Comprehensive Quality Care, Inc. Foundation

“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 of review of Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 10/2/24 and 10/3/24. The plan lacked documentation that a facility-based and/or community-based risk assessment was completed for 2022 and 2023. 2. During an interview with the Director of Patient Services 10/3/24 at 10:30 AM, the Director of Patient Services confirmed the above findings.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan, In-services training records and staff interview, it was determined the Agency failed to conduct staff training related to Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and In-services training records were reviewed on 10/3/24. The In-services training records lacked documentation of staff training related to Emergency Preparedness for Employee #2 (LPN/Date of Hire 2/16/23) in 2022 and 2023 and Employee #3 (LPN/ Date of Hire 4/2/24) in 2024. 2. During an interview with the Director of Patient Services on 10/3/24 between 10:30 AM to 2:00 PM, the Director of Patient Services confirmed the above findings.”

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. Findings include: 1. The Emergency Preparedness Plan was reviewed on 10/2/24 and 10/3/24. The Plan lacked documentation that the Agency conducted Emergency Preparedness exercise since 2021. 2. During an interview with the Director of Patient Services on 10/3/24 at 10:30 AM, the Director of Patient Services confirmed the above findings.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 38 of 60 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 7/2023 to 6/2024, was reviewed on 10/1/24. The report included error # -3330 for 38 of 60 late submissions, which was 63.33 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Director of Patient Services on 10/2/24 at 3:30 PM, she confirmed that the error occurred.”

“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 review of the Agency’s Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 9/30/24 and lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 9/30/24 and 10/1/24: Patient #1. SOC 9/13/24. Patient #2. SOC 2/14/24. Patient #3. SOC 9/18/24. During the home visits of Pts. #1, #2, and #3, the patient’s admission folder was observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed from 10/1/24 to 10/2/24: Pt. #1. SOC 9/13/24. Pt. #2. SOC 2/14/24. Pt. #3. SOC 9/18/24. Pt. #4. SOC 2/14/24. Pt. #5. SOC 9/9/24. Pt. #6. SOC 8/4/23. Pt. #7. SOC 10/27/23. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During an interview with the Director of Patient Services on 10/3/24 at 3:00 PM, she confirmed the Agency failed to provide the Pt./patient’s representative with the Administrator’s name and contact information.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, clinical record review, observation, and staff interview, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. Findings include: 1. The Patient’s admission folder was reviewed on 9/30/24 and lacked documentation of the Agency’s transfer and discharge policies. 2. The following clinical records were reviewed from 10/1/24 to 10/2/24: Pt. #1. SOC 9/13/24. Pt. #2. SOC 2/14/24. Pt. #3. SOC 9/18/24. Pt. #4. SOC 2/14/24. Pt. #5. SOC 9/9/24. Pt. #6. SOC 8/4/23. Pt. #7. SOC 10/27/23. The records lacked documentation the Agency provided Pts./patient’s representative information regarding the Agency’s transfer and discharge policies. 3. The following home visits were conducted on 9/30/24 and 10/1/24: Patient #1. SOC 9/13/24. Patient #2. SOC 2/14/24. Patient #3. SOC 9/18/24. During the home visits of Pts. #1, #2, and #3, the patient’s admission folder was observed, and lacked documentation the Agency had provided Pts./patient’s representative information regarding the Agency’s transfer and discharge policies. 4. During interview with the Director of Patient Services, on 10/2/24 at 1:30 PM and 10/3/24 at 10:30 AM, the above findings were confirmed.”

