Every finding on record at Zuni Home Health Care Agency, Inc.

E0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 06/01/22 to 06/03/22 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

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: E0001- CONDITION Based on emergency preparedness (EP) plan review and interviews, the home health agency (HHA) failed to develop and maintain a comprehensive EP plan that would address the health, safety, and security needs of the agency staff and patients in the event of a community natural, man-made, or facility-based emergency or disaster situation. The HHA failed to ensure the EP plan included required policies and procedures updated at least every two years, develop, and maintain a communication plan, provide staff training, and test the effectiveness of the EP plan. These deficient practices had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: The HHA failed to ensure the EP was reviewed and updated at least every two years. (See findings in tag E0004) The HHA failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach, was conducted, and strategies for addressing emergency events were developed based on the risk assessment. (See findings in tag E0006) The HHA failed to ensure the EP addressed the patient population and the type of services the HHA had the ability to provide in an emergency. (See findings in tag E0007) The HHA failed to ensure the EP included the process for cooperating and collaborating with local, tribal, regional, State, and federal emergency preparedness officials. (See findings in tag E0009) The HHA failed to develop and update policies and procedures based on a facility and community-based risk assessment at least every two years (See findings in tag E0013) The HHA failed to maintain an EP communication plan that complied with Federal, State, and local laws and was reviewed and updated at least every two years. (See findings in tag E0029) The HHA failed to ensure the communication plan included a method for sharing information with other health providers for continuity of care and a means of providing information about the general condition and location of patients. (See findings in tag E0033) The HHA failed to ensure the communication plan included a means of providing information about the agency’s occupancy, needs, and its ability to assist the authority having jurisdiction. (See findings in tag E0034) The HHA failed to ensure its EP included the requirement that the training and testing of the program be reviewed and updated at least every two years. (See findings in tag E0036) The HHA failed to ensure the HHA staff received training on the agency’s EP every two years. (See findings in tag E0037) The HHA failed to ensure the HHA conducted emergency preparedness exercises annually to test the EP. (See findings in tag E0039)

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: E0004 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP was reviewed and updated at least every two years. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP had not reviewed and updated since October 2018. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, BC stated the agency had a staff meeting in April 2022 regarding the EP plan. BC stated revisions needed were discussed, but the revisions have not been completed. BC confirmed the HHA’s EP had not been reviewed and updated at least every two years as required by regulation.

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: E0006 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach, was conducted, and strategies for addressing emergency events were developed based on the risk assessment. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP did not include a documented facility-based and community-based risk assessment, utilizing an all-hazards approach. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, BC stated the agency had a staff meeting in April 2022 regarding the EP plan. BC and Administrator confirmed a facility-based and community-based risk assessment, utilizing an all-hazards approach, had not been conducted.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: E0007 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP addressed the patient population and the type of services the HHA had the ability to provide in an emergency. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP did not address the patient population and the type of services the HHA had the ability to provide in an emergency. The EP indicated the name of an individual no longer employed by the HHA as having the authority to implement the EP. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, Administrator and BC confirmed the EP did not address the patient population and the type of services the HHA had the ability to provide in an emergency. BC confirmed the individual named as having the authority to implement the EP was no longer employed.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: E0009 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the EP included the process for cooperating and collaborating with local, tribal, regional, State, and federal emergency preparedness officials. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP did not address the process for cooperating and collaborating with local, tribal, regional, State, and Federal emergency preparedness officials. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, Administrator and BC confirmed the EP did not address the process for cooperating and collaborating with local, tribal, regional, State, and Federal emergency preparedness officials.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: E0013 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to develop, and update at least every two years, policies and procedures based on a facility and community-based risk assessment. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated a facility-based and community-based risk assessment had not been conducted, and the policies and procedures that had been developed (without the risk assessment being conducted) had not been reviewed and updated at least every two years. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, BC stated the agency had a staff meeting in April 2022 regarding the EP plan. BC stated revisions needed were discussed, but the revisions have not been done. Administrator and BC confirmed the HHA had not conducted a facility-based and community-based risk assessment, and the policies and procedures were not based on such an assessment.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: E0029 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to maintain an EP communication plan that complied with Federal, State, and local laws and was reviewed and updated at least every two years. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP communication plan had not been reviewed and updated at least every two years. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, Administrator and BC confirmed the EP’s communication plan had not been reviewed and updated since October 2018.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: E0033 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the communication plan included a method for sharing information with other health providers for continuity of care and a means of providing information about the general condition and location of patients. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP communication plan did not include a method for sharing information with other health providers for continuity of care and a means of providing information about the general condition and location of patients. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, Administrator and BC confirmed the EP’s communication plan did not address a method for sharing information with other health providers and a means of providing information about the general condition and location of patients.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: E0034 Based on emergency preparedness plan (EP) review and interview, the home health agency (HHA) failed to ensure the communication plan included a means of providing information about the agency’s needs, and its ability to assist the authority having jurisdiction. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated the EP communication plan did not include a means of providing information about the agency’s needs, and its ability to assist the authority having jurisdiction. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, Administrator and BC confirmed the EP’s communication plan did not address a means of providing information about the agency’s needs, and its ability to assist the authority having jurisdiction.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: E0036 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure its emergency preparedness plan (EP) included the requirement that the training and testing of the program be reviewed and updated at least every two years. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated training and testing of the EP was not addressed in the plan. In an interview on 06/02/22 at 1:30 PM with Administrator and BC, BC stated the agency had a staff meeting in April 2022 regarding the EP plan. BC stated revisions needed were discussed, but the revisions have not been done. BC confirmed the EP did not include information about the training and testing of the EP.

