Good Samaritan Society - Legacy Home Care

“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, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and staff interviews it was determined the home health agency failed to ensure an emergency preparedness plan specific to the agency’s needs and include emerging infectious diseases in the plan. This deficient practice has the potential that home health staff are not prepared in the event of an emergency placing strain on the agency and identifying a vulnerable population at risk. Findings include: A review of the Emergency Preparedness policies did not include home health-specific preparedness procedures. All policies were inclusive to all lines of services from Sanford. No documentation to incorporate emerging infectious diseases was presented. No additional documentation could be provided. In an interview with Employee #1, he/she confirmed there was no delineation between the home health agency and hospice agency emergency preparedness plans. he/she further confirmed no additional documentation for policies to update the emergency plan to include new and emerging infectious diseases.”

“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: Based on record review and staff interviews it was determined the agency failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. This deficient practice has the potential that issues regarding patient care, patient services, and agency concerns are not identified, addressed, and corrected posing the risk of negative outcomes. Findings include: A review of Sanford Policy titled, “ Quality Assurance and Performance Improvement-QAPI”, revealed, “... Sanford Health and Good Samaritan Society locations will implement and maintain an ongoing comprehensive QAPI program... The QAPI program will measure, analyze, and track quality indicators, including adverse events, and other aspects of performance that enable the location to assess processes of care, services, and operations....e. Location will document QAPI governance and structure in an annual written QAPI plan... The QAPI committee is responsible to track and trend performance, systematically analyze[sic] and prioritize quality deficiencies, develop action plans, and monitor effectiveness and sustainability. b. The QAPI Committee, at a minimum, meets quarterly....” A request for the quarterly QAPI committee meeting minutes for 2023 and 2024 was asked for and not received. A request for the QAPI annual written plan for years 2023 and 2024 was asked for and not received. A request for QAPI 2023 and 2024 programs was made for and not received. A request for the QAPI committee members was asked for and not received. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that the aforementioned requested material was not available. He/she also confirmed he/she was not educated on who the QAPI committee members were.”

“Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This Condition is not met as evidenced by: Based on record review and staff interviews it was determined the agency failed to maintain compliance with State Law posing the risk that patient care, needs, and services cannot be fully reviewed and compliance determination cannot be evaluated posing the risk of poor care and negative outcomes. Findings include: A request was made on June 7, 2024, for full access to the HHA’s electronic medical record system. On June 12, 2024, after multiple attempts were made to access patient files, the surveyors were given limited access to medical records and could not view complete records. A review of the Good Samaritan Society Home Health Admissions Packet document titled, “Client’s Rights And Responsibilities (Bill Of Rights) Nondiscrimination Statement” revealed the required Arizona State Patient Rights were incorrect. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that full access to the medical records was not given to the surveyors. He/she further confirmed the patient’s rights were incorrect in the admission packet. In an interview with Employee #2, conducted on June 12, 2024, he/she was unable to access all patient records to review with the surveyors. No further attempts to complete the medical records were made on June 13, 2024, or June 14, 2024. Employee #2 confirmed the Electronic Medical Record(EMR) was not working properly and patient records were not fully accessible.”

