provided to a client, a Registered Nurse/Therapist must make a supervisory visit to the client’s residence at least every two weeks…” 3. The findings were confirmed during the interview with the Alternate Administrator on 12/21/23 between 12:30 PM and 1:30 PM.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on onsite observations, policy review and staff interview, it was determined the Agency failed to maintain personnel files for review, as part of the day to day operations. This was observed for 2 of 14 Employees (Employee #7 and 11). Findings include: 1.On 12/19/23 at 10:45 AM, it was observed that the Clinical Manager (Employee #12) was not available to come to the office to assist with the survey until 12/20/23. It was observed the Agency's office was staffed with the Office Manager (Employee #11) and another office Staff (Employee # 7). It was observed that both Employees #7 and #11 were included on the list of employed staff as "contracted". 2. On 12/22/23 at 9:40 AM, the personnel files were requested for review. The Agency was not able to present the personnel files for Employees #11 and #7. 3. On 12/22/23 at 9:45 AM the Agency’s policy titled “Personnel Files” was reviewed and required “Personnel files will be established and maintained for all personnel…” 4. On 12/22/23 at 10:00 AM, during the interview with Employee #7, it was stated she has a personnel file but unable to locate the file. 5.The findings were confirmed during the interview with the Manager/ Alternate Administrator on 12/22/23 at 10:00 AM.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on onsite observations and staff interview, it was determined the Agency failed to ensure the Administrator or the pre-designated person to act in the absence of the Administrator, was available during operating hours. This was observed for 1 of 4 survey days (12/19/23). Findings include: 1.On 12/19/23 at 10:45 AM, it was observed that the Administrator (Employee #2) was not on site. The Administrator was contacted and was interviewed by telephone. The Administrator stated over the telephone, that the Director of Nursing (Employee #12) was covering as the Alternate Administrator and was not available to come to the office until 12/20/23. 2. On 12/19/23, it was observed that the Agency's office was staffed with the Office Manager (Employee #11) and another office Staff (Employee # 7). 3. The findings were confirmed during the interview with the Alternate Administrator on 12/20/23 between 1:30 PM and 2:30 PM, and on 12/22/23 at 10:00 AM.