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), §485.625(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, "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: E0037 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure the HHA staff received training on the agency’s emergency preparedness plan (EP) every two years. This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated training of the HHA staff on the agency’s EP was not included in the plan. There was no documentation presented that indicated the HHA staff had received training at least every two years. In an interview on 06/02/22 at 1:30 PM, BC stated BC spoke with Office Manager (OM) by phone and verified that the HHA had never conducted EP training with the staff.

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: E0039 Based on emergency preparedness plan review and interview, the home health agency (HHA) failed to ensure the HHA conducted emergency preparedness exercises annually to test the emergency preparedness plan (EP). This deficient practice had the potential to affect the current six patients, the eight employees, and any future patient admitted to the HHA for services and any future employee hired by the HHA. Findings include: Review of the HHA’s “Emergency Preparedness Plan,” dated October 2018 and presented as the agency’s current plan by Billing Clerk (BC), indicated testing of the agency’s EP was not included in the plan. There was no documentation the agency’s EP had been tested annually. Specifically, there is no documentation the HHA had participated in a full-scale community-based exercise, an individual facility-based exercise, or a table-top exercise. In an interview on 06/02/22 at 1:30 PM, BC stated BC spoke with Office Manager (OM) by phone and verified that the HHA had never conducted EP exercises to test the EP.

G0000 A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of State of New Mexico Department of Health. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 06/01/22 to 06/03/22 resulted in noncompliance with Conditions of Participation Care Planning, Coordination, and Quality of Care, Infection Prevention and Control, and Quality Assessment/Performance Improvement respective to applicable CoP under 42 CFR 484 Subparts A through C and the following standard-level deficiencies listed below. The HHA census was six.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: G570- CONDITION Based on record reviews, policy reviews, observation, and interviews, the home health agency (HHA) (1) failed ensure physician orders were obtained and implemented and (2) failed to ensure the registered nurse (RN) documented telephone orders in accordance with agency policy. These deficient practices had the potential to affect the current six patients and any future patient admitted for services. Findings include: 1. The HHA failed to ensure physician orders were obtained and implemented for referrals to home health, wound care, lab draws, and/or extra nursing visits for six (Patient (P) 1, P3, P4, P5, P6, P7) of seven patient records reviewed for physician orders and referrals. (See findings in tag G580) 2. The HHA failed to ensure the registered nurse documented telephone orders in accordance with agency policy for two (Patient (P) 4, P7) of seven patient records reviewed for telephone orders. (See findings in tag G584)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: G580 Based on policy review, record reviews, and interviews, the home health agency (HHA) failed to ensure physician orders were obtained and implemented for referrals to home health, wound care, lab draws, and/or extra nursing visits for six of seven patient (Patient (P) 1, P3, P4, P5, P6, P7) records reviewed. This deficient practice had the potential to affect the current six patients and any future patient admitted for services. Findings include: Review of the policy titled, "Client Plan of Care," dated 1998, indicated ". . . The client plan of care . . . is written by the physician and made available to the home health care agency or is prepared as a written record by the home health care agency based on the physician's verbal order . . . Changes in the plan of care are documented through written and signed plans of modifications or, if the changes are requested orally, are reduced to writing, signed by a home health care registered nurse and countersigned by the attending physician." Review of the policy titled, "Admission Process," dated 2016, indicated ". . . Intermittent home health care services are provided to patients based on the following criteria: . . . there is reasonable expectation that the patient's health and social needs can be safely met in the patient's place of residence. . . the organization must be capable of meeting the care needs of the patient." Review of the policy titled, "Client Home health Care Visit Protocol," dated 1998, indicated field staff make visits to clients according to physician orders." Review of the policy titled, "Referral Mechanisms: Telephone/Verbal Referrals," dated 1998, indicated "All persons receiving telephone or verbal referrals must complete a phone referral form. . . Referral sources can be the physician, social worker, discharge planner . . . The phone referral can be completed by any [initials of HHA] staff person and must be followed up by the appropriate RN [registered nurse] Team leader with the patient's physician." 