Glory Home Health Care Management, Inc.

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. 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 develop policies and procedures based on the all-hazards risk assessment, and ensure each hazard was assigned a score, as required by the Agency. This has the potential to affect all staff providing care/services, and Pts. receiving services from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in 2023 was reviewed on 4/16/24. The plan contained the “Hazard Vulnerability Assessment” that included a scoring system that ranged from 1 to 7 to identify potential hazard events, within the Agency’s service area and this included: “Hazardous Material Accident, Mass Casualty Event, Communication Failure, Information system Failure, Water Failure, Environmental/Altered Air Quality Pollution”. The Agency lacked policies and procedures regarding the hazard events listed above. The hazard events, “Information system Failure” and “Water Failure” lacked a score. 2. During an interview with the Administrator and Clinical Manager on 4/17/24 at 10:20 AM, the Administrator stated the scoring system ranged from 1 to 7 (1 to 2 = mild, 3 = moderate, 4 and above = severe), identifying the severity of each hazard event within the Agency’s service area. During the same interview, the Administrator 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 a review of the Agency’s staff in-service binders, personnel files, and staff interview, it was determined in 2 of 6 (Employees #3 and 5) personnel files reviewed, the Agency failed to ensure staff receive training pertaining to the Agency’s Emergency Preparedness plan. This has the potential to affect Pts. receiving services. Findings include: 1. The Agency’s staff in-service binders were reviewed on 4/16/24, and lacked documentation of Emergency Preparedness staff training. 2. The following personnel files were reviewed on 4/17/24: Employee #3. Date of hire 9/11/23. Lacked initial training. Employee #5. Date of hire 7/22/13. Lacked ongoing training in 2022, 2023 and 2024 (as of 4/17/24). 3. During an interview with the Administrator, and Clinical Manager on 4/17/24 at 10:20 AM, the Administrator confirmed the above findings.”

“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 a review of the Agency’s Pt. Admission folder, observation during home visits, clinical records review, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline. Findings include: 1. The Pt. Admission folder was reviewed on 4/15/24 and contained the form titled, “Welcome” The Agency required each discipline to enter their name, and the frequency of their visits on this form. 2. Home visits were conducted on the following Pts. on 4/17/24: Pt. #1. SOC 3/20/24. Pt. #2. SOC 3/15/24. Pt. #3. SOC 3/26/24. During the home visits, the Pt. Admission folders were observed, and lacked documentation that staff included the visit frequency for each discipline providing service. 3. The following clinical records were reviewed on 4/15/24 and 4/16/24: Pt. #1. SOC 3/20/24. Pt. #2. SOC 3/15/24. Pt. #3. SOC 3/26/24. Pt. #4. SOC 2/8/24. Pt. #5. SOC 3/14/24. Pt. #6. SOC 11/3/23. Pt. #7. SOC 8/7/23. The records lacked documentation the Agency had provided in writing, the visit frequency for each discipline that provided service. 4. During interviews with the Administrator, and Clinical Manager on 4/17/24 at 9:50 AM, 10:20 AM and 1:15 PM, both confirmed the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical records review, and staff interviews, it was determined for 3 of 7 (Pts. #1, 5, and 7) clinical records reviewed, the Agency failed to ensure staff provided services in accordance with the POC, and as indicated by the Physician. 3. Pt. #7 was admitted to home health services on 8/7/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 4/15/24. The record contained the POC for the certification period of 10/6/23 to 12/4/23 that required: “...Notify physician of...Systolic BP greater (>) 160 or less than () 90 or less than ( 4. During interviews with the Administrator, and Clinical Manager on 4/17/24 at 9:50 AM and 10:20 AM, both confirmed the Agency failed to ensure staff provided services in accordance with POC, and as indicated by the Physician. Findings include: 1. Pt. #1 was admitted to home health services on 3/20/24 with the primary diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/16/24. The record contained the Physician’s order for SN visits “1wk9”. The record lacked documentation of a SN visit for the week of 3/31/24 to 4/6/24. 2. Pt. #5 was admitted to home health services on 3/14/24 with a primary diagnosis of Pressure Ulcer Stage 3 of the Left Ankle. The clinical record was reviewed on 4/16/24. The record contained the Physician’s order for SN visits “1wk9”. The record lacked documentation of a SN visit for the week of 3/31/24 to 4/6/24.”