“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), §485.542(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: Based on observation, record review, and staff interview, it was determined the facility failed to develop and maintain a completed Emergency Preparedness Plan. This deficient practice has the potential that in the event of an emergency, staff members are not prepared to respond and implement actions needed to ensure the safety of the vulnerable population they serve. Findings include: Review of facility policy “ Emergency Preparedness - HBS Enterprise” revealed “...Each agency has a communication plan in place that complies with federal, state, and local laws. The EMP is reviewed at least every 2 years and updated as necessary. The update plan can be printed and placed into an accessible binder in hard copy form as well as electronically. 2. The communication plan includes: Names and contact information for: Staff, Entities providing contract services, Patient’s health provider/s, Volunteer. Contact information for: Federal, state, and tribal regional/local emergency preparedness staff, Other sources of assistance....” Review of the emergency control documentation presented revealed name and contact information for staff, entities providing contract services, patient health care provider/s, and volunteer names and contact information was either incomplete, missing, or outdated. In interview with employee #1, he/she confirmed the names and contact information for emergency preparedness communication plan needs to be updated to align with policy. Review of facility policy “ Emergency Management, Resource” packet revealed “...D. Alternative meeting locations (if agency is not operational): 1. Primary: Sheriff’s office 255 E Gurley St, Prescott, AZ 86301....” Review of the facility “Home and Community Based Services Emergency Management Plan” presented revealed the primary alternative meeting location Sheriff’s office 255 E Gurley St, Prescott, AZ 86301. During interviews with two staff members, they were unable to provide any information regarding the alternative meeting location. Review of facility policy “ Emergency Management, Resource” revealed “..B. Direction and Control... 2. Identify the chain of command to ensure continuous authority in key positions: Name: [name redacted] Title: Clinical Supervisor Cell phone number: Home number: ....” Review of the facility Emergency Management Plan presented revealed facility failed to document contact information for the chain of command. In interview with employee #1, he/she confirmed the contact information for the chain of command needs to be completed to align with policy. Review of facility policy “ Emergency Management, Resource” packet revealed “...C. Notification...11. Describe how you will account for all clients and staff during the emergency and notify emergency services of staff members and clients that cannot be accounted for...” Review of the facility Emergency Management Plan revealed that the facility failed to identify a method to account for all clients and staff during the emergency and notify emergency services of staff members and clients that cannot be accounted for. In interview with employee #1 it was acknowledged the packet needs to be updated and information completed. Review of facility policy “ Emergency Management, Resource” packet revealed “...C. Notification...12. Describe the method of sharing information and medical documentation for clients under care as needed with other health care providers to ensure continuity of care...” Review of the facility Emergency Management Plan revealed that the facility failed to outline the method of sharing information and medical documentation for clients under care as needed with other health care providers to ensure continuity of care. In interview with employee #1 it was acknowledged the packet needs to be updated and information completed to align with policies and procedures. Review of facility “Home and Community Based Services Emergency Management Plan” revealed “...D. Evacuation...7. Identify procedures and personnel that will be used to keep track of clients once they have been evacuated; this should be a log system...” Review of the facility Emergency Management Plan revealed that the facility failed to Identify procedures and personnel that will be used to keep track of clients once they have been evacuated In interview with employee #1 it was acknowledged the packet needs to be updated and information completed. Review of facility “Home and Community Based Services Emergency Management Plan” revealed “...D. Evacuation...10. Establish procedures for responding to inquires about clients who have been evacuated....” Review of the Emergency Management Resource plan revealed that the facility failed to identify procedures for responding to inquires about clients who have been evacuated. In interview with employee #1 it was acknowledged the packet needs to be updated and information completed. Review of facility “Home and Community Based Services Emergency Management Plan” revealed “...IV Information, Training and Exercise...B. Identify the disaster training for employees regarding their disaster-related roles. Twice a year emergency preparedness exercise will be planned. No more than one tabletop exercise will be used....” Review of the Emergency Preparedness documentation presented revealed that the facility failed to conduct twice yearly emergency preparedness training exercise as outline in the “Home and Community Based Services Emergency Management Plan”. In interview with employee #1, documentation to support emergency preparedness training exercise have been conducted twice yearly. Not provided. .”

