Every finding on record at Xcel Healthcare Providers, Inc

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed 05/31/22.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on review of documentation and staff interview, the facility failed to maintain an emergency preparedness program per the requirements of 42 CFR 484.102. This had the potential to affect all clients receiving services from the agency. During survey of the facility from 05/25/22 to 05/31/22, the facility failed to provide any documentation of their emergency preparedness program including procedures and policies, training and testing. Administrative staff were present when this deficiency was identified and verified the lack of an emergency preparedness program.

Extended Recertification Survey Substantial Allegation Survey Substantial Allegation OH0062887. Xcel Healthcare Providers Inc. is in compliance with the requirements of 42 CFR Part 484, Subpart B, C for Home Health Agency.

Substantial Allegation Survey Substantial Allegation 31968 An entrance conference was conducted on 10/18/21 at 10:15 AM with administrative personnel, and an exit conference was completed on 10/19/21 at 4:00 PM with administrative personnel. No deficiencies were cited related to allegations contained in substantial allegation 31968 completed on 10/19/21; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiencies are cited. Xcel Healthcare Providers, Inc 368051, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care for three of four medical records reviewed (Patient #1, #3, and #4). This could affect all patients receiving services from the agency. The agency census was 94. Findings include: 1. Review of the medical record for Patient #1 revealed a plan of care dated 08/21/21 to 10/19/21 with orders for home health aide services up to 35 hours per week for nine weeks. The medical record contained documentation of 36 hours and 50 minutes to 41 hours and 41 minutes per week the weeks of 09/05/21, 09/12/21, 09/26/21, and 10/03/21. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 10/19/21 at 1:50 PM. 2. Review of the medical record for Patient #3 revealed plans of care dated 08/14/21 to 10/12/21 and 10/13/21 to 12/11/21 with orders for home health aide services up to 56 hours per week for nine weeks. The medical record contained documentation of 14 to 39 hours of home health aide services provided each week from 09/19/21 to 10/16/21. The medical record contained documentation of physician notification of home health aide missed visits on 09/21/21 and 10/06/21 through 10/13/21, but only if a visit was not made daily. The medical record lacked documentation of physician notification that the amount of hours of home health aide services ordered were not provided. The findings were verified in an interview with Staff B on 10/19/21 at 1:50 PM. 3. Review of the medical record for Patient #4 revealed a plan of care dated 08/02/21 to 09/30/21 with orders for home health aide services up to 14 hours per week for nine weeks. The medical record contained documentation of 20 hours of home health aide services the weeks of 09/19/21 and 09/26/21. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 10/19/21 at 3:40 PM.

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 medical record review and staff interview, the agency failed to ensure the plans of care included the frequency and duration of visits to be made for four of four medical records reviewed (Patient #1, #2, #3, and #4). This could affect all patients receiving services from the agency. The agency census was 94. Findings include: 1. Review of the medical record for Patient #1 revealed a plan of care dated 08/21/21 to 10/19/21 with orders for home health aide services up to 35 hours per week for nine weeks. The orders lacked the frequency and duration of the home health aide hours to be provided. The medical record contained documentation from 09/05/21 to 10/09/21 of daily visits from four hours and 12 minutes to seven hours and nineteen minutes each visit and from 26 hours and 35 minutes to 41 hours and 41 minutes per week. The findings were verified in an interview with Staff B on 10/19/21 at 1:50 PM. 2. Review of the medical record for Patient #2 revealed a plan of care dated 07/21/21 to 09/18/21 with orders for home health aide services up to seven hours per week for nine weeks. The orders lacked the frequency and duration of the home health aide hours to be provided. The medical record contained documentation the week of 08/15/21 of two home health aide visits for three hours each visit. The medical record contained documentation the week of 08/22/21 of two home health aide visits, one for a three hours and 33 minutes and one for an hour and two minutes. The findings were verified in an interview with Staff B on 10/19/21 at 1:50 PM. 3. Review of the medical record for Patient #3 revealed plans of care dated 08/14/21 to 10/12/21 and 10/13/21 to 12/11/21 with orders for home health aide services up to 56 hours per week for nine weeks. The orders lacked the frequency and duration of the home health aide hours to be provided. The medical record contained documentation of 14 to 39 hours of home health aide services provided each week from 09/19/21 to 10/16/21. Home health aide visits were from four to eight hours each visit. The medical record contained documentation daily of either a home health aide visit or a missed visit. The findings were verified in an interview with Staff B on 10/19/21 at 1:50 PM. 4. Review of the medical record for Patient #4 revealed a plan of care dated 08/02/21 to 09/30/21 with orders for home health aide services up to 14 hours per week for nine weeks. The medical record contained a plan of care dated 10/01/21 to 11/29/21 with orders for home health aide services up to 20 hours per week for nine weeks. The orders lacked the frequency and duration of the home health aide hours to be provided. From 09/19/21 to 10/09/21, the medical record contained documentation of 20 hours of home health aide services per week with five visits per week for four hours each visit. The findings were verified in an interview with Staff B on 10/19/21 at 3:40 PM.