1. Review of P1's "Admission referral to Home Health," located under the "Medical History" tab and signed by Physician (MD) 3 on 04/28/22 at 3:40 PM, indicated disciplines requested were skilled nursing for medication management, wound care, and PICC (peripherally inserted central catheter) line management and dressing changes, physical therapy to evaluate, occupational therapy to evaluate, and home health aide for personal care and household services. Review of P1's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 05/05/22 to 07/03/22 indicated skilled nursing services was the only discipline ordered and signed by MD4. There was no documentation in P1's medical record that MD3, who ordered home health, and MD4, who signed P1's plan of care, were informed that the HHA only provided nursing and aide services and did not have a physical therapist (PT) or occupational therapist (OT) employed or contracted to provide such services. In an interview on 06/02/22 at 1:30 PM with Administrator and Billing Clerk (BC) present, Administrator (the RN who provided nursing home visits) stated he/she didn’t see the request for PT, OT, and aide services when he/she reviewed the intake order. Administrator confirmed the HHA only provides nursing and aide services. Administrator confirmed the HHA does not have an OT or PT employed or contracted to provide PT and OT services. BC stated when he/she gets a referral, he/she tells the referral source that the HHA can only provide nursing services, and the referral source asks if there is a hospital where the patient can receive PT and OT services. BC stated he/she informs the referral source that there is a hospital where PT and OT services can be provided, but the PT and OT service would have to be directly arranged between the referral source and the hospital. BC stated he/she doesn’t get a revised order from the referring physician for nursing services only. 2. Review of P3's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 05/05/22 to 07/03/22 indicated an order for "Assist in wound care using wound vacuum (NPWT) [non-pressure wound therapy] every visit." There was no documentation of the specific wound care to be performed and the pressure at which the wound vacuum was to be maintained. Further review indicated an order for "Venipuncture for labs: CBC [complete blood count - blood test used to evaluate one's overall health and detect a wide range of disorders, including anemia, infection and leukemia], INR [International Normalized Ratio - preferred blood test of choice for patients taking vitamin K antagonists and can also be used to assess the risk of bleeding], Vit. [vitamin] D [role is to keep bones healthy by increasing the intestinal absorption of calcium]and CMP [comprehensive metabolic panel – to conduct a broad assessment of various aspects of physical well-being]." There was no documentation of the frequency that the labs were to be drawn. Review of P3's skilled nursing visits, located under the "Nurses' Notes" tab, indicated wound care was performed by Administrator on 05/05/22, 05/06/22, 05/09/22, 05/12/22, 05/17/22, 05/19/22, 05/24/22, and 05/25/22 without Administrator obtaining and documenting a clarification order for specific wound care orders. Further review indicated Administrator performed a venipuncture to obtain a lab specimen on 05/19/22 and 05/25/22 without obtaining and documenting a clarification order to determine the frequency at which lab draws were to be performed. There was no documentation in each visit note of the specific lab tests that were to be performed. Observation during a home visit on 06/02/22 at 11:40 AM revealed Administrator did not perform wound care as ordered to be done every visit. In an interview on 06/02/22 at 1:30 PM, Administrator stated the "standard wound vacuum setting is 125 mmHg [millimeters mercury] once a week for one week and two times a week after that." Administrator confirmed the doctor’s orders did not include specific wound care and lab orders. Administrator confirmed that he/she did not obtain and document a clarification order with specific orders for wound care and lab draws. Administrator stated he/she called P3's mother who stated, "everything was good with the cannister after she had changed it yesterday." Administrator stated he/she saw "the cannister was running good." Administrator confirmed he/she didn’t assess P3's wound, the connection of the wound vacuum, and provide wound care as ordered to be done on every visit. 3. Review of P4's "Home Health Orders," located under the "Referral" tab, indicated "Home Health agency personnel to draw CBC, CMP (Chem 13), ESR [erythrocyte sedimentation rate - a blood test that helps detect inflammation from autoimmune diseases, infection, cancer, and more], CRP [C-reactive protein - useful in monitoring people with chronic inflammatory conditions to detect flare-ups and/or to determine if treatment is effective], and Vancomycin trough [most accurate and practical method for monitoring efficacy of an antibiotic] weekly on Mondays. . ." Review of P4's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 04/18/22 to 06/16/22 indicated an order for "Venipuncture for labs: trough, CBC w/diff [with differential], CMP, CRP, ESR, CK [most often used to diagnose and monitor muscular injuries and diseases]. There was no documentation that the venipuncture was to include a CRP test and that the labs were to be drawn each Monday as indicated on the referral for home health. There was no documentation that labs were drawn each week after 04/28/22. Further review indicated the nursing visit frequency was three times a week for two weeks, two times a week for four weeks, and one time a week for three weeks. There was no order for PRN (as needed) visits for administration of intravenous fluids. Review of P4's nursing visit notes, located under the "Nurses' Notes" tab, indicated lab samples were drawn on 04/22/22, a Friday, and on 04/28/22, a Thursday. Further review indicated two nursing visits were performed on 04/22/22 with no physician order for the second visit. In an interview on 06/02/22 at 1:30 PM, Administrator stated P4's wife decided to take P4 to the hospital every week for labs. Administrator stated he/she should have received an order to discontinue the labs. Administrator stated sometimes the family wanted P4's labs to be done on days other than Monday and confirmed that he/she should have notified the doctor and received an order for the change. Regarding the second visit on 04/22/22, Administrator stated he/she didn’t know he/she needed an order for a second visit. 