Covenant Home Health

“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 interview, review of policy and procedures and review of facility documents, it was determined the hospice failed to ensure that an emergency preparedness plan was created that was individualized to the specific needs of the facility and was comprehensively updated every two years. Failure to ensure that an emergency preparedness plan is developed that is designed for the specific facility and is updated every two years can result in an emergency preparedness plan that provides inaccurate or false information during an emergency, creating hazards for both staff and patients. A review of the provided facility emergency preparedness plan revealed: “...The purpose of this plan is to provide an all-hazards approach to guide Fellowship Square/Christian Care Phoenix in the event of an emergency....” Although Covenant Home Health was mentioned in the document, much of the document was generalized to the larger organization, Fellowship Square/Christian Care Phoenix. Throughout the 79-page document, the company referenced was Fellowship Square/Christian Care Phoenix. The majority of items in the emergency preparedness plan were dated from 2019, with the exception of a report of food and water stores from 2016. The manager and contact numbers contained within, “...Introduction to the Emergency Management Plan....” were for two individuals not known to be currently employed and physically present in Covenant Home Health. Neither of the two Administrators listed were current Administrators for Covenant Home Health. The Director of Nursing listed was not the Director of Nursing for Covenant Home Health. The details provided regarding number of staff per shift, number of buildings and number of beds/breakdown types of beds was not information specific to Covenant Home Health. “...Section V: Emergency Response....” revised according to the document in October 2012 and approved by the safety committee for use in 2024 revealed, “...The proper incident is emailed to the Phoenix Site and paged via radio and over head page....” Observation while on tour March 27, 2024 revealed that Covenant Home Health does not have an overhead system to page staff and does not have any radios with which to communicate with staff. Employees #1 and #2 confirmed that no overhead system or radios could be provided. In an interview conducted with Employee #4, Employee #4 stated she was responsible for maintaining the emergency preparedness plan for Covenant Home Health and would be responsible for activating the plan in the event of an emergency; however, when asked, Employee #4 confirmed that she was not an employee of Covenant Home Health and did not maintain a physical presence at Covenant but rather worked for the larger corporation of Christian Care. Employee #4 confirmed that the safety committee, who does not work or maintain a physical presence at Covenant but is associated with the larger corporation of Christian Care approved the emergency preparedness plan for 2024 and made no changes; however, some of the information within the plan that had not been updated since 2019 was no longer accurate.”

“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 interview, review of medical records, review of facility policy and procedure and review of facility records, it was determined the home health agency failed to ensure that individualized emergency preparedness plans were developed with each patient, included as part of the patient’s comprehensive assessment and documented for seventeen (17) of 17 patients reviewed. Failure to ensure that individualized emergency plans are created with patients at time of assessment and appropriately documented can result in patient needs not being addressed during emergencies, increasing the likelihood of patient harm or mortality. Findings include: Facility policy titled, “...Patient Education Process....” revised November 2018 revealed: “...The patient and family/caregiver will receive verbal and...written instructions...on...emergency preparedness...Documentation of patient and family/caregiver education will consist of...Describing what was taught to patient...Describing the patient’s response to teaching...Describing additional learning needs not already met...Describing teaching planned for subsequent visits....” A review of the medical records revealed no individualized emergency preparedness plans documented during the comprehensive assessment for the seventeen (17) patients reviewed. A review of the facility Emergency Preparedness plan and binder revealed no copies of individualized patient emergency preparedness plans or information addressing the individual needs of patients in the event of an emergency. In a subsequent interview with Employees #1 and #4 conducted on March 28, 2024, the employees confirmed this information could not be provided and this was not in accordance with facility policies.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documents, it was determined the home health agency has failed to ensure that a procedure was developed to ensure that patients can be contacted in the event of a disruption in services due to an emergency or a policy or procedure for informing state and local officials of any on-duty staff or patients they are unable to contact and any special evacuation needs patients may have in an emergency. Failure to develop these policies and practices can result in an inability to connect patients with vital services and life-saving measures during a crisis, leading to increased patient injury and mortality. Findings include: A review of the “...Emergency Management Plan....” revised April 2019 revealed: “...The agency maintains a hard-copy of a current patient list including contact information and categories identified for each patient in the event there is a power failure...The organization will maintain an emergency preparedness communication plan...The plan includes the following...Names and contact information for...Staff...” A review of the facility’s emergency preparedness plan revealed no hard copy of a current patient list containing patient contact information or information that would assist in an evacuation of patients. No staff list containing current contact information for staff that would assist officials in locating staff could be found. A subsequent interview was conducted with Employees #1, 2 and 4. This information was requested but could not be provided. Employee #4 confirmed the provision of this information in the emergency preparedness plan would be in accordance with facility policies.”