“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), §485.542(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: Based on record review and staff interviews it was determined the Home Health Agency(HHA) failed to have a process to engage in collaborative planning for an integrated emergency response and include this integrated response process in its emergency plan. This deficient practice has the potential that HHA staff, patients, and patient caregivers are ill-prepared in the event of an emergency posing the risk for negative and potentially fatal outcomes. Findings include: A review of the Good Samaritan Society Home Health Emergency Preparedness binder revealed no documentation of the facility process to engage in collaborative planning for an integrated emergency response. A request for documentation for the cooperation and collaboration process was asked for and not received. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that the Emergency binder contained no evidence of emergency contact information.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to ensure to keep a copy of the patient’s individualized emergency plan in the patient’s file as well as provide a copy to the patient and or their caregiver. This deficient practice has the potential that patients and patient caregivers are not being educated posing the risk they are not prepared in the event of an emergency. Findings include: A review of Sanford Policy titled” Admissions Process, Home Health- Enterprise”, revealed,:... 15. The patient/family should be provided with information regarding the following when an initial assessment or Comprehensive Assessment is provided: Patient Bill of Rights Toll-free state “hotline” phone numbers Patient’s responsibility for payment Agency objectives and scope of care and services Business hours of the agency Process for after-hour employee access Statement that acceptance for service does not ensure continuation of service beyond the agency’s ability to care for patient safely DO Resuscitate/DO NOT Resuscitate (DR/DNR) information Advance Beneficiary Notice (ABN), if applicable Advance Directive information-provided before hands-on care Services which are provided by contract employees/agencies Notice of Privacy Practices (NPP) Acknowledgement of Receipt of Notice of Privacy Practices....” No documentation in the policy regarding an individualized emergency plan to be discussed and a copy is left with the patient in the home. A review of the Good Samaritan Society Home Health Admissions Packet revealed no documentation of an individualized emergency plan that is to be completed and left in the patient’s home. A review of 14 patient medical records revealed no evidence of an individualized emergency plan that was developed and a copy left in the patient’s home. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that there was no form/document of an individualized patient emergency plan in the aforementioned admission packet. No additional documentation was provided. In an interview conducted on June 13, 2024, with Employee #2, he/she confirmed that no documentation of individualized patient emergency plans was present in the aforementioned patient records reviewed. He/she further confirmed that there is no form completed upon admission for individualized emergency planning.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview, review of policy and procedure and review of facility documents, it was determined the facility has failed to ensure policy creation for the provision of volunteers or other emergency staffing strategies to address surge staffing needs during an emergency. Failure to ensure there is a policy for the provision of volunteers or other staffing strategies during surge or emergency event puts patients at risk for increased mortality and morbidity, increased risk of disease transmission, adversely effects existing staff, and places patients and staff and increased safety risk. Review of Policies and Procedures presented revealed policy to proactively address surging staff needs could not be identified. In interview with employee #1, requested policy to address surge needs during and emergency. Not provided.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and staff interview it was determined the HHA failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws that included names and contact information of current staff, entities providing services under arrangement, and patients’ physicians. This deficient practice has the potential that the agency is unprepared to respond to any potential emergencies posing the risk for potential harm to both staff and the vulnerable population of homebound patients that they serve. Findings include: A review of the Emergency Preparedness Plan revealed an outdated staff contact roster. No documentation of the current patient’s physicians, patient names, or contracted entities was present. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed the contact list was outdated, with no patient roster with physician contact numbers, or contracted entities in the Emergency Plan. No additional documentation could be provided.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and staff interview it was determined the HHA failed to maintain or produce agency-specific performance improvement projects/activities. This deficient practice has the potential that issues regarding high-risk or problem-prone areas are not being recognized, and evaluated posing the risk that immediate correction of any identified problem will directly or potentially threaten the health and safety of patients. Findings include: A review of Sanford Policy titled, “Quality Assurance and Performance Improvement- QAPI”, revealed, “...4. Performance Improvement Projects At a minimum one performance improvement project will either be in development, on-going or completed annually utilizing the improvement model adopted by location. Performance Improvement activity m will be monitored for progress and sustainability by the location....” A request was made for the agency’s performance improvement projects or performance improvement activities were asked for and not received. In an interview conducted on June 12, 2024, and June 13, 2024, with Employee #1, he/she confirmed no documentation could be provided for any performance improvement activities/projects.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and review of policies and procedures it was determined the facility failed to provide evidence of a performance improvement plan that addresses issues specific to the population served with the goal of improving healthcare processes and outcomes by strategizing ways to improve care for the individuals receiving services. Failure to develop, implement, and monitor patient-centered performance improvement plans can adversely effect patient safety, outcomes, and satisfaction. Finding include: Review of facility policy, “Quality Assurance and Performance Improvement - QAPI...” revealed 4. Performance Improvement Projects...At a minimum one performance improvement project will either be in development on-going or completed annually utilizing the improvement model adopted by the location. Performance Improvement activity will be monitored for progress and sustainability by the location. a. Performance improvement activities will focus on high risk, high volume, or problem-prone areas....” Documentation provided in QAPI binder did not support documentation of quality improvement projects undertaken focusing on high risk, high volume, or problem-prone areas, the reasons for conducting these projects, and the measurable progress achieved on these projects. In interview with employee #1, she stated she was unaware of any other documentation related to process improvement. activities.”