4. Review of P5's "Consult Requisition," located under the "Referrals" tab and signed by MD5 on 05/09/22 at 10:47 AM, indicated physician orders for ". . . PT, OT, and nursing to eval [evaluate] and treat patient." Review of P5's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 05/11/22 to 07/09/22 indicated skilled nursing was ordered one time a week for one week and two times a week for eight weeks. There was no documentation that orders included an order for PT and OT to evaluate and treat P5 as ordered on the referral. Review of P5's medical record indicated no documentation that MD1, the physician who signed the plan of care, was informed that PT and OT were ordered by MD5 and that the HHA did not provide PT and OT services. There was no documentation in P5's medical record that MD5 was informed at the time of the referral that the HHA did not provide PT and OT services. In an interview on 06/02/22 at 1:30 PM, Administrator confirmed that he/she did not inform MD1 that MD5 had requested PT and OT services and that he/she did not inform MD5 that the HHA did not provide PT and OT services at the time that the referral was made. 5. Review of P6's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 12/23/21 to 02/20/22 indicated an order to "Assist in wound care to (R) [right] upper arm/wrist/hand/fingers. Wash gently, apply Silvadene cream [used with other treatments to help prevent and treat wound infections in patients with serious burns], cover each with Xeroform, wrap with kerlix, secure with tape and wrap with ace bandage. Instruct family member re: [regarding] Wound care and procedure." Review of P6's nursing visit note of 01/27/22, located under the "Nurses' Notes" tab, indicated P6 had a non-removable dressing that was placed by the specialist. No wound care was performed on 01/27/22, 01/31/22, and 02/11/22. There was no documentation that P6's physician who signed the plan of care, MD1, was notified that a non-removable dressing had been placed by the specialist to obtain new orders to discontinue wound care. In an interview on 06/02/22 at 1:30 PM, Administrator confirmed he/she did not notify MD1 that P6 had a non-removable dressing to receive an order to discontinue wound care. 6. Review of P7's "Home Health Orders," located under the "Referral" tab and signed by the physician on 01/26/22 at 7:00 AM, indicated orders for nursing, PT to evaluate, and Social Work. There was no documentation in P7's medical record that the physician ordering home health services was informed that the HHA did not provide PT and social work services. Review of P7's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period from 02/03/22 to 04/03/22 indicated nursing services was the only service ordered. There was no documentation that MD1 was informed that the physician who ordered home health had requested PT and social work services and that the HHA did not provide these services. Further review of the "Home Health Certification and Plan of Care" indicated an order for ". . . Venipuncture for labs. Assist in wound care to abdominal area-midline using wound vacuum every visit . . ." There was no documentation of specific wound care orders and specific lab tests to be done and the frequency of the lab testing. There was no documentation of a clarification order by the RN to address the specific wound care and lab orders. Review of P7's nursing visit note for 02/04/22, located under the "Nurses' Notes" tab, indicated lab was drawn with no documentation of what lab tests were performed. Further review indicated the nursing visit note of 02/16/22 indicated ". . . Client asked me to do a venipuncture for labs. Drew blood from the R [right] arm [symbol denoting without] difficulty. . ." there was no documentation of the specific lab tests performed. In an interview on 06/02/22 at 1:30 PM, Administrator stated he/she called the lab to see what labs the physician had ordered and didn’t directly check with MD1 to obtain the order. Administrator confirmed he/she did not notify the physician requesting home health services that the HHA did not provide PT and social work services, and he/she did not inform MD1 that PT and social work services had been requested by the referring physician and that the HHA did not provide these services. Administrator confirmed he/she did not obtain specific wound care and lab orders from MD1.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: G584 Based on chart review, policy review, and interview, the home health agency (HHA) failed to ensure the registered nurse documented telephone orders in accordance with agency policy for two (Patient (P) 4, P7) of seven patient records reviewed for telephone orders. This deficient practice had the potential to affect the current six patients and any future patient admitted for services. Findings include: Review of the policy titled, “Physician Telephone Orders,” dated 1998, indicated “. . . Home health care registered nurses: a. document physician telephone orders on a physician telephone order form, specifically designating the order as a telephone order. . .” 1. Review of P4's "Telephone Orders" dated 05/06/22 indicated "Discontinued Vancomycin as of 5-4-22 Start Daptomycin 720 mg [milligrams] on 5-5-22 then continue Daptomycin IV [intravenous] push daily." Further review indicated Administrator (registered nurse documenting the telephone order) signed the order at 13:56 (1:56 PM). There was no documentation that the order was a telephone order and no name of the practitioner giving the telephone order. In an interview on 06/02/22 at 1:30 PM, Administrator confirmed the telephone order he/she documented on 05/06/22 did not include that it was a telephone order and the name of the practitioner giving the order. Administrator confirmed that this information should be included when documenting a telephone order. 2. Review of P7’s “Telephone Orders” dated 02/25/22 indicated “Discontinue the NPWT [negative pressure wound therapy]/wound vacuum therapy since 2-23-22 during the clinic appt. [appointment]. Start using mepilex border to cover the mid-abdominal wound daily." Further review indicated Administrator (registered nurse documenting the telephone order) signed the order at 11:25 (no AM or PM was documented). There was no documentation that the order was a telephone order and no name of the practitioner giving the telephone order. In an interview on 06/02/22 at 1:30 PM, Administrator confirmed the telephone order he/she documented on 02/25/22 did not include that it was a telephone order and the name of the practitioner giving the order. Administrator confirmed that this information should be included when documenting a telephone order.