“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 interview and review of facility records, it was determined the home health agency failed to ensure the facility’s emergency preparedness communication plan included the contact information for facility staff servicing patients, the contact information for doctors servicing patients, and for entities providing services under arrangements to the patients. Failure to include contact information for staff, physicians, and entities providing services under arrangement to patients can result in patients losing contact with vital services through their facility. Facility policy titled, “...Emergency Management Plan....” revised April 2019 revealed: “...The organization will maintain an emergency preparedness communication plan...The plan includes the following...Entities providing services under arrangement...Patients’ physicians....” A review of the facility’s emergency preparedness communication plan revealed no list of physicians currently servicing patients containing contact details. A list of entities providing services under arrangement and contact information could not be found in the communication plan. In a subsequent interview conducted with Employees #1, 2 and #4 on March 28, 2024, these employees confirmed that the contact lists requested could not be found in the communication plan and were not available in the communication plan.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on observation while on a tour of the facility, interview, and review of facility records, it was determined the home health agency failed to ensure that alternate means of communication was available in an emergency event. Failure to ensure the availability of alternate means of communication can result in an inability to contact emergency services or to advise the AHJ (Authority Having Jurisdiction) of the needs of patients or of the facility in an emergency, leading to increased mortality and injury for both patients and staff. Facility policy titled, “...Emergency Management Plan....” revised April 2019 revealed: “...The organization will maintain an emergency preparedness communication plan...The plan includes the following...Primary and alternate means of communicating....” A review of the facility’s Emergency Preparedness Communications Plan revealed that walkie talkies and a satellite radio were intended as the alternate methods of communication should an alternate means of communication be needed in an emergency. During observation on tour conducted on March 27, 2024, no walkie talkies or satellite radios could be found. A subsequent interview was conducted with Employees #1, #2 and #4 who confirmed that there were no walkie talkies or satellite radios present in the facility or on the grounds of Covenant Home Health. A request was made for alternate means of communication in the event of an emergency, but these alternate means of communcation as outlined in the emergency preparedness communication plan could not be provided. Findings include: Facility policy titled, “...Emergency Management Plan....” revised April 2019 revealed: “...The organization will maintain an emergency preparedness communication plan...The plan includes the following...Primary and alternate means of communicating....” A review of the facility’s Emergency Preparedness Communications Plan revealed that walkie-talkies and a satellite radio were intended as the alternate methods of communication should an alternate means of communication be needed in an emergency. During observation on the tour conducted on March 27, 2024, no walkie-talkies or satellite radios could be found. A subsequent interview was conducted with Employees #1, #2 and #4 who confirmed that there were no walkie talkies or satellite radios present in the facility or on the grounds of Covenant Home Health. A request was made for alternate means of communication in the event of an emergency, but these alternate means of communication as outlined in the emergency preparedness communication plan could not be provided.”

“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), §485.542(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, REHs at §485.542, 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: Based on interviews, a review of facility policy and procedure, and facility documents, it was determined the agency failed to ensure the facility exercised its emergency preparedness plan every two years by participating in a full-scale exercise. Failure to participate in exercises that test the emergency preparedness plan can result in an emergency preparedness plan being ineffective in an emergency due to unforeseen circumstances, leading to patient jeopardy. Facility policy titled, “...Emergency Management Plan....” revised April 2019 revealed: “...Testing...Covenant Home Health will test the emergency management plan, at each site included in the plan, at least annually...The agency participates in a full-scale exercise...An additional exercise is conducted....” A review of “...Emergency Preparedness 2023 Full Scale Exercise (FSE): Active Shooter....” revealed attendance of Doug Dreyer on behalf of Covenant Home Health and Diane Kubala on behalf of Covenant Health Network. In a subsequent interview conducted on March 28, 2024, Employees #1, 2 and 4 confirmed that neither Doug Dreyer nor DIane Kubala are employed at Covenant Home Health nor do they physically work on the premises of the facility. Employees #1, 2 and 4 confirmed that no after-action meetings were held with the staff of Covenant Home Health regarding the exercise so the staff could learn or benefit from the exercise.”

“Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This Standard is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to ensure information must be provided to patients in plain language and in a manner that is accessible and timely. This blatant deficient practice has the potential that patients and patient representatives are not being afforded their rights and civil liberties posing the risk of negative patient outcomes and Civil Rights violations as well as patient rights violations. Findings include: A review of Covenant Home Health Policy No. 1-010.1. titled, “ Regulatory Compliance”, revealed, “... The organization will maintain evidence of regulatory compliance, including but not limited to: ... 2. Organization and ACHC policies and procedures...13. Professional standards and principles A. Federal regulations...”. A review of Covenant Home Health Policy No. 2-002.1. titled, “Patient Bill Of Rights”, revealed, “... The Patient Bill of Rights statement defines the right of the patient to:... 21. To have the communication needs met... a. The organization shall provide verbal notice of the patient’s rights and responsibilities in the patient’s primary or preferred language and in a manner the individual understands, free of charge, with the use of a competent interpreter if necessary, no later than the completion of the second(2nd) visit from a skilled professional (RN, PT, SLP, OT)... 5. The Patient Bill of Rights statement will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language, communication method or manner he/she can be reasonably expected to understand...7. The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights... B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available. C. Written information will be provided to patients in English and predominant non-English languages of the population served...”. A review of Covenant Home Health Policy No. 2-040.1, titled, “ Facilitating Communication”, revealed, “... those who have limited command of the English language, have access to appropriate interpretive assistance and other aides at no cost to the patient(s) being served... Policy... Organizational personnel will consistently and clearly communicate with patients in a language or form they can reasonably understand. The organization will facilitate communication by using special devices, interpreters or other communication aides... 3. Limited English Proficiency(LEP): A person with Limited English Proficiency is one whose command of the English language is not sufficient to promote meaningful interaction for service... A. If a patient refuses offered communication assistance, the clinician will document refusal in the patient’s clinical record... 2. All patient related forms, such as Consent for Services, Complaint/Grievance Process, Etc., will be available in English, and other languages as appropriate...5. For patients who has limited English proficiency (LEP) and requires an interpreter: A. The organization will maintain a list if organization personnel who speak languages other than English... B. If an interpreter in the required language is not available, a telephone interpreting service may be used. Directions for the use of this service can be accessed by calling that service... E. Family members or friends of the patient will not be used as interpreters unless specifically requested by the individual and after the patient has understood that an offer of an interpreter at no charge has been made. Such an offer and response will be made documented in the patient’s record. If the patient chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the patient... F. Document all language assisted care in the patients clinical record...”. A review of the Covenant Home Health admission folder was reviewed and a document titled, “Multi-Language Interpreter Services”, revealed, “... ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-800-794-5907...”. A phone call was placed to the aforementioned phone number and it revealed the Company name Care Plus. A PIN code was required as well as the patient’s zip code, and date of birth. A review of Patient #12’s medical record revealed the patient did not speak English. No evidence that a language assistance line was offered and declined by the patient before the HHA used the patient’s ex-spouse as the interpreter. The patient spoke Cantonese. There were 3 missed visits related to no interpreter. Language line was not mentioned in the medical record as being utilized when the clinicians could not reach the ex-spouse to schedule appointments. The patient was discharged without notice and without a NOMNC being signed per agency policy. In an interview conducted on March 28, 2024, with Employee #1, he/she stated the language line was a free service. He/she also stated the patient spoke Cantonese and that was not a language offered according to the “Multi-Language Line Interpreter Services” document. Employee #1 was unaware Cantonese was a dialect of Chinese, an offered language listed on the aforementioned document. A contract agreement between Covenant Home Health and Care Plus was asked for and not received. In an interview conducted on March 28, 2024, with Employee #4, he/she stated that no contract for Care Plus could be located and that he/she was under the impression it was a free service and no contract was available. No additional documentation could be provided.”

