Vanura Homehealth Services Arizona

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and staff interviews it was determined the home health agency failed to develop an emergency preparedness plan based on a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach. This deficient practice has the potential that the home health agency and employees are not prepared for emergencies and how to respond posing the risk for negative and potentially fatal outcomes. Findings include: A review of Vanura Homehealth Services Arizona Policy No. 4-001, titled, “Emergency Management Plan”, revealed, “... To establish a plan which will allows[sic] for the continuation of services in the event of a disaster affecting the organization or the community... 2. Hazard Vulnerability Analysis: The identification of potential emergencies and the direct and indirect effects these emergencies may have on health care organization’s operations and the demand for its services... POLICY... The organization will establish an all-hazards approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capabilities...PROCEDURE Planning Process-Before an Emergency Organization leadership will conduct a hazard vulnerability analysis (HVA) to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to patients. 1. The HVA is evaluated at least every two (2) years to reflect changes in organization, risk conditions, patient information, and changes in staff....” A review of a binder titled “Emergency Preparedness Plan” revealed a document titled” Hazard Vulnerability Assessment”. The document was blank and not completed. In an interview conducted on October 29, 2024, with Employee #1, he/she confirmed the aforementioned document had not been completed and the emergency plan was not complete or reviewed since April 2022.”

“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 failed to incorporate a collaboration process with local, state, and tribal agencies. This deficient practice has the potential that the agency as a whole including office staff and clinicians not prepared in the event of an emergency posing the risk for negative and poor outcomes. Findings include: A review of Vanura Home Healthcare Services Arizona Policy No. 4-001, titled, “ EMERGENCY MANAGEMENT PLAN”, revealed, “...POLICY... COMMUNICATION PLAN 2. Contact information for the following: A. Federal, state, tribal, regional[sic] and/or local emergency preparedness staff... A review of the Emergency Preparedness Binder that was last updated in April 2022 revealed no documentation of contact information for the aforementioned entities. In an interview conducted on October 28 and October 29, 2024, with Employee #1, he/she confirmed no communication contact information was available and no further documentation could be provided.”