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: G616 Based on record reviews, policy review, observation, and interviews, the home health agency (HHA) failed to ensure the patient's current list of medications (medication profile) was in the patient's home for one (Patient (P) 3) of one home visit made on 06/02/22 and the medication profile in the patient's medical record was current for two (P1, P3) of seven patient medication profiles reviewed for current medications from a sample of seven patients. This deficient practice had the potential to affect the current six patients and any future patient admitted for services. Findings include: Review of the policy titled, "Admission Process," dated 2016, indicated ". . . The patient/patient representative will be involved with their care and shall be provided with written information regarding the following: a. services provided by [initials of HHA] b. the regular business hours of the organization c. the organization's objectives and scope of care and services d. the patient Bill of Rights e. the charges for services through third party reimbursement\ [sic] f. the Home Health Hotline number g. the process for after hour assistance h. local emergency telephone numbers. . ." There was no documentation in the policy that indicated the patient's written medication profile would be provided to the patient. Review of the policy titled, "Charting," dated 1998, indicated ". . . Clinical notes include the following information: . . . e. Drugs. Dose and frequency. Notation in [sic] made of drug allergies and remedies which may be contradicted. . ." There was no documentation in the policy that indicated information regarding a medication profile (list of patient medications with start date, drug name, dose, frequency and route, discontinue date, and drug classification) that was to be kept current and included in the patient's medical record. Review of the policy titled, "Client Plan of Care," dated 1998, indicated ". . . Home health care services are furnished to clients: a. under the general supervision of a physician, b. based on a client plan of care established and periodically reviewed by the physician to ensure appropriate application of the services to the client's condition. 2. The client plan of care: a. is developed by a physician in consultation with the home health care staff and interdisciplinary team members. B. includes the following: . . . (11) client medication . . . " There was no documentation in the policy that indicated information about maintaining a patient's medication profile. 1. Review of P1's "Home Visit Report Skilled Intervention/Teaching/Patient Response," located under the "Nurses' Notes" tab, dated 05/19/22 indicated an entry by Administrator from 10:45 AM to 11:45 AM of "". . . Noted has a new med [medication] of Melatonin/Tracedone [sic][medication used to help with sleep] to take as needed for sleep. . ." Review of P1's "Medication Profile," located under the "Medication Profile" tab, indicated Melatonin/Trazodone was not added to the medication list. In an interview on 06/02/22 at 1:30 PM, Administrator stated the Melatonin/Trazodone were new medications added after the plan of care was initiated. Administrator stated the new medication was not added to "Medication Profile" in P1's medical record but should have been added. 2. Observation on 06/02/22 at 11:40 AM during a home visit to P3 revealed Administrator (the RN conducting the home visit) did not review P3's medications. Further observation indicated there was no "Medication Profile" in P3's home that listed the medications being taken by P3. Review of the "Medication Profile," located under the "Medication Profile" tab, indicated Spironolactone 25 mg (milligrams) (used to treat high blood pressure and heart failure), two tablets were to be taken orally every day, and Folic Acid 1 mg (B-vitamin naturally found in some foods needed to form healthy cells, especially red blood cells), one tablet was to be taken orally daily. Further review indicated also listed was Lactulose 10 gm (grams) per 15 milliliters (laxative used to treat constipation), was to be taken daily. Observation of the medications in P3's home on 06/02/22 at 11:40 AM by the surveyor revealed a bottle of Spironolactone dated 05/10/22 that had instructions to take five tabs daily and a bottle of Folic Acid dated 05/17/22 with instructions to take two tablets daily. There was also a bottle of Vitamin D2 (used to treat and prevent bone disorders) dated 05/31/22 with instructions to take one capsule every week and a bottle of Polyethylene Glycol (used to treat occasional constipation) dated 05/31/22 with instructions to take once daily as needed for constipation. In an interview on 06/02/22 at 11:40 AM, P3's mother stated Lactulose had been discontinued, and Polyethylene Glycol had been prescribed to replace it. P3's mother also stated Vitamin D2 was a new medication added at the last physician appointment. In an interview on 06/02/22 at 1:30 PM, Administrator stated he/she reviews the medications at the start of care (admission visit), but after that he/she just asks the patient if they have any changes to their medications Administrator confirmed he/she did not review P3's medications during the home visit on 06/02/22 and did not update the medication profile with the changes in medication doses, the discontinuation of the Lactulose, and didn't add the new medications ordered.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: G640-CONDITION Based on policy review and interviews, the home health agency (HHA) failed to maintain and evaluate an effective, ongoing, HHA-wide, data-driven quality assessment and performance improvement (QAPI) program. These deficient practices had the potential to prevent the HHA from identifying opportunities for improvement in providing quality care and to implement corrective/preventive actions for the HHA’s six patients and any future patient admitted to the HHA for services. Findings include: 1. The HHA failed to develop, measure, analyze, and track quality indicators, including adverse events. (See findings in tag G642) 2. The HHA failed to track adverse patient events, analyze their causes, and implement preventive actions. (See findings in tag G654)