“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 interviews, it was determined that the Home Health Agency(HHA) failed to provide the current HHA Administrator’s name to receive complaints. This deficient practice has the potential that patient and patient representatives are inadequately informed on whom to contact to file a complaint posing the risk of patient rights violations. Findings include: A review of Covenant Home Health Policy No. 1-010.1. titled, “ Regulatory Compliance”, revealed, “... The organization will maintain evidence of regulatory compliance, including but not limited to: ... 2. Organization and ACHC policies and procedures...13. Professional standards and principles A. Federal regulations...”. A review of Covenant Home Health Policy No. 2-002.1, titled, “ Patient Bill Of Rights”, revealed, “...Procedure 1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. 2. The Patient Bill of Rights Statement defines the right of the patient to:... 3. Voice grievances regarding treatment or care... A review of the Covenant Home Health admission folder, revealed a document titled, “... Grievance/Problem Solving Procedure... 1. Notify ... Director of Health Care Services... You may also submit your complaint in writing to: ... Director of Health Care Services...”. In an interview conducted on March 26, 2024, with Employee #1, he/she confirmed he/she was the current Administrator and the person listed in the admission folder was a “PRN Administrator”. A request for the appointment of a PRN administrator was asked for and could not be provided. In an interview conducted on March 26, 2024, with Employee #2, he/she confirmed that Employee #1 was the current Administrator for the HHA. In an interview conducted on March 28, 2024, with a person stating he/she represented Christian Care, stated the Administrator listed in the admission folder was not the Administrator in any capacity and no longer been an employee of Covenant Home Health. An employee file could not be provided for the aforementioned person representing Christian Care and admitted to not being an employee of the HHA being surveyed. He/she works for Christian Care Corporation and is the Executive Director.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to allow the patient to participate in care and the staff failed to keep the patient informed of changes in the plan of care. This deficient practice has the potential that patients and their representatives are not being allowed to voice concerns and participate in the changes being made to the care being furnished posing the risk of negative patient outcomes and patient rights violations. Findings include: A review of Covenant Home Health Policy No. 1-010.1. titled, “ Regulatory Compliance”, revealed, “... The organization will maintain evidence of regulatory compliance, including but not limited to: ... 2. Organization and ACHC policies and procedures...13. Professional standards and principles A. Federal regulations...”. A review of Covenant Home Health Policy No. 2-002.2, titled, “Patient Bill Of Rights”, revealed, “... 7. Be advised in advance of any change, orally and in writing in the plan of care before the change is made... 9. The establishment and revision of the plan of care...”. A review of Patient #11’s record revealed missed visits and complaints made to the agency for lack of visits made per the plan of care. There was no evidence in the medical record that the patient was ever made aware of their rights as no consent for treatment was located in the medical record. A request for additional documentation was asked for and not received. A review of Patient #12’s medical record revealed that neither the patient nor the patient’s representative was informed or allowed to participate in the changes made to the plan of care. The patient did not speak English and the HHA relied on the patient’s ex-spouse to be present at all appointments to translate. When the ex-spouse was not readily available the appointments were documented as missed visits and the patient was discharged from the agency without being notified of his/her plan of care changes. A language line was also not utilized to inform the patient of his/her rights to be informed of changes. A review of Patient #13’s medical record revealed the patient was discharged without the patient being notified. The discharge reason stated, “Unable to schedule”. There was no evidence of how many attempts were made before the patient was discharged without being notified of a change in the plan of care. In an interview conducted on March 28, 2024, with Employee #1, he/she confirmed that no additional documentation for the aforementioned patient(s) or patient(s) representative(s) had received written or verbal notices of the changes to the plan of care. In an interview conducted on March 28, 2024, with Employee #2, he/she confirmed that no additional documentation for the aforementioned patients had received written or verbal notices to the plan of care.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and staff interviews it was determined the HHA failed to furnish patient(s) proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. This deficient practice has the potential for patients and patient representatives not being allowed to exercise their rights posing the risk of negative outcomes and potential for patient rights violations. Findings include: A review of Covenant Home Health Policy No. 1-010.1. titled, “ Regulatory Compliance”, revealed, “... The organization will maintain evidence of regulatory compliance, including but not limited to: ... 