Every finding on record at Wellcare Group Home Health Inc

A recertification survey was conducted on 12/13/2022. The census was 0 Licensed and Certified patients and 112 Personal Assistance Services patients. An exit conference was conducted on 12/19/2022. Abbreviations: COVID-19 SARS Coronavirus EPP- Emergency Preparedness Program or Plan QAPI- Quality Assurance Performance Improvement QAPI /PI- Quality Assurance Performance Improvement / Performance Improvement NAR/EMR – Nurse Aide Registry / Employee Misconduct Registry PAC – Personal Attendant Care PAS – Personal Assistance Services

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), §485.625(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 record review and interview the agency failed to maintain an emergency preparedness plan that was based on a risk assessment and updated at least every 2 years for 2019 and 2021. The risk assessment was last updated in 2017 and did not contain the risks from the COVID-19 pandemic. This failure placed the agency’s active patients at risk of harm during the actual emergency of the COVID-19 pandemic in 2019, 2020, 2021, and 2022. Review of the Emergency Preparedness manual provided by the Administrator on 12/13/2022 revealed a risk assessment document that was dated 2017. The risk assessment did not identify pandemic or COVID – 19 as a high-risk threat to the agency patients and staff. There were no updates to the risk assessment documented for 2019, 2020 or 2021. In an interview with the Administrator on 12/13/2022 at approximately 3:35 PM the surveyor asked if the agency had any additional information to add to the EPP documents. The Administrator stated they did not have anything else. The surveyor asked if the Administrator was the Disaster Coordinator for the agency, and the Administrator stated: “Yes.” The surveyor reviewed the findings of no evidence of an update to the risk assessment and internal reviews annually for 2019, 2020, 2021, after the COVID-19 pandemic, and the winter storms in February of 2021 and 2022, and through 12/13/2022. The Administrator stated that the lack of a risk assessment and the internal reviews “all go together.” The Administrator stated: “Ok, I cannot explain it. The Office Manager, [Employee A]’s mom is sick, and the employee is working from home.” The surveyor asked about the outcome of the deficient practice. The Administrator stated: “It depends on the individual (patient). Each client is in a different category. Someone in a wheelchair might not be able to help themselves. We will do a plan of correction.” Agency policy titled: “Emergency Preparedness and Response Plan EC.8 dated 080111 read in part: “Purpose – To ensure Agency develops, maintains, and implements a written Emergency Preparedness and Response Plan (Plan), based on the Agency’s risk assessment… Policy … The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that ore likely to occur in Agency’s service area…Agency will complete an internal review of the plan at least annually … to update the plan as needed… Procedure A. Risk Assessment Analysis 1. Agency will conduct a risk assessment to identify potential disasters likely to occur in the agency’s services area…”

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: This citation was previously cited during the survey that ended 12/30/2019. Based on record review and interview, the agency failed to conduct exercises to test the emergency plan annually for 3 (2020, 2021, and through December 2022) of 3 years of the review period for the survey. The agency also failed to document implementation of the plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed following severe winter storms in the Dallas and Fort Worth, Texas area February 2021 and February 2022. This failure placed the agency’s active patients at risk of harm during the actual emergencies in 2021 and 2022 and places all patients at risk from the agency’s inability to carry out an emergency plan effectively. A review of the emergency preparedness plan binder provided by the Administrator on 12/13/22 failed to find documentation of any records to establish the agency conducted an internal reviews annually for 2019, 2020, 2021, after the winter storms in February of 2021 and 2022 and through the date of review 12/13/2022. In an interview with the Administrator on 12/13/22 at approximately 3:35 PM, the surveyor asked if the agency had any additional information to add to the EPP documents. The Administrator stated they did not have anything else. The surveyor asked if the Administrator was the Disaster Coordinator for the agency, and the Administrator stated: “Yes.” The surveyor reviewed the findings of no evidence of internal reviews annually for 2019, 2020, 2021, after the winter storms in February of 2021 and 2022, and through 12/13/2022. The surveyor asked about the findings. The Administrator stated: “Ok, I cannot explain it. The Office Manager, [Employee A]’s mom is sick, and the employee is working from home.” The surveyor asked about the outcome of the deficient practice. The Administrator stated: “It depends on the individual (patient). Each client is in a different category. Someone in a wheelchair might not be able to help themselves. We will do a plan of correction.” The agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN...EC.8" with a revision date of 08/01/11 read in part: " The agency will 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..."