“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: Based on record review and staff interviews it was determined the HHA failed to 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. This negligent and deficient practice has the potential that infections are not being recognized, evaluated, and addressed posing the risk of infectious diseases being spread to a vulnerable population with potentially negative outcomes. Review of facility policy, “...Infection Prevention and Control Program....” revealed, “...The components of an Infection Prevention and Control Program include but are not limited to: Program Oversight; 2. Policies and Procedures; 3. Surveillance; 4. Data Analysis; 5. Antibiotic Stewardship; 6. Outbreak Management; 7. Prevention of Infection; 8. Immunizations; and 9. Employee Health and Safety…C. Surveillance 1. The facility has established a system for Surveillance based on national standards of practice and the facility assessment...D. Data Analysis 1. The Infection Preventionist, or appointed designee, utilizes data gathered during surveillance to identify unusual or unexpected outcomes (i.e., outbreaks), infection trends, and patterns; this data is reported to the Quality Assurance and Process Improvement Committee....I. Employee Health and Safety.... I. All locations: Employee surveillance is completed via the “Monthly Report of Infections in Location - Employee, Children, Family and Visitors” (GSS #392) form....” A review of the Good Samaritan Society Infection Control binder revealed the facility was not actively engaging in infection control surveillance activity. A request for documentation to support infection control surveillance activities per facility policy was asked for and not received. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that the Infection control binder contained no evidence of surveillance activities. Review of facility policy,”...Infection Prevention and Control Program....” revealed, “....C. Surveillance.... Process surveillance (ex hand hygiene compliance program) and outcome surveillance (ex, monthly infection rates) are used as measures of the Infection and Control Program effectiveness. A review of the Good Samaritan Society Infection Control binder revealed the facility was not actively engaging in infection control process surveillance and outcome activity. A request for documentation to support infection control process surveillance and outcome activities per facility policy was asked for and not received. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that the Infection control binder contained no evidence of process surveillance and outcome activities. Review of facility policy, “...Infection Prevention and Control Program....” revealed, “....Antibiotic Stewardship 1. The facility has established an antibiotic stewardship program which includes the development of protocols and a system to monitor antibiotic use...” A review of the Good Samaritan Society Infection Control binder revealed the facility was not actively engaging antibiotic stewardship program activity. A request for documentation to support antibiotic monitoring activities per facility policy was asked for and not received. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed that the Infection control binder contained no evidence of antibiotic monitoring activities. 1”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and staff interview it was determined notification had not been provided to update contact information for the administrator, including the administrator’s name, business address, and business phone number to receive complaints. This deficient practice has the potential of patients and patient caregivers being uneducated on whom to address posing the risk for patient rights violations. Findings include: A review of the Good Samaritan Society Home Health Admissions Packet revealed, a document printed on green paper that stated”... If you have any concerns regarding your care, or individual staff members, please call Good Samaritan’s Home Health Clinical Manager, [name redacted]...”. No documentation was present in the admission packet that listed the administrator’s name or contact information. A review of the personnel list provided did not list the employee mentioned in the admission packet. In an interview conducted on June 12, 2024, with Employee #1, he/she confirmed the person listed on the aforementioned document in the admission packet, was no longer an employee of the agency. No additional documentation could be provided.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to advise patients of the names, addresses, and telephone numbers of the required Federally-funded and state-funded entities that serve the area where the patient resides. This deficient practice has the potential that patients and patient caregivers are not being educated posing the risk of patient rights violations. Findings include: A review of the Good Samaritan Society Home Health Admissions Packet revealed the following document titled, “ Client’s Rights and Responsibilities (Bill Of Rights) Nondiscrimination Statement”, revealed, “ As a person who receives Home Health services and as a client representative (if any), you have the following rights:... 