2. Organization and ACHC policies and procedures...13. Professional standards and principles A. Federal regulations...”. A review of Covenant Home Health Policy No. 4-045.1, titled, “Discharge Criteria And Process”, revealed, “... Discharge/Reduction of Services Criteria... Procedure 1. The organization will verbally notify the patient of the decision to terminate or reduce the services within one(1) visit prior to the time the change in service is to occur( ie., prior to the last scheduled visit)...”. A review of a document titled, “Covenant Home Health... Notice of Medicare Non-Coverage...”, revealed, “... Call your QIO at: 602 801-6600- Health Services Advisory Group to appeal, or if you have questions... If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights: If you have Original Medicare: Call the QIO listed on page 1... Please sign below to indicate you received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. Signature of Patient or Representative Date...”. A review of Patient #1, 2, 3, 4, 5, 7, 10, 12, 14, and 16 had the Notice of Medicare Non-Coverage( NOMNC) signed upon the admission date. The phone number for the QIO was not listed for the appropriate agency Livanta. There was no evidence that the patients were properly informed of the correct information or reminded that they had the right to appeal the decision for discharge or a reduction in the services being provided. In an interview conducted on March 28, 2024, with Employee #1, he/she confirmed that the NOMNC listed the incorrect phone number and agency for the QIO for Medicare patients residing in Arizona. No additional documentation could be provided. This was not corrected while onsite during the survey. In an interview conducted on March 28, 2024, with Employee #2, he/she confirmed that the NOMNC listed the incorrect phone number and agency for the QIO for Medicare patients residing in Arizona. No additional documentation could be provided and this was not corrected while onsite.”

“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 and patient representatives of the names, addresses, and telephone numbers of the required federally and state-funded entities. This deficient practice has the potential that patients are not being adequately informed and educated on resources posing the risk of negative outcomes and patient rights violations. Findings include: A review of Covenant Home Health Policy No. 1-010.1. titled, “ Regulatory Compliance”, revealed, “... The organization will maintain evidence of regulatory compliance, including but not limited to: ... A. Federal regulations...”. A review of Covenant Home Health Policy No. 2-002.1, titled, “ Patient Bill Of Rights”, revealed, “...Procedure... 2. The Patient Bill of Rights Statement defines the right of the patient to:... 30. The names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency 4. Aging and Disability Resource Center 5. Quality Improvement Organizations...”. A review of the Covenant Home Health admission folder revealed a document titled, “State & Federal Agencies Important Contact Information”. This document had the following agency’s phone numbers and electronic mail(email) listed; Arizona Department of Health Services, D.E.S. Arizona Adult Protective Services, Arizona Long-Term Care Ombudsman, The Arizona Center for Disability Law, and Arizona Attorney General’s Office. The phone number to the Arizona Department of Health Services listed as 602-364-2079, rang to Special Licensing, not the correct number for Medical Licensing. In an interview conducted on March 28, 2024, with Employee #1, he/she confirmed that the required agencies were not listed in the patient admission folder. No additional information could be provided. In an interview conducted on March 28, 2024, with Employee #2, he/she confirmed that the required agencies were not present in the agency admission folder and that the admission folder was the most current to date. No additional documentation could be provided.”

“Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This Element is not met as evidenced by: Based on interview, review of policy and procedure and medical records review, the Department has determined the Administrator has failed to ensure that access to language services and the ability to access language services was provided to one (1) out of seventeen (17) patients surveyed, Patient #12. Failure to inform patients of their right to auxiliary language services and then to provision of language services can result in patients with language barriers receiving substandard levels of care. Findings include: A review of the medical records of Patient #12 revealed that Patient #12’s ex-wife was utilized as the interpreter for his initial assessment. It was noted in the medical record that Patient #12 preferred to use his ex-wife as his interpreter. However, subsequent to the initial assessment, the ex-wife declined to continue to be involved in Patient #12’s care. No alternate interpretation options were offered to Patient #12. Patient #12’s skilled nursing appointments were canceled due to lack of an interpreter and Patient #12’s physical therapist communicated with the patient to the best of his ability without an interpreter. In a subsequent interview with Employee #1 conducted on March 27, 2024, Employee #1 stated there was a Language Line service available; however, a call to the service revealed that this service required a paid account and Covenant Home Health did not have a paid account. In an interview conducted with Employees #1, #2 and #4 on March 28, 2024, these Employees acknowledged such practices were not in accordance with facility policies.”