A recertification survey was conducted on 12/13/2022. The census was 0 Licensed and Certified patients and 112 Personal Assistance Services patients. An exit conference was conducted on 12/19/2022. Abbreviations: COVID-19 SARS Coronavirus EPP- Emergency Preparedness Program or Plan QAPI- Quality Assurance Performance Improvement QAPI /PI- Quality Assurance Performance Improvement / Performance Improvement NAR/EMR – Nurse Aide Registry / Employee Misconduct Registry PAC – Personal Attendant Care PAS – Personal Assistance Services

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Improvement / Performance Improvement Program to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that would enable the agency to assess processes of care, services, and operations for the three-year period of review 12/2019 to 12/2022. This failure subjected patients to substandard care from problems the agency had not evaluated and corrected. The surveyor requested the QAPI program documents during the entrance conference on 12/13/2022. A review of the QAPI documents provided by the Administrator on 12/13/2022 at 1:30 PM revealed: a written plan with blank forms to be completed. The forms were not completed. A review of the binder found no evidence of a review of implementation of the plan. There were no data collection documents, no analysis of current performance, no samples of auditing services furnished to clients in active and discharged charts, and no evidence of review of unprofessional conduct by licensed staff and misconduct by unlicensed staff, no infection control activities, and no review of personal assistance services to evaluate if the services were performed as outlined in the service plan. There was also no evidence of an annual agency evaluation of the total operation for 2019, 2020, and 2021. An interview was conducted with the Administrator on 12/13/2022 at 3:47 PM. The surveyor reviewed the findings of the review of the QAPI documents and asked about the QAPI activities the agency had conducted for the last three years. The Administrator stated: “In PAC [Personal Assistance Care] [it] is not too well defined, and they don’t have it [QAPI activities]. The surveyor asked about the outcome of the lack of QAPI activities. The Administrator stated: “This is my first time for [a] surveyor to ask for QAPI on PAS. They are not writing notes, so they don’t do notes, so we don’t do QAPI. The surveyor clarified the Administrator was speaking of the attendants who don’t write notes. The surveyor asked about the potential risks to the clients when the agency does not conduct QAPI documents. The Administrator stated: “I don’t think there is any potential risk for the client. I will look for anything else.” On 12/19/2022 the Administrator provided additional documents to the surveyor which included: A blank form titled Consumer Attendant Services or Family Care Transfer, A blank form titled Consumer Attendant Services / Primary Home Care. 5 documents titled: QUALITY ASSESSMENT/PERFORMANE IMPROVEMENT PAS SERVICE WELLCARE GROUP HOME HEALTH INC dated 12/29/2020, 06/10/2020, 06/29/2021, 12/29/2021, and 06/24/2022. The 4 documents were identical and contained the same typos (Chats for Charts), IDICATOR for Indicator, and rights of elderly (rights of the elderly), except for the dates as listed above, and the numbers either 1,2, 3 or 5 before the numbers of active charts or discharged charts. There were no completed audit forms or indication of which records were reviewed. Agency annual evaluation forms for 2019, 2020, and 2021 with only the Administrator’s signature on them in the area designated for the evaluation committee members signatures. On 12/19/2022 after review of the additional documents provided, the surveyor requested the forms used for completing the audits. The Administrator stated he had no other documents to provide. An interview was conducted with the Administrator on 12/19/2022 at 4:37 PM. The surveyor reviewed the findings from the review of the additional QAPI documents provided by the Administrator. The surveyor asked about the lack of evidence of the active and discharged charts reviewed. The Administrator stated he had watched the Alternate Administrator type the QAPI documents provided to the surveyor this past weekend, and there were no other documents available for the surveyor to review. The surveyor requested to interview the Alternate Administrator and the Administrator stated: “She has another job and works nights and is sleeping.” The surveyor asked why there were no signatures on the agency annual evaluations for the other participants. The Administrator stated he had completed the three years reports last week and there were no other participants. The Administrator stated: “The way I did it before was to go to their offices.” The surveyor asked if the members listed on the agency annual evaluation had participated in the agency’s annual evaluation. The Administrator stated they had not participated. A review of the agency policy and procedures revealed a policy titled: "Quality Assessment Performance Improvement Plan QAPI.1” with a revision date of 060106 which read in part: "Purpose - To develop a Quality Assessment Performance Improvement (QAPI)/Performance Improvement Plan, implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal services and are used in the care planning and coordination of services and events. Policy - Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee. Agency will strive to improve operational and client health outcomes by implementing a performance improvement plan that incorporates the following essential processes: Designing processes, Monitoring performance through data collection, analyzing current performance, and improving and sustaining improved performance over time… Areas for improvement will be identified through the collection of data for analysis of Agency services. System of measures significant outcomes for optimal care include: A representative sample of services furnished to clients contained in both active and discharged charts, Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, Infection control activities, Services have been performed as outlined in the services plan, Client complaints and satisfaction survey data, including agency response to complaints, Effectiveness and safety of all services provided, including: Competency of agency staff, Promptness of service delivery, Agency leaders will be responsible for setting expectations, developing plans and managing processes to improve the Agency’s performance …”