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: G0642 Based on policy review and interview, the home health agency (HHA) failed to identify, analyze, and track quality indicators, including adverse events, that enables the HHA to assess processes of care, HHA services, and operations. This deficient practice had the potential to prevent the HHA from identifying opportunities for improvement in providing quality care for the HHA’s six patients and any future patient admitted to the HHA for services. Findings include: Review of the policy titled “Quality Improvement Plan,” dated 2001, indicated “. . . 2. The quality improvement plan shall be addressed with quarterly meetings of the committee to review, monitor, and address ways to improve services. The focus of quality efforts shall encompass the following points: … improving organizational performance … leadership … education … rules, responsibilities, and ethics… assessment of client and environment … care, treatment, and service … continuum of care … management of information … management of personnel … infection prevention … control, and surveillance …3. Sampling of events and activities pertaining to monitoring results will be reviewed at least quarterly by the committee, more frequently when necessary. The activities reviewed shall be: client record reviews … customer satisfaction survey … incident reports … red flags … equipment maintenance … client follow-up … State, Federal, Tribal and other regulatory policies … 4. All departments shall initiate appropriate follow-up actions in response to identified improvements or problem areas. . .” No documentation of quality indicators, including adverse events and infections, were presented for review during the survey. Review of the QAPI program itself, in addition to the policy, indicated adverse events were not included in QAPI. Review of the QAPI information provided did not include adverse events such as infections, falls, rehospitalizations, emergent care, etc. During an interview on 06/03/22 at 9:13 AM, Quality Assurance Clerk (QA) stated QA does chart reviews monthly and completes a billing log. When asked if QA tracks adverse events, QA stated “What’s that?” QA stated QA doesn’t track infections, and QA stated, “I only keep a copy of the wound log.” When asked about quality indicators, QA stated, "I don’t do that anymore.” and stated he/she didn’t know why he/she stopped tracking, measuring, and analyzing quality indicators. QA stated that “it just went away.” QA confirmed the HHA has not developed quality indicators, and the HHA does not have QA meetings as stated in the “Quality Improvement Plan.”

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: G654 Based on review of quality assessment and performance improvement (QAPI) documentation, policy review, and interview, the home health agency (HHA) failed to track adverse patient events, analyze their causes, and implement preventive actions. This deficient practice had the potential to prevent the HHA from identifying opportunities for improvement in providing quality care and to implement corrective/preventive actions for the HHA’s six patients and any future patient admitted to the HHA for services. Findings include: Review of the policy titled “Quality Assurance/Quality Improvement program,” dated 2001, indicated “. . . [name of HHA agency] implements QA/QI [quality assurance/quality improvement] activities to achieve the following objectives: 1. To develop, implement, and evaluate standards to measure nursing. [sic] practice, and delivery of health care services. 2. To develop effective systems for problems assessments, corrective. [sic] action, and evaluation of nursing team and health care services. . . QA/QI activities are established by developing, implementing, and evaluating: 1. QA/QI Program, 2. policies and procedures, 3. program operations, 4. clinical record reviews, 5. data collection, 6. in-service [sic] training for staff, 7. client service survey, 8. patient conferences.” There was no documentation that adverse events were listed as QAPI activities to be tracked, analyzed, and to have preventive actions implemented. Review of the HHA QAPI program indicated adverse events were not included in QAPI. Review of the QAPI information provided did not include adverse events such as infections, falls, rehospitalizations, or emergent care. In an interview on 06/03/22 at 9:13 AM, Quality Assurance Clerk (QA), when asked if QA tracked adverse events, QA stated “What’s that?” When adverse events were explained by the surveyor, QA confirmed QA does not track adverse events, analyze the causes of the events, or implement preventive actions.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: G680 - CONDITION Based on policy review, medical record review, observation, and interviews, the home health agency (HHA) failed to (1) screen patients for COVID-19 and complete hand hygiene, glove use, and disinfect patient care equipment per standard precautions, (2) document an infection control surveillance program, and (3) develop a COVID-19 vaccination policy. These deficient practices had the potential to expose patients and staff to communicable disease and affect the six current patients, the eight current staff members, and any future patient admitted for services and any future individual hired by the agency. Findings include: During a home visit with a Registered Nurse observed breaches in standard precautions and lack of screening for signs/symptoms of COVID-19. (See findings in G682) The agency was unable to provide documentation of an infection surveillance program. (See findings in G684) The HHA failed to develop a policy for COVID-19 vaccination of staff that included all required components of the regulation. (See findings in tag G0687)

