Professional Home Care Advantage Inc.

“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 the Emergency preparedness Plan review and staff interview, it was determined that the Agency failed to ensure testing of the emergency preparedness plan was completed. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 02/15/24 at 11:00 AM. The Emergency Preparedness plan did not include documentation indicating that the Agency conducted / participated in any community-based testing exercises, since 2020. 2. The findings were confirmed during the interview, with the Administrator on 02/15/24 between 11:00 AM and 1:30 PM.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical records review and staff interview, it was determined that for 5 of 7 (Pts. #1, 4, 5, 6 and 2) clinical records reviewed, the Agency failed to ensure the staff followed the Physician orders. 5. Patient # 2 was admitted to home health services on 12/24/23 with Diagnosis of Bilateral Primary Osteoarthritis. The clinical record was reviewed on 02/15/24. The clinical record contained a POC for certification period beginning 12/24/3 to 02/21/24 that required PT services to evaluate and treat. The clinical record lacked documentation indicating that PT evaluated patient. No modification orders were found in the record. 6. Findings of Agency staff failing to follow Physicians orders as indicated in the PsOC was confirmed during interviews with the Administrator on 02/15/24 between 10:30 AM and 1:00 PM. 3. Patient #5 was admitted to the home health services on 08/08/23 with the Diagnoses of Heart Failure , Unspecified and Type 1 Diabetes Mellitus without Complications. The clinical record was reviewed on 02/14/24. The Physician orders dated 12/06/24 and 02/04/24 required the Physical Therapy to evaluate and treat. As of 02/15/24 the PT evaluation was not conducted. The physician orders also required the Skilled Nurse to assess each visit the “ Type1 Diabetes Mellitus without Complications”. The Skilled Nurse failed to include the patient’s blood glucose results for the entire certification period of 12/06/23 thru 02/03/24. 4. Patient #6 was admitted to the home health services on 06/07/23 with the diagnoses of Bilateral Osteoarthritis of Knee and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24. The Physician orders dated 12/04/24 required the Physical Therapy to evaluate and treat. As of 02/15/24 the PT evaluation was not conducted. The physician orders also required the Skilled Nurse to assess each visit the “ Type Diabetes Mellitus without Complications”. The Skilled Nurse failed to include the patient’s blood glucose results for the entire certification period of 12/04/23 thru 02/01/24. 1. Pt. #1 was admitted to home health services on 12/29/23 with diagnoses that include Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Chest Pain on Breathing. The clinical record was reviewed on 02/14/24. The record contained the POC effective 12/29/23 requiring: “SN to perform complete physical assessment each visit with emphasis on... Chest pain on breathing... Notify the Physician immediately of any potential problems that impede the completion of patient recovery...” The SN visit notes dated 01/19/24 and 02/02/24 contained documentation that the Pt. experienced, “Chest pain on breathing”. The record lacked documentation the SN notified the Physician the Pt. experienced “Chest pain on breathing” on 01/19/24 and 02/02/24. The POC effective 12/29/23 required: “PT Frequency: Eval and Treat”. As of 02/14/24, the record lacked documentation the PT evaluated and treated Pt. #1. 2. Pt. #4 was admitted to home health services on 01/19/24 with diagnoses that include “Unspecified Osteoarthritis”. The clinical record was reviewed on 02/15/24. The record contained the POC effective 01/19/24 requiring: “SN Frequency 1wk9”. The record lacked documentation the SN provided service during the week of 1/28/24 to 2/3/24. The POC effective 01/19/24 required “PT Frequency: Eval and Treat”. As of 02/15/24, the record lacked documentation the PT evaluated and treated Pt. #4.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on home visit observations, clinical records review and staff interview, it was determined that for 5 of 7 (Pts. #2, 3, 5, 1 and 4) clinical records reviewed, the Agency failed to ensure all entries were clear, complete and authenticated. __. Pt. #1 was admitted to home health services on 12/29/23 with diagnoses that include Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Chest Pain on Breathing. The clinical record was reviewed on 02/14/24. The record contained a SOC order completed by the SN. The SOC order lacked the name/signature of the SN that obtained the physician’s order, date the order was written, pertinent diagnoses, and discipline(s) to provide service, as required by the Agency’s SOC order. The SOC comprehensive assessment form completed by the SN and dated 12/29/23, lacked the Emergency Preparedness priority code and date of the referral. The assessment contained documentation that the Pt. lives with others in the home, the assessment lacked the name, age, sex and relationship of those that reside with the Pt., as required by the SOC comprehensive assessment form. The form titled “Beneficiary Elected Transfer” completed by the SN, signed by the SN, Pt. and dated 12/29/23 lacked the name of the Agency the Pt. previously received home health services, and notification that the Pt. is currently receiving services from this Agency, as required by the Agency’s form. The form titled “Notice of Medicare Non-Coverage” completed by the SN, signed by the SN, Pt. and dated 12/29/23 lacked the effective date that home health coverage will end, as required by the CMS form. __. Pt. #4 was admitted to home health services on 01/19/24 with diagnoses that include “Unspecified Osteoarthritis”. The clinical record was reviewed on 02/15/24. The record contained the Telephone Order dated 1/19/24 and completed by the SN. The Order lacked “Pertinent Diagnoses” and the disciplines to provide service, as required by the Agency’s Physician order form. ___. During interviews with the Administrator on 02/15/24, the Administrator confirmed the above findings. 