Human Touch Home Health, 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 a review of the Agency’s Emergency Preparedness Plan, Agency’s policy and staff interview, it was determined the Agency failed to ensure the Agency conducted the required Agency and community exercises bi-annually to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. This has the potential to affect all patients receiving Home Health Care services. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/6/23. The Plan lacked documentation the Agency conducted testing of emergency preparedness procedures biannually. The Agency also was unable to provide documentation that full-scale or tabletop testing exercises were conducted for the years 2021 and 2022. 2. The Agency’s Policy “Emergency Operations Plan Risk Assessment and Planning” revised on 6/22/22 was reviewed on 12/6/23. The policy required, “Agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current plans and any forms developed for use in a disaster.” 3. During an interview with the Alternate Administrator on 12/6/23 at 1:15 PM, it was confirmed the Agency failed to provide Emergency Preparedness testing of its Emergency Plan for the years 2021 and 2022.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency staff failed to follow physician orders indicated in the Plan of Care. This was found in 4 of 7 (Pt. #6, 7, 2 and 5) clinical records reviewed. 3. Pt. # 2 was admitted to skilled home health on 9/11/23 with Diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 12/5/23. The clinical record contained a POC for certification period 11/10/23 to 01/8/23 that required SN frequency of 1 time a week for 9 weeks. The clinical record lacked SN visit notes for week of 11/19/23 (week 2) and week of 11/26/23 (week3) of certification period. 4. Pt. # 5 was admitted to skilled home health on 8/18/22 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 12/6/23. The clinical record contained a POC for certification period 8/13/23 to 10/11/23 that required: Notify physician of: pulse greater than 90 or less than 60....Diastolic blood pressure greater than 90 or less than 60. The clinical record contained SN visit note dated 9/19/23 with a pulse rate reading of 56, a SN visit note dated 9/25/23 with a pulse rate of 55 and blood pressure of 149/55. The clinical notes and clinical record lacked documentation that the physican was notified of pulse rates or blood pressure reading. 5. During interviews with the Alternate Administrator on 12/6/23 at 2:45PM and 12/7/23 at 10:30 AM, the above finding was confirmed. Findings include: 1. Pt. #6 was admitted for skilled home health on 2/1/23 with a Primary Diagnosis of Moderate Persistent Asthma with (acute) Exacerbation. The clinical record was reviewed on 12/6/23. The record included a Plan of Care for the certification period of 6/3/23 to 8/1/23 which required, “SN to assess (oxygen) saturation on room air every visit… SN to assess patient’s weight log every visit…” Pt. #6’s SN visit notes for 6/20/23, 6/27/23 and 7/7/23 lacked documentation of the patient’s oxygen saturation and weights; and the SN visit notes for 7/11/23, 7/18/23 and 7/25/23 lacked documentation of the patient’s weights. 2. Pt. #7 was admitted for skilled home health on 9/29/23 with a Primary Diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 12/6/23. The record included a Plan of Care for the certification period of 9/29/23 to 11/27/23 which required, “SN to assess (oxygen) saturation on room air every visit” and a Physician order dated 9/29/23 which required, “Weigh every SN visit, if weight is greater /lesser 5 pounds a week, notify MD.” The SN note dated 10/4/23 lacked documentation of the patient’s weight and oxygen saturation.”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on observation and staff interview it was determined that Administrator failed to ensure a Clinical manager or alternate Clinical manager was available to oversee patient care services. This has the potential to affect all patients receiving Home Health Care services. Findings include: 1. On 12/5/23 it was observed that Agency did not have a clinical manager. During an interview with the Alternate Administrator on 12/5/23 at 1:00 PM the Alternate Administrator stated that she is the Agency’s Clinical Manager. The Administrator is out of town, and she takes the Alternate Administrator role. The staff member that covers the Alternate Clinical Manager position is also out of town. As of 12/5/23 the Alternate Administrator fulfills both roles. 2. During an interview on 12/7/23 at 10:30 AM the Alternate Administrator confirmed that Agency currently has no Clinical Manager.”

“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 Agency office observation and staff interview it was determined that Administrator failed to maintain continuous Agency operations. This has the potential to affect all patients receiving Home Health Care services. Findings include: 1. On 12/5/23 surveyor #1 arrived to Agency office after Physical Therapy home visit at 11:00 AM. It was observed that the Home Health Agency was open, however, no office staff were present and no one answered the Agency telephone number for 40 minutes. 2. During an interview with the Alternate Administrator on 12/7/23 at 10:30AM. The Alternated Administrator agreed that no one was available at that time in the Agency office.”

“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 review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge/Transfer Summary. This was found in 3 of 7 (Pts. #6, 7 and 5) clinical records reviewed. 3. Pt. # 5 was admitted to skilled home health on 8/18/22 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 12/6/23. The clinical record contained a Transfer Comprehensive Assessment dated 8/23/23. The clinical record lacked evidence that a Transfer Summary was completed and sent to the accepting facility or to the physician. 4. During interviews with the Alternate Administrator on 12/6/23 at 2:45PM and 12/7/23 at 10:30 AM, the above finding was confirmed. Findings include: 1. Pt. #6 was admitted for skilled home health on 2/1/23 with a Primary Diagnosis of Moderate Persistent Asthma with (acute) Exacerbation. The clinical record was reviewed on 12/6/23. The record contained a Discharge comprehensive assessment dated 9/26/23, indicating that Pt. #6 was discharged from the Agency. As of the date of the clinical record review on 12/6/23, the record lacked documentation that a copy of the Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted for skilled home health on 9/29/23 with a Primary Diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 12/6/23. The record included a Transfer comprehensive assessment dated 10/13/23, indicating that Pt. #7 was transferred to an in-patient facility and was subsequently discharged from the Agency. As of the date of the clinical record review on 12/6/23, the record lacked documentation of a Transfer Summary for Pt. #7.”