Every finding on record at Vanguard Health & Wellness, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 4/12/24. Standard level deficiency cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness program, review of personnel files and Staff interview, it was determined that the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness program and personnel files were reviewed on 04/10/24 at 1:00 PM. The Agency’s Emergency Preparedness program and personnel files lacked documentation that the Agency conducted Emergency preparedness training in 2021, 2022 and 2023. 2. During interview with the Administrator and Director of Nursing on 04/11/24 at 12:00 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 4/12/24. The Agency was in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies, for this survey.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 4/29/21. Standard level deficiency cited. Abbreviations: WK = Week E = Employee AM = Morning mg = milligrams POC = Plan of Care SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse HFA = Hydrofluroalkane PM = Afternoon/Evening HHA = Home Health Aide SOB = Shortness of Breath Pt./Pts. = Patient/Patients DON = Director of Nursing COVID-19 = Coronavirus 2019 MSW = Medical Social Worker PTA = Physical Therapy Assistant OTA = Occupational Therapy Assistant PT = Physical Therapy/Physical Therapist OT = Occupational Therapy/Occupational Therapist SARS = Severe Acute Respiratory Syndrome

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: . A. Based on a clinical record review and staff interview, it was determined the Agency failed to ensure the POC was followed per physician's order. This was found in 3 of 10 (Pts. # 7, 4 and 8) clinical record reviews. Findings include: 1. Pt. #7. SOC 3/2/21. Primary Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 4/27/21 at 9:40 AM. The record contained a POC for the period of 3/2/21 to 4/30/21 which required: HHA Frequency: 2 week 9. The clinical record lacked documentation of a second HHA visit for the week of 3/28/21 to 4/3/21 and lacked documentation the clinical manager and the physician were notified. 2. Pt. #4. SOC 1/22/21. Primary Diagnosis: Other Displaced Fracture of Upper End Right Humerus. The clinical record was reviewed on 4/27/21 at 2:30 PM. The record contained the OT care plan dated 3/22/21 and signed by the Physician, which indicated "Visit Frequency 2WK4 starting 3/28/21." The record lacked documentation the OT/OTA provided twice weekly service for the week of 3/28/21 to 4/3/21. There was no documentation the OT/OTA notified the Physician of these missed visits. 3. Pt. #8. SOC 8/27/20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/28/21 at 10:50 AM. The record contained the Physician order dated 10/29/20: "Please provide Physical Therapy for pain management, gait training, strength, and endurance." The record lacked documentation the PT subsequently evaluated the Pt., or a Physician's order to cancel PT services. 4. During an interview with the Administrator and the DON on 4/28/21 at 1:45 PM, the DON confirmed the above findings, and stated missed visits should be made up before the end of the treatment week. If this isn't possible, the Physician should be notified.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, observations and interview during home visits, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were provided a written list of their medications. This was found in 2 of 4 Pts. (Pt. #3 and 4) home visits conducted. Findings include: 1. Pt. #3. SOC 2/16/21. Primary Diagnosis: Fibromyalgia. The clinical record was reviewed on 4/27/21 at 9:30 AM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period beginning 4/17/21 which contained a list of the patient's medications with the dosage, frequency, route of administration, classification and effective date of each medication. A home visit was conducted with E #1 (HHA) on 4//27/21 at 10:40 AM. During the home visit the Patient's admission folder was observed and reviewed; the folder lacked a written list of the patient's medications. During an interview with the Pt.#3, the Pt. stated the Agency did not provide a written list of the medications. 2. Pt. #4. SOC 1/22/21. Primary Diagnosis: Other Displaced Fracture of Upper End Right Humerus. The clinical record was reviewed on 4/27/21 at 2:30 PM. The record contained the "Patient Medication Profile" form completed by the RN for the certification period beginning 3/23/21 which contained a list of the patient's medications with the dosage, frequency, route of administration, classification and effective date of each medication. A home visit was conducted with E #2 (OT) on 4//27/21 at 12:30 PM. During the home visit the Patient's admission folder was observed and reviewed; the folder lacked a written list of the patient's medications. During an interview with the Pt. #4 and Pt. #4's Caregiver, both stated the Agency did not provide a written list of the medications. 3. The Agency policy titled "Medication Profile" was reviewed on 4/28/21 at 1:20 PM. The policy required: "...The original Medication record will be filed in the Patient's Medical Record. A copy may be placed in the Patient's home..." 4. During an interview with the Administrator and the DON on 4/28/21 1:45 PM, the DON confirmed the Pts. indicated above lacked a written list of their medications.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing care and/or service. This was found in 7 of 10 (Pts. # 7, 9, 3, 4, 5, 6 and 8) clinical records reviewed, wherein Pt. COVID-19 screening was required. Findings include: 1. Pt. #7. SOC 3/2/21. Primary Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 4/27/21 at 9:40 AM. The record contained SN notes dated: 3/9/21, 3/16/21, 3/23/21, 3/30/21, 4/6/21, 4/13/21 and 4/20/21, indicating that Pt. #7 received SN service on those dates. The record lacked documentation the Pt. was screened for signs and symptoms of COVID prior to these visits. 