2. Patient #3 was admitted to the Home Health Services on 10/06/23 with the diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24 and included incomplete SN visit notes. The SN visit notes lacked the documentation of the blood glucose results that was observed in the patient’s home records for the entire certification period, 12/04/23 thru 02/15/24. 3. Patient #5 was admitted to the Home Health Services on 08/08/23 with the diagnoses of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 02/14/24 and included an incomplete Skilled Nursing note dated 02/06/24 and 02/13/24. The Skilled Nurses notes lacked the signature of the clinician. 1. Patient # 2 was admitted to home health services on 08/26/23 with Diagnosis of Bilateral Primary Osteoarthritis. A SN home visit was conducted on 02/15/24 at 9:30 AM. During an interview with the visiting nurse, the SN stated she has been providing SN visits weekly for certification period beginning 12/24/23. The clinical record was reviewed on 02/15/24. The clinical record contained weekly SN visit notes for certification period beginning 12/24/3 with a different clinician name.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Administrator failed to ensure information provided to Pts. was accurate and/or complete. Findings include: 1. The Pt. admission folder was reviewed on 02/14/24. The folder lacked documentation identifying the Administrator’s and Clinical Manager’s name, address, and phone number; information regarding the Agency’s transfer and discharge policies; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; correct address for the State Complaint Hotline; the Patient’s Bill of Rights and Responsibilities lacked the correct phone number of the Agency. The admission folder included multiple pages with the State Complaint Hotline phone number, the reference page with multiple listing multiple contacts lacked the correct State Complaint Hotline phone number. The Administrator failed to ensure information provided daily to Pts. was accurate and/or correct. 2. The following home visits were conducted on 01/14/24 and 01/15/24: Pt. #1. SOC 12/29/23. Pt. #2. SOC 08/26/23. Pt. #3. SOC 10/06/23. During the home visits, the patient’s admission folder was observed and lacked documentation identifying the Administrator’s and Clinical Manager’s name, address, and phone number; information regarding the Agency’s transfer and discharge policies; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; correct address for the State Complaint Hotline; the Patient’s Bill of Rights and Responsibilities lacked the correct phone number of the Agency. The admission folder included multiple pages with the State Complaint Hotline phone number, the reference page with multiple listing multiple contacts lacked the correct State Complaint Hotline phone number. The Administrator failed to ensure information provided daily to Pts. was accurate and/or correct. 3. The clinical records of the following Pts. were reviewed on 02/14/24 and 02/15/24: Pt. #1. SOC 12/29/23. Pt. #2. SOC 08/26/23. Pt. #3. SOC 10/06/23. Pt. #4. SOC 01/19/24. Pt. #5. SOC 08/08/23. Pt. #6. SOC 06/07/23 Pt. #7. SOC 04/15/23. The records lacked documentation the Agency provided the Pt./patient’s legal guardian with the name, address and phone number for the Administrator and Clinical Manager; transfer and discharge policy information; names, addresses, telephone numbers for State and Federally funded organizations that the Pt. resides; the correct State Complaint Hotline phone number and address; and the correct Agency’s phone number on the Patient’s Bill of Rights and Responsibilities. 4. During the entrance interview with the Administrator on 02/14/24 at 10:30 PM, the Administrator confirmed this was the Pt. admission folder used for all Pts. admitted to this Agency. 5. During an interview with the Administrator on 02/15/24 at 10:37 AM, the Administrator stated services are initiated as required, including weekends and holidays. During the same interview the Administrator confirmed he is responsible for ensuring information provided to Pts. is accurate and complete.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on observation and staff interview, it was determined the Administrator failed to ensure a pre- designated person is assigned in writing to cover the duties of the Administrator when he is not available. Findings include: 1. During the entrance interview on 02/14/2024 at 10:00 AM. The Administrator stated the Clinical Manager was out on maternity leave. During the same interview the Administrator stated that he covers for the Clinical Manager and that the Clinical Manager was expected to return 02/14/2024. 2. During an interview with the Clinical Manager on 02/14/2024 at 11:30 AM, the Clinical Manager stated she is not returning fully to work schedule. The Clinical Manager added that the Administrator was covering the duties as the Clinical Manager while performing duties as the Administrator. 3. During an interview with the Administrator on 02/14/2024 at 11:30 AM the Administrator stated and confirmed he is fulfilling both duties of Administrator and Clinical Manager and he has no pre - assigned alternate Administrator while covering for the Clinical Manager.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical records review and staff interview, it was determined that for 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure the discharge summaries were complete and sent to the physician. 2. Patient # 7 was admitted to home care services on 04/15/23 with Diagnosis of Bilateral Primary Osteoarthritis. The clinical record was reviewed on 02/15/24. The clinical record contained a discharge document SN assessment dated 12/07/23. The clinical record lacked documentation indicating that a discharge summary was completed and sent to the Physician. 3. Finings of the discharged records not having a discharge summary were confirmed during interviews with the Administrator on 02/15/24 between 11:30 AM and 1:00 PM. Findings include: 1. Patient #6 was admitted to the home health services on 06/07/23 with the diagnoses of Bilateral Osteoarthritis of Knee and Type 2 Diabetes Mellitus. The clinical record was reviewed on 02/14/24. The clinical record included an incomplete discharge document dated for 12/-04/23 -02/01/24 that lacked the discharge summary.”