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: G682 Based on record reviews, policy review, observation, and interview, the home health agency (HHA) (1) failed to ensure the Registered Nurse followed infection prevention standard precautions when providing care to one of one patients (Patient (P)1) observed during a home visit and (2) failed to ensure patients were screened for COVID-19 in accordance with the agency policy for one (P3) of one home visit observation and for five (P1, P3, P4, P6, P7) of seven patient records reviewed for screening of patients for COVID-19. These deficient practices had the potential to affect the current six patients and any future patient admitted for home health services. Findings include: 1. Review of the policy titled, “Infection Control,” dated 2016, indicated “. . . 2. Hand Hygiene a. protective gloves must be worn when handling blood and body fluids b. hands must be washed and dried before and after any direct contact with patient and when gloves are removed c. hands are washed with soap and water covering all surfaces per the World Health Organization (WHO) guidelines d. when hand washing facilities are not available, a hand sanitizer with at least 70% [per cent] isopropyl alcohol base may be used to clean hands . . . 5. Bag Technique A. Field staff who carry patient care supplies when performing home visits must follow bag technique procedure to prevent the possible spread of infectious germs: a. bag must be specifically for patient care items, never carry patient care items in personal bag, purse or backpack b. when taking a bag into a home, place a disposable barrier between the bag and a clean, dry surface, never place bag on floor . . . d. clean hands per acceptable guidelines e. open bag, remove all needed items from the bag, place items on a clean barrier f. close the bag to protect from contamination g. clean hands prior to re-opening bag h. disinfect all used items with at least 70 percent isopropyl alcohol or acceptable germicidal wipes, place on clean barrier, clean hands prior to returning clean items to the supply bag . . . j. keep the supply bag closed when not in use.” During a home visit observation on 06/02/22 at 11:40 AM, Administrator entered P3’s room and placed the supply bag on a barrier on the table at the foot of the bed. Administrator washed his/her hands and donned gloves. Administrator removed the blood pressure cuff that was in a plastic bag in the supply bag. Administrator assessed P3’s blood pressure. Administrator cleaned the blood pressure machine with a germicidal wipe after use but did not wipe the cuff that touched P3’s arm. Administrator then placed the blood pressure cuff in the plastic bag and placed the plastic bag in the supply bag, all while wearing contaminated gloves that had touched P3’s arm and bed linens. Administrator then removed the pulse oximeter (used to assess the patients blood oxygen saturation) from a plastic bag that was in the supply bag. After assessing P3’s oxygen saturation, Administrator wiped the pulse oximeter with a germicidal wipe, placed the pulse oximeter in the same plastic bag, and placed the plastic bag in the supply bag, all while wearing the same contaminated gloves. Administrator then removed the stethoscope from a plastic bag that was in the supply bag. After auscultating P3’s heart and lungs, Administrator placed the stethoscope in the same plastic bag and placed the plastic bag in the supply bag without disinfecting the stethoscope, all while wearing the same contaminated gloves. Administrator removed his/her gloves and washed his/her hands. Observation revealed the supply bag remained open throughout the home visit. Observation revealed Administrator did not change his/her gloves and sanitize his/her hands between using patient care equipment to assess P3 and disinfecting the equipment. Administrator did not remove all patient equipment and place on a clean barrier, close the supply bag, disinfect the equipment after use, place disinfected equipment on a clean barrier, and return the disinfected equipment to the supply bag. In an interview on 06/02/22 at 1:30 PM, when the above observations were reviewed with Administrator, Administrator confirmed he/she did not follow the agency’s policy for hand hygiene, glove use, and bag technique. 2. Review of the policy titled “COVID-19 (aka [also known as] Coronavirus) – Addendum 04/2020,” dated April 2020, indicated “. . . When making a home visit, [name of HHA] clinical staff will identify patients at risk for having COVID-19 infections before or immediately upon arrival to the home. Home Health clinical staff shall ask the patients the following: 1. Has the patient traveled within the last fourteen (14) days. 2. In the last fourteen (14) days, has the patient had contact someone who had tested positive for COVID-19 or are sick with a respiratory illness. 3. Does the patient have signs and symptoms of: a. Fever b. Cough c. Sore throat d. Shortness of breath 4. Clinician must be observant on where patient resides; has any other family member visited or may have been in contact with someone who may be sick. . .” Observation on 06/02/22 at 11:40 AM during a home visit with P3 revealed Administrator did not screen P3 for COVID-19. Administrator assessed P3’s temperature but did not ask P3 the above-listed screening questions. Review of the skilled nursing visit notes for P1, P3, P4, P6, and P7 indicated there was no documentation that each patient was screened for COVID-19 during the home visits. In an interview on 06/02/22 at 12:57 AM, Billing Clerk (BC) stated the county positivity rate for COVID-19 was 8.20%, and the transmission rate is in the “red” area on the map (indicating the rate is high). In an interview on 06/02/22 at 1:30 PM, Administrator confirmed he/she did not screen P3 for COVID-19 by asking the screening questions listed in the above policy. Administrator stated he//she does not ask patients the COVID-19 screening questions before or immediately upon arrival to the home as required by agency policy.