2. Pt. #9. SOC 7/27/20. Primary Diagnosis: Atrial Fibrillation. The clinical record was reviewed on 4/27/21 at 12:30 PM. The record contained SN notes dated: 8/4/20, 8/11/20, 8/25/20, 9/2/20, 9/8/20, 9/15/20 and 9/22/20, indicating that Pt. #9 received SN service on those dates. The record lacked documentation the Pt. was screened for signs and symptoms of COVID prior to these visits. 3. Pt. #3. SOC 2/16/21. Primary Diagnosis: Fibromyalgia. The clinical record was reviewed on 4/27/21 at 9:30 AM. The record contained documentation the SN provided weekly service from 3/23/21 to 4/20/21. The SN visit notes lacked documentation the SN screened the Pt. for COVID-19 symptoms prior to providing service. The record also included documentation the PT/PTA provided twice weekly service from 3/2/21 to 4/15/21. The record lacked documentation the PT/PTA screened the Pt. prior to providing service. The record also contained a OT visit note dated 4/16/21, indicating the OT provided service. The record lacked documentation the OT screened the Pt. for symptoms of COVID-19 prior to this visit. 4. Pt. #4. SOC 1/22/21. Primary Diagnosis: Other Displaced Fracture of Upper End Right Humerus. The clinical record was reviewed on 4/27/21 at 2:30 PM. The record contained documentation the SN provided service on 3/18/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to this visit. The record also contained documentation the OT/OTA provided service on 3/5/21, 3/10/21, 3/12/21, twice weekly from 4/9/21 to 4/17/21, as well as on 4/21/21 and 4/27/21. The record lacked documentation the OT/OTA screened the Pt. for symptoms of COVID-19 prior to these visits. 5. Pt. #5. SOC 3/31/20. Primary Diagnosis: Pneumonia due to SARS-Associated Coronavirus. The clinical record was reviewed on 4/26/21 at 3:15 PM. The record contained documentation the SN provided weekly service from 4/5/21 to 4/23/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to these visits. The record also included documentation the PT/PTA provided twice weekly service from 4/5/21 to 4/22/21. The record lacked documentation the PT/PTA screened the Pt. for symptoms of COVID-19 prior to these visits. 6. Pt. #6. SOC 2/22/21. Primary Diagnosis Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 4/28/21 at 9:50 AM. The record contained documentation the SN provided weekly service from 3/3/21 to 4/20/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to these visits. The record also included documentation the PT/PTA provided twice weekly service from 3/8/21 to 4/15/21. The record lacked documentation the PT/PTA screened the Pt. for symptoms of COVID-19 prior to these visits. The record also contained a MSW visit note dated 3/9/21, indicating the MSW provided service. The record lacked documentation the MSW screened the Pt. for symptoms of COVID-19 prior to this visit. 7. Pt. #8. SOC 8/27/20. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/28/21 at 10:50 AM. The record contained documentation the SN provided service on 11/12/21, 11/19/21, 12/17/21, and 12/23/21. The record lacked documentation the SN screened the Pt. for symptoms of COVID-19 prior to these visits. 8. During an interview with the Administrator and the DON on 4/28/21 at 1:45 PM, the DON confirmed the above findings, and stated the Agency requires clinical staff providing Pt. care must screen the Pt. for symptoms of COVID-19 prior to providing service, and document these screenings in the Patient's clinical record.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on observations and interviews during home visits, clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure the clinical record contained accurate medication records. This was found in 2 of 4 Pts. (Pt. #3 and 4) home visits conducted. Findings include: 1. Pt. #3. SOC 2/16/21. Primary Diagnosis: Fibromyalgia. SOC 2/16/21. The clinical record was reviewed on 4/27/21 at 9:30 AM. A home visit was conducted on 4/27/21 at 10:40 AM, along with E #1 (HHA). During this home visit, an observation was made of Pt. #3's medications, which was compared with Pt. #3's Medication Profile. This Medication Profile did not include the following medications: Ferrous Sulfate 325 mg daily, and Pantoprazole 40 mg daily before breakfast. Pt. #3 denied taking the following medications, which were listed on this Medication Profile: Aspirin 81 mg daily, Omeprazole 40 mg daily, Miralax 17 gm daily as needed for constipation, and Albuterol Sulfate HFA 2 puffs every 4 hours as needed for SOB. As of 4/27/21, the Medication Profile was inaccurate. 2. Pt. #4. SOC 1/22/21. Primary Diagnosis: Other Displaced Fracture of Upper End Right Humerus. A home visit was conducted on 4/27/21 at 12:30 PM, along with E #2 (OT). During this home visit, an observation was made of Pt. #4's medications, which was compared with Pt. #4's Medication Profile. This Medication Profile did not include the following medication: Geritol one tablet daily. Pt. #4 denied taking the following medications, which were listed on this Medication Profile: Diclofenac 75 mg twice a day, Meclizine 25 mg three times a day as needed, Vitamin D2 50,000 Units once a week, Cyclobenzaprine 5 mg tablet 3 times a day as needed, Hydrocodone-Acetaminophen 10 mg-325 mg one tablet every 4 hours as needed, Meloxicam 15 mg daily, and Pantoprazole 40 mg daily. The clinical record was reviewed on 4/27/21 at 2:30 PM. The record lacked any Physician orders for changes in medications. As of 4/27/21, the Medication Profile was inaccurate. 3. The Agency policy titled "Medication Profile" was reviewed on 4/28/21 at 1:20 PM. The policy required "...The Nurse or Therapist will add all new/changed medication(s) to the medication profile. Discontinued ("D/C") medications will be documented and dated..." 4. During an interview with the Administrator and the DON on 4/27/21 at 1:45 PM, the DON confirmed the above Medication Profiles were inaccurate.