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 record review and interview the Administrator failed to be responsible for all day-to-day operations of the agency and failed to be responsible for implementing and supervising the administrative policies of the agency and administratively supervising the provision of all services. The Administrator failed to ensure that the policies for QAPI, Emergency Preparedness, and Personnel Records were implemented for the survey review period of December 2019 to December 2022. The outcome was the patients and staff were subjected to risk of poor or unsafe care from agency problems not being identified and corrected, the agency not being prepared for emergencies and staff whose qualifications and competence had not been evaluated. QAPI A review of the QAPI documents provided by the Administrator on 12/13/2022 at 1:30 PM revealed: a written plan with blank forms to be completed. The forms were not completed. A review of the binder found no evidence of a review of implementation of the plan. There were no data collection documents, no analysis of current performance, no samples of auditing services furnished to clients in active and discharged charts, and no evidence of review of unprofessional conduct by licensed staff and misconduct by unlicensed staff, no infection control activities, and no review of personal assistance services to evaluate if the services were performed as outlined in the service plan. There was also no evidence of an annual agency evaluation of the total operation for 2019, 2020, and 2021. An interview was conducted with the Administrator on 12/13/2022 at 3:47 PM. The surveyor reviewed the findings of the review of the QAPI documents and asked about the QAPI activities the agency had conducted for the last three years. The Administrator stated: “In PAC [it] is not too well defined, and they don’t have it [QAPI activities]. The surveyor asked about the outcome of the lack of QAPI activities. The Administrator stated: “This is my first time for [a] surveyor to ask for QAPI on PAS. They are not writing notes, so they don’t do notes, so we don’t do QAPI. The surveyor clarified the Administrator was speaking of the attendants who don’t write notes. The surveyor asked about the potential risks to the clients when the agency does not conduct QAPI documents. The Administrator stated: “I don’t think there is any potential risk for the client. I will look for anything else.” On 12/19/2022 the Administrator provided additional documents to the surveyor which included: A blank form titled Consumer Attendant Services or Family Care Transfer, A blank form titled Consumer Attendant Services / Primary Home Care. 5 documents titled: QUALITY ASSESSMENT/PERFORMANE IMPROVEMENT PAS SERVICE WELLCARE GROUP HOME HEALTH INC dated 12/29/2020, 06/10/2020, 06/29/2021, 12/29/2021, and 06/24/2022. The 4 documents were identical and contained the same typos (Chats for Charts), IDICATOR for Indicator, and rights of elderly (rights of the elderly), except for the dates as listed above, and the numbers either 1,2, 3 or 5 before the numbers of active charts or discharged charts. There were no completed audit forms or indication of which records were reviewed. Agency annual evaluation forms for 2019, 2020, and 2021 with only the Administrator’s signature on them in the area designated for the evaluation committee members signatures. On 12/19/2022 after review of the additional documents provided the surveyor requested the forms used for completing the audits. The Administrator stated he had no other documents to provide. An interview was conducted with the Administrator on 12/19/2022 at 4:37 PM. The surveyor reviewed the findings from the review of the additional QAPI documents provided by the Administrator. The surveyor asked about the lack of evidence of the active and discharged charts reviewed. The Administrator stated he had watched the Alternate Administrator type the QAPI documents provided to the surveyor this past weekend, and there were no other documents available for the surveyor to review. The surveyor requested to interview the Alternate Administrator and the Administrator stated: “She has another job and works nights and is sleeping.” The surveyor asked why there were no signatures on the agency annual evaluations for the other participants. The Administrator stated he had completed the three years reports last week and there were no other participants. The Administrator stated: “The way I did it before was to go to their offices.” The surveyor asked if the members listed on the agency annual evaluation had participated in the agency’s annual evaluation. The Administrator stated they had not participated. EMERGENCY PREPAREDNESS A review of the emergency preparedness plan binder provided by the Administrator on 12/13/22 failed to find documentation of any records to establish the agency conducted an internal review annually for 2019, 2020, 2021, after the winter storms in February of 2021 and 2022, and through the date of review 12/13/2022. In an interview with the Administrator on 12/13/19 at approximately 3:35 PM the surveyor, asked if the agency had any additional information to add to the EPP documents. The Administrator stated they did not have anything else. The