“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 review of the Agency’s Pt. admission folder, clinical records, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the the frequency of visits provided by each discipline. Findings include: 1. The patient’s admission folder was reviewed on 9/30/24 and included a form titled, “Authorization and Agreements for Home Health Services”. The Agency required the SN to complete the form during the SOC visit, indicating the visit frequency and charge per visit. 2. The following clinical records were reviewed from 10/1/24 to 10/2/24: Pt. #1. SOC 9/13/24. Pt. #2. SOC 2/14/24. Pt. #3. SOC 9/18/24. Pt. #4. SOC 2/14/24. Pt. #5. SOC 9/9/24. Pt. #6. SOC 8/4/23. Pt. #7. SOC 10/27/23. The clinical records lacked a completed “Authorization and Agreements for Home Health Services” form, documenting the Pt./representative was notified of the frequency of visits in writing. 3. Home visits were conducted on the following Pts. from 9/30/24 to 10/1/24: Pt. #1. SOC 9/18/24. Pt. #2. SOC 2/14/24 Pt. #3. SOC 9/18/24. During the home visits, the patient’s admission folder was observed and lacked documentation indicating the Pt./representative was notified of the frequency of visits in writing. 4. During interview with the Director of Patient Services, on 10/2/24 at 1:30 PM and 10/3/24 at 10:30 AM, the above findings were confirmed.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined in 3 of 7 (Pts. #1, 5, and 4) clinical records reviewed, the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. Findings include: 1. Pt. #1 was admitted to home health services on 9/13/24 with the diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The record included a Physician referral for home health services dated 3/13/24. The record included the initial SOC assessment, dated 9/13/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/3/24, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #5. Was admitted to home health services on 9/9/24 with the diagnosis of Mild Intermittent Asthma, Uncomplicated. The clinical record was reviewed on 10/1/24. The record included a Physician referral for home health services dated 8/5/24 and faxed to Agency on 8/26/24. The record included the initial SOC assessment, dated 9/9/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/3/24, the record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #4 was admitted to home health services on 2/24/24 with the diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 10/1/24. The record included a verbal order signed the Physician dated 2/2/24 and faxed dated 2/3/24. The record included the initial SOC assessment, dated 2/14/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 10/3/24, the record lacked documentation the Agency initiated service within the required time frame. 4. During interviews with the Director of Patient Services on 10/2/24 at 1:30 PM and on 10/3/24 at 10:30 AM, the Director of Patient Services confirmed the above findings.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure that a comprehensive assessment was updated at discharge. Findings include: 1. Pt. #6 was admitted to home health services on 8/4/23 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 10/2/24. The record documented that the last visit by the SN was on 2/27/24. The record included a discharge summary dated 3/29/24 and indicated that Pt. #6 was discharged from home health services. As of 10/3/24, the clinical record lacked documentation of an updated comprehensive assessment upon discharge. 2. Pt. #7 was admitted to home care services on 10/27/23 with diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The discharge date was 12/29/23. As of 10/4/24, the clinical record lacked documentation of an updated comprehensive assessment upon discharge. 3. During interview with the Director of Patient Services, on 10/2/24 at 1:30 PM and 10/3/24 at 10:30 AM, the above findings were confirmed.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined that in 6 of 7 (Pts. #1, 5, 7, 3, 4, and 6) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines, as required by the Agency. Findings include: 1. Pt. #1 was admitted to home health services on 9/13/24 with the diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The record lacked documentation the Agency had assessed the patient’s need for the Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 2. Pt. #5. Was admitted to home health services on 9/9/24 with the diagnosis of Mild Intermittent Asthma, Uncomplicated. The clinical record was reviewed on 10/1/24. The record lacked documentation the Agency had assessed the patient’s need for the Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 3. Pt. #7 was admitted to home health services on 10/27/23 with the diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The record lacked documentation the Agency had assessed the patient’s need for the Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 4. Pt. #3 was admitted to home health services on 9/18/24 with the diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 10/1/24. The record lacked documentation the Agency had assessed the patient’s need for the Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 5. Pt. #4 was admitted to home health services on 2/24/24 with the diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 10/1/24. The record lacked documentation the Agency had assessed the patient’s need for the Influenza and Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 6. Pt #6 was admitted to home health services on 8/4/23 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 10/2/24. The record lacked documentation the Agency had assessed the patient’s need for the Influenza and Pneumococcal Pneumonia vaccine, during the SOC visit as required by the Agency. 