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: G684 Based on policy review, document review, and interview, the home health agency (HHA) failed to maintain ongoing documentation of surveillance, identification, and investigation of infectious and communicable diseases and include data from an infection control surveillance program as a part of its quality assessment and performance improvement (QAPI) program. This deficient practice had the potential to affect the current six patients and any future patient admitted for home health services. Findings include: Review of the agency policy titled, “Infection Control,” dated 2016, indicated the HHA “. . . follows the recommended standard precautions set forth by the World Health Organization (WHO) to prevent and/or minimize infections and infection transmissions. . .” Review of the entire policy indicated there was no documentation related to tracking, trending, and investigating infections. Review of the policy titled “Infection Control,” dated 1998, indicated “Policy Home health care staff members implement universal precautions and infection control measures with all clients. Purpose To control the spread of infection. To protect individuals from transmission of communicable/infectious diseases. . .” Review of the entire policy indicated there was no documentation related to tracking, trending, and investigating infections. Review of the policy titled “Quality Improvement Plan,” dated 2001, indicated “. . . The focus of quality efforts shall encompass the following points: . . . infection control, prevention, and surveillance. . .” Review of the “Wound Tracking Log,” the document presented by Administrator and Quality Assurance Clerk (QA) when a request was made to review the agency’s tracking of infections, indicated patient wounds were listed with the site, measurements, tissue granulation, drainage, and a description of the wound. The log had no information related to infections. No documentation of infection identification and surveillance, including tracking, trending, and investigation of infections, was presented during the survey. During an interview on 06/03/22 at 9:08 AM, Administrator stated he/she is responsible for Infection Control. Administrator stated he/she did not track infections and had no data to present related to infections, tracking, and investigation.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: G687 Based on policy review and interviews, the home health agency (HHA) failed to develop a policy for COVID-19 vaccination of staff that included all required components of the regulation. This deficient practice had the potential to affect the six current patients, the eight current staff members, and any future patient admitted for services and any future individual hired by the agency. Findings include: Review of the undated policy titled “Chapter 9 Employee Conduct and Safety – COVID – 19 (Coronavirus) Telecommuting and Working At Home,” presented by Billing Clerk (BC) when a request was made to review the COVID-19 vaccination policy, indicated the purpose of the policy was “. . . to define the practices that are to be followed when working from home.” The HHA was unable to provide documentation in a policy that addressed COVID-19 vaccination as required by regulation. In an interview on 06/02/22 at 1:30 PM, Administrator stated he/she wasn’t aware of the need for a COVID-19 vaccination policy. Administrator stated he/she was not aware of the regulation for COVID-19 vaccination of staff. Administrator confirmed a policy had not been developed for staff COVID-19 vaccination.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: G718 Based on record review, policy review, and interview, the home health agency (HHA) failed to ensure the registered nurse (RN) notified the physician when a nursing visit was missed in accordance with agency policy for one (Patient (P) 2) of seven patient records reviewed for missed visits. This deficient practice had the potential to affect the current six patients and any future patient admitted for services. Findings include: Review of the policy titled "Client Home Health Care Visit Protocol," dated 1998, indicated ". . . When a visit is missed by any discipline: a. document the missed visit on a home visit narrative form, indicated the date, time, and an explanation of why the visit was missed. . . c. a copy of the missed visit documentation for any discipline will be sent to the physician with the date and time sent stamped and a copy filed in the client's chart. . ." Review of P2's "Home Health Certification and Plan of Care," located under the "Physician's Orders" tab, for the certification period of 04/04/22 to 06/02/22 indicated the skilled nursing visit frequency was one time a week for nine weeks. The plan of care was signed by Physician (MD) 2. Review of P2's nursing visits, located under the "Nurses' Notes" tab, indicated no nursing visit was made the week of 04/17/22 in accordance with P2's plan of care. In an interview on 06/02/22 at 1:30 PM, Administrator (the RN making the home visit and documenting in P2's medical record) stated P2 was admitted to the hospital by MD1, and the physician signing the "Home Health Certification and Plan of Care" was MD2. Administrator confirmed the ordering physician, MD2, was not notified of the missed visit the week of 04/17/22.