“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 interview it was determined the facility failed to ensure personnel should document that these discussions regarding emergency preparedness occurred and, also a copy of the individualized emergency plan is kept in the patient’s file as well as providing a copy to the patient and or their caregiver. This deficient practice has the potential that patients and their caregivers are not prepared in the event of an emergency posing the risk of negative outcomes. Findings include: A review of Vanura Home Health Services Arizona Policy No. 6-042, titled, “ CONTENTS OF A CLINICAL RECORD” revealed, “... POLICY...A clinical record will be maintained for each patient... accurately document care provided, and results in detail, and facilitate continuity of care among organization... PROCEDURE...1. The following information will be available in the clinical record for patients....” No documentation in the policy refers to the individualized emergency plan being kept as part of the clinical record. A review of Vanura Home Health Services Arizona Policy No.4-001, titled, “ EMERGENCY MANAGEMENT PLAN”, revealed, “... PROCEDURE...9. Individualized plans for patients during a natural or man-made disaster will be included as part of the comprehensive assessment...10. The organization educates patients and their families on emergency preparedness at time of admission including where they can go to shelter and what is required by the shelter...12. The agency maintains hard-copy of a current patient list including contact information and categories identified for each patient....” No documentation in the aforementioned policy refers to leaving a copy of the individualized patient emergency plan. A review of Vanura Home Health Services admission packet revealed a document titled, “EMERGENCY PLANNING”. The aforementioned document revealed, “... You should always be prepared for emergency situations. The following are general guidelines for preparing for emergencies followed by more specific instructions for floods and tornadoes. In any life-threatening situation, call 911...Before an emergency, discuss with family members who you would contact... AGENCY SERVICES If conditions, such as disaster, prevent or interrupt routine services, the Agency Staff will contact you, if possible...”. A review of 11 patient medical records revealed no documentation of individualized patient emergency plans. In an interview conducted on October 29, 2024, with Employee #1, he/she confirmed the admission packet was the most current and up-to-date. He/she confirmed there is no copy of an individualized emergency plan that was present in 11 of 11 patient charts. In an interview conducted on October 30, 2024, with Employee #2, he/she confirmed that no individualized patient emergency plans were present in the admission packets nor are copies being given to the patient(s) and a copy being placed into the medical record for reference.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and staff interview it was determined the home health agency failed to ensure an emergency preparedness training and testing program was documented, reviewed, and updated reflecting the risks identified in the facility’s risk assessment and included in the emergency plan. This deficient practice has the potential that the agency leadership and staff are not prepared in the event of an emergency posing the risk for negative outcomes. Findings include: A review of Vanura Homehealth Services Arizona Policy No. 4-001,”Emergency Management Plan”, revealed, “... To establish a plan which will allows[sic] for the continuation of services in the event of a disaster affecting the organization or the community... 2. Hazard Vulnerability Analysis: The identification of potential emergencies and the direct and indirect effects these emergencies may have on health care organization’s operations and the demand for its services... POLICY... The organization will establish an all-hazards approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capabilities...PROCEDURE Planning Process-Before an Emergency Organization leadership will conduct a hazard vulnerability analysis (HVA) to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to patients. 1. The HVA is evaluated at least every two (2) years to reflect changes in organization, risk conditions, patient information, and changes in staff...Training and Testing The training and testing program is reviewed and updated at least every two (2) years..3. Organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency management plan...4. All training will be documented in the personnel record of staff, individuals under arrangement[sic] and volunteers, if applicable. Testing VANURA HOME HEALTH SERVICES, ARIZONA will test the emergency management plan, at each site included in the plan, at least every two (2) years...7. The evaluation results and proposed improvements of any exercise or actual emergency will be presented to staff, individuals under agreement, volunteers as applicabel[sic] and the Governing Body...”. A review of the Emergency Preparedness Binder revealed a 2022 drill titled, “ 2022 Great Shake Out”, revealed a California earthquake drill. In an interview conducted on October 28, 2024, with Employee #1, he/she confirmed no documentation of the emergency drills for 2023, or 2024 could be provided. He/she confirmed he/she was unaware of the HVA and the risks for the area.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on record review and staff interviews it was determined the home health agency failed to advise patients orally and in writing of charges for services and charges that may not be covered. This deficient practice has the potential that patients and patient caregivers may not know the cost of services posing the risk for patient rights violations. Findings Include: A review of VANURA HOMEHEALTH SERVICES ARIZONA policy, titled, “ HOME HEALTH PATIENT BILL OF RIGHTS “, revealed, “... N. Be informed, verbally and in writing and before care is initiated of the extent to which: 1. Payment may be expected from Medicare, Medicaid, or any other federally funded or aided program know to the organization 2. Charges for services that will not be covered by Medicare 3. Charges that the individual may have to pay....” A review of Vanura Homehealth Services Arizona patient admission packet revealed no documentation of a fee schedule or explanation of benefits for home healthcare services and fees a patient may incur if the insurance failed to pay. A review of 11 medical records revealed no evidence of consent(s) signed that fees/costs were explained to 11 of 11 patients. In an interview conducted on October 30, 2024, with Employee #1, he/she confirmed the Vanura patient admission packet was the most current and no fee schedule was present in the admission packets given to the Patient(s) #1-11. He/she further confirmed the agency had no fee schedule and no further documentation could be provided.”

“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 home health agency failed to ensure patients 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. This deficient practice has the potential that patients are not being allowed to appeal the decision for the termination of home health care services posing the risk for poor outcomes and patient rights violations. Findings include: A review of a binder presented on October 29, 2024, titled, “ NOMNC 2024”, revealed, 10 patient Notice of Medical Non-Coverage (NOMNC) letters that were signed and dated with the incorrect Quality Improvement Organization (QIO) name and phone number listed. The document titled “NOTICE OF MEDICARE NON-COVERAGE”, revealed, “... HOW TO ASK FOR AN IMMEDIATE APPEAL... Call your QIO at: [name redacted] at (888) 375-6436 to appeal....” The phone number was called and it was for a company Care Centrix. All 10 of the NOMNC’s in the 2024 NOMNC binder were listed with the incorrect information. A review of the Vanura Homehealth Services Arizona Admission binder had the NOMNC listing the incorrect information, “... Call your QIO at: [name redacted] at (888) 375-6436 to appeal, or if you have questions....” In an interview with Employee #1 on October 29, 2024, he/she confirmed the admission packet was the most current and was unable to name the QIO for Arizona.”

“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 home health agency failed to ensure the names, addresses, and telephone numbers of the 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 given resources posing the risk of patient rights violations and poor outcomes. Findings include: A review of the Vanura Homehealth Services Arizona patient admission packet revealed no evidence of the following Federally-funded and state-funded entities’ phone numbers and addresses; Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. A review of the Vanura Homehealth Services Arizona Policies Table of Contents revealed no policy on the requirements. In an interview conducted on October 30, 2024, with Employee #1, he/she confirmed the required agencies and the addresses and phone numbers were not present in the patient admission packet. No additional documentation could be provided.”