7. The Agency Policy titled: “Medication Administration”, revised 2024, was reviewed on 10/3/24. The policy indicated “....8. Administration, refusal, documentation includes Influenza vaccine recommendation. The policy did not address Pneumococcal Pneumonia vaccination. 8. During interviews with the Director of Patient Services on 10/2/24 at 1:30 PM and on 10/3/24 at 10:30 AM, the Director of Patient Services confimed the above findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, clinical records, observation during home visits, and staff interview, it was determined the Agency failed to provide information regarding the Director of Patient Services and their contact information. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 9/30/24. The folder lacked information identifying the Agency Supervisor’s (Director of Patient Services) name and contact information. 2. The following clinical records were reviewed on 10/1/24 and 10/2/24: Pt. #1. SOC 9/13/24. Pt. #2. SOC 2/14/24. Pt. #3. SOC 9/18/24. Pt. #4. SOC 2/14/24. Pt. #5. SOC 9/9/24. Pt. #6. SOC 8/4/23. Pt. #7. SOC 10/27/23. The clinical records reviewed lacked information identifying the Director of Patient Services name and contact information. 3. The following home visits were conducted from 9/30/24 at 2:00 PM and 10/1/24 at 10:30 AM and 2:00 PM. Pt. #1. SOC 9/13/24. Pt. #2. SOC 2/14/24. Pt. #3. SOC 9/18/24. 4. During the home visits, the Pt. admission folders were observed. The folders lacked the name and contact information of the Director of Patient Services. 5. During staff interview with the Director of Patient Services on 10/2/24 at 3:30 PM it was indicated the same admission folder is given to all Pts. the Director of Patient Services confirmed the above findings.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on a review of clinical records, Agency policy and staff interview, it was determined in 5 of 7 (Pts. # 4, 6, 1, 5 and 7) clinical records reviewed, the Agency failed to provide services as ordered by the Physician. Findings include: 1. Pt. #4 was admitted to home health services on 2/24/24 with the diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 10/1/24. The clinical record contained a POC effective 8/12/24, required: “….SN 1 x wk x 9, including telehealth….” The clinical record included a Missed visit form dated 8/15/24, indicated: “No answer to phone call….MD notified: No…” The clinical record included a Communication Note dated 8/19/24, indicated: “….Nursing visit on hold…PT only”. There was no modification in the Physician orders for the SN visits. The clinical record contained documentation that PT visits were provided, 1 x a week from 8/7/24 to 9/25/24. The record lacked a physician order for the PT visits. 2. Pt. #6 was admitted to home health services on 8/4/23 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 10/2/24. clinical record contained a POC effective 1/30/24, required: “….SN 1 x wk x 9 wk which includes telehealth visits….” The clinical record included: “Telehealth…” dated 2/8/24 and 2/22/24 and Missed visit forms dated 3/7/24 and 3/21/24, indicated: “No answer to phone call….MD notified: No…” The week of 3/11/24 to 3/24/24, lacked documentation of an SN visit. There were no modifications in the Physician orders for the SN visits. 6. The Agency policy titled, revised 2024, “Telehealth” was reviewed on 10/2/24, and required: “….Contacting the physician if no visit is to be made, and/or includes missed visit documentation…” 7. During interviews with the Director of Patient SErvices on 10/2/24 at 1:30 PM and on 10/3/24 at 10:30 AM, the Director of Patient Services confirmed the above findings. 3. Pt. #1 was admitted to home health services on 9/13/24 with the diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The record included the initial SOC assessment, dated 9/13/24 requiring: “SN 1 x wk x 9 wk including telehealth visits”. The clinical record lacked documentation of SN missed visit on 11/9/24. 4. Pt. #5. Was admitted to home health services on 9/9/24 with the diagnosis of Mild Intermittent Asthma, Uncomplicated. The clinical record was reviewed on 10/1/24. The record included the initial SOC assessment, dated 9/13/24 requiring: “SN 1x wk x 9 wk including telehealth visits” and PT evaluation and treatment. The clinical record lacked documentation of notification of SN missed visit and notification of Physician of delay in initiating PT services. 5. Pt. #7 was admitted to home care services on 10/27/23 with diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The record included the initial SOC assessment, dated 10/27/23 requiring: “SN 1 x wk x 9 wk including telehealth visits and PT evaluation and treatment”. The clinical record lacked documentation of notification SN missed visits and notification of Physician that PT services were not provided.”

“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 review of clinical records and staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. Findings include: 1. Pt. #6 was admitted to home health services on 8/4/23 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 10/2/24. The record included a discharge summary dated 3/29/24 and indicated that Pt. #6 was discharged from home health services. The Agency lacked documentation that a copy of the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to home care services on 10/27/23 with diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 10/1/24. The discharge date was 12/29/23. As of 10/5/24, the clinical record lacked evidence that the discharge summary was sent to the physician. 3. During interview with the Director of Patient Services, on 10/2/24 at 1:30 PM and 10/3/24 at 10:30 AM, the above findings were confirmed.”