13. The right to be advised of the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that serve the area where you reside; Agency on Aging; Center for Independent Living: Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Agency....” No addresses or telephone numbers were provided in the admission packet. In an interview conducted on June 11, 2024, with Employee #1, he/she confirmed the admission packet did not contain the addresses or phone numbers for the required agencies. He/she further confirmed the admission packet was the current packet being distributed to patients. No additional documentation was provided.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview, review of policies and procedures it was determined the facility failed to conduct an initial assessment within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date or 2 (two) out of 14(fourteen) patients. Failure to conduct timely initial assessments can make care less effective and increase discomfort and risk for patients with serious injuries or illnesses. Findings include: A review of facility policy, “... Admissions Process, Home Health - Enterprise...” revealed “...7. Patients should be admitted into the agency within 48 hours of referral unless otherwise specified by the provider. 8. If the patient requests a delay in the SOC date, the provider should be contacted to request the date change and it should be documented in the medical record and an order generated for the provider’s signature...” A review of Patient #5 records revealed the physician’s order to initiate care dated April 30, 2024. Per records, the start of care began May 20, 2024. A review of patient #6 records revealed the physician’s order to initiate care dated April 6, 2023. Per records, the start of care began on April 28, 2023. Interview with Employee #2 revealed no documentation or order in patient #5 or #6 records to support a reason for delay in care. Findings include: Review of facility policy, “... Admissions Process, Home Health - Enterprise...” revealed “...7. Patients should be admitted into the agency within 48 hours of referral unless otherwise specified by the provider. 8. If the patient requests a delay in the SOC date, the provider should be contacted to request the date change and it should be documented in the medical record and an order generated for the provider’s signature...” Review of patient #5 records reveal physician’s order to initiate care dated April 30, 2024. Per records, start of care began May 20, 2024. Review of patient #6 records reveal physician’s order to initiate care dated April 6, 2023. Per records, start of care began April 28, 2023. Interview with Employee #2, revealed no documentation or order in patient #5 or #6 records to support reason for delay in care.”

“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: Based on interview, review of policies and procedures it was determined the facility failed to obtain physician orders prior to services being rendered. This deficient practice can result adverse outcomes to patients. Findings include: Facility policy review “...Provider Orders and Notification, Home Health Enterprise....” revealed, “...All treatments and care must be ordered, dated and signed by the provider and consistent with state and federal regulations. The orders may be obtained by telephone or in writing...When services are provided on the basis of a provider’s verbal orders, a nurse (acting in accordance with state licensure requirements) or a qualified practitioner responsible for furnishing/supervising the ordered services in accordance with state law and agency policies, must document orders in the patient’s medical record and sign, date, and time the orders. Verbal orders must be authenticated and dated by the provider in accordance with applicable state laws and regulations, as well as the agency’s policies. All provider orders must be documented in the EMR. A review of Patient #12 medical record revealed no documentation of a physician’s order to initiate home health services. In an interview conducted on June 13, 2024, with Employee #2, he/she confirmed no home health orders to begin services were present in Patient #12’s medical record. No additional documentation could be provided. In an interview conducted on June 14, 2024, with Employee #1, he/she acknowledged drugs, services and treatments are to be administered in accordance with the physician orders. Findings include: Facility policy review “...Provider Orders and Notification, Home Health Enterprise....” revealed, “...All treatments and care must be ordered, dated and signed by the provider and consistent with state and federal regulations. The orders may be obtained by telephone or in writing...When services are provided on the basis of a provider’s verbal orders, a nurse (acting in accordance with state licensure requirements) or a qualified practitioner responsible for furnishing/supervising the ordered services in accordance with state law and agency policies, must document orders in the patient’s medical record and sign, date, and time the orders. Verbal orders must be authenticated and dated by the provider in accordance with applicable state laws and regulations, as well as the agency’s policies. All provider orders must be documented in the EMR. During patient recorded review it was determined patient 1(one) did not have physician’s order to initiate home health services. Interview with employee #1 acknowledged drugs, services and treatments are to be administered in accordance with the physician orders.”