surveyor asked if the Administrator was the Disaster Coordinator for the agency, and the Administrator stated: “Yes.” The surveyor reviewed the findings of no evidence of internal reviews annually for 2019, 2020, 2021, after the winter storms in February of 2021 and 2022, and through 12/13/2022. The surveyor asked about the findings. The Administrator stated: “Ok, I cannot explain it. The Office Manager, [Employee F]’s mom is sick and the employee is working from home.” The surveyor asked about the outcome of the deficient practice. The Administrator stated: “It depends on the individual (patient). Each client is in a different category. Someone in a wheelchair might not be able to help themselves. We will do a plan of correction.” PERSONNEL POLICY / PERFORMANCE EVALUATIONS Active employee list provided by the Administrator on 12/13/22 reflected the following: Attendant A was hired as an attendant on 12/28/15 Attendant B was hired as an attendant on 10/19/21 Attendant C was hired as an attendant on 06/12/18 Attendant D was hired as an attendant on 11/01/16 Attendant E was hired as an attendant on 08/30/21 Review of Attendant A’s personnel record did not include evidence of an annual performance evaluation in 2020, and 2021. Review of Attendant B’s personnel record did not include evidence of an annual performance evaluation in 2020, 2021 and 2022. Review of Attendant C’s personnel record did not include evidence of an annual performance evaluation in 2020, 2021 and 2022. Review of Attendant D’s personnel record did not include evidence of an annual performance evaluation in 2020, 2021 and 2022. Review of Attendant E’s personnel record did not include evidence of an annual performance evaluation in 2020, 2021 and 2022. In an interview with the Administrator on 12/19/22 at approximately 4:30pm, the surveyor presented the above findings. The Administrator stated, “it is a little confusing, we do performance evaluations for skilled and unskilled employees, and it is confusing.” “We must treat them the same” (attendants and skilled care employees) and the administrator stated, “I am responsible for all policy enforcement and to make sure personnel records are there.” The administrator stated the possible outcome risk was, “Without evaluations the client may be exposed to an attendant that is not knowledgeable for the job.” AGENCY POLICIES AND PROCEDURES Agency policy and procedure titled: “Responsibilities of the Administrator LD.4” dated 04/01/2013 read in part: “Agency Administrator will assume overall responsibility and authority for administrative and leadership functions … The Administrator will be responsible for implementing and supervising the administrative policies and operations of the agency… Administratively supervise the provision of quality care to agency patients / clients, supervise to ensure the implementation of agency policy and procedures, Ensuring maintenance of the appropriate personnel records, administrative records, and policy and procedures of Agency…” A review of the agency policy and procedures revealed a policy titled: "Quality Assessment Performance Improvement Plan QAPI.1” with a revision date of 060106 which read in part: "Purpose - To develop a Quality Assessment Performance Improvement (QAPI)/Performance Improvement Plan, implemented by the QAPI/PI committee, that captures significant outcomes that are essential to optimal services and are used in the care planning and coordination of services and events. Policy - Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee. Agency will strive to improve operational and client health outcomes by implementing a performance improvement plan that incorporates the following essential processes: Designing processes, Monitoring performance through data collection, analyzing current performance, and improving and sustaining improved performance over time… Areas for improvement will be identified through the collection of data for analysis of Agency services. System of measures significant outcomes for optimal care include: A representative sample of services furnished to clients contained in both active and discharged charts, Issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff, Infection control activities, Services have been performed as outlined in the services plan, Client complaints and satisfaction survey data, including agency response to complaints, Effectiveness and safety of all services provided, including: Competency of agency staff, Promptness of service delivery, Agency leaders will be responsible for setting expectations, developing plans and managing processes to improve the Agency’s performance …” The agency policy titled "EMERGENCY PREPAREDNESS AND RESPONSE PLAN...EC.8" with a revision date of 08/01/11 read in part: " The agency will 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..." Review of agency policy dated 02/01/02 and titled, PAS Policy Manual – HOME CARE Personnel Performance Evaluations, quoted in part, HR.6- page 1 of 1. Purpose – To establish a consistent process for assessing Agency staff members’ demonstrated ability to achieve the expectations stated in the respective job descriptions. Policy – Agency will establish a consistent process utilizing objective, measurable criteria for assessing Agency staff members’ demonstrated ability to achieve the expectations stated in the respective job descriptions, to identify individual growth needs, and to implement an improvement plan, as needed. Procedure; 1. Agency’s performance evaluation will be continuous and will include input from each employee’s direct supervisor, and from each employee. 2. Formal performance evaluations will be performed and documented annually. 3. All documentation of ongoing performance evaluations (whether positive, negative or progress comments) will be completed and reviewed with the employee, signed by both parties, and filed in the employee’s personnel record.