“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 a review of the Agency’s Pt. Admission folder, observation during home visits, clinical records review, 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 information pertaining to the Clinical Manager. Findings include: 1. The Pt. Admission folder was reviewed on 4/15/24. The folder lacked documentation identifying the Clinical Manager and contact information. 2. The following home visits were conducted on 4/16/24: Pt. #1. SOC 3/20/24. Pt. #2. SOC 3/15/24. Pt. #3. SOC 3/26/24. During the home visits, the Pt. Admission folders were observed and lacked information identifying the clinical manager and the contact information. 3. The clinical records of the following Pts. were reviewed from 4/15/24 to 4/17/24: Pt. #1. SOC 3/20/24. Pt. #2. SOC 3/15/24. Pt. #3. SOC 3/26/24. Pt. #4. SOC 2/8/24. Pt. #5. SOC 3/14/24. Pt. #6. SOC 11/3/23. Pt. #7. SOC 8/7/23. The records lacked documentation the Agency had provided the Clinical Manager’s name and contact information. 4. During an interview with the Administrator, and Clinical Manager on 4/17/24 between 9:50 AM to 1:45 PM, the Administrator confirmed this was the admission folder used for all Pts. admitted to this Agency, and the Agency failed to provide information pertaining to the Clinical Manager. .”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of a clinical record, and staff interview, it was determined in 1 of 1 (Pt. #7) clinical record reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conducted Home Health Aide supervision every 14 days. Findings include: 1. Pt. #7 was admitted to home health services on 8/7/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 4/15/24. The record contained the Home Health Aide visit notes for 2 times a week from 10/10/23 to 11/10/23. The Home Health Aide supervision notes dated 10/9/23, 10/16/23, 10/23/23, and 10/30/23 were signed by the RN and left blank. 2. During interviews with the Administrator and Clinical Manager on 4/17/24 at 9:50 AM and 10:20 AM, both confirmed the Agency failed to ensure the RN conducted Home Health Aide supervision every 14 days.”

“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 a review of clinical records and staff interview, it was determined in 2 of 2 (Pts. #6 and 7) closed 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 11/3/23 with the primary diagnosis of Type 2 Diabetes with Hyperglycemia. The clinical record was reviewed on 4/16/24. The record contained the Agency’s “Discharge Summary” form completed by the SN and dated 11/22/23. As of 4/16/24, the record lacked documentation the Agency sent a copy of the “Discharge Summary” to the Physician. 2. Pt. #7 was admitted to home health services on 8/7/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 4/15/24. The record contained the Agency’s “Discharge Summary” form completed by the SN and dated 11/13/23. As of 4/15/24, the record lacked documentation the Agency sent a copy of the “Discharge Summary” to the Physician. 3. During an interview with the Administrator and Clinical Manager on 4/17/24 at 10:20 AM, both confirmed the Agency failed to ensure the Physician was sent a copy of the Discharge Summary.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on the review of the Governing Body minutes and staff interview, it was determined the Governing Body failed to document the appointment of the Agency’s Administrator. Findings include: 1. During an interview with the Administrator on 01/05/24 at 10:20 AM, he stated that he was temporarily serving as the Administrator. 2. On 01/05/24 at 11:40 AM, the Governing Body minutes dated November 8, 2023 and December 18, 2023 were presented for review. The Governing Body minutes lacked documentation of the appointment of the Agency’s Administrator. 3. The findings were confirmed on 01/05/24 between 11:40 AM and 3:00 PM with the Administrator.”

“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 Agency failed to ensure the Administrator designated in writing, a qualified Alternate Administrator to be available during his absence. Findings include: On 01/05/24 at 9:00 AM, the Administrator was not on site. On 01/05/24 at 10:20 AM, during an interview with the Acting Administrator, he stated his designated alternate was Employee #2. The Agency lacked documentation designating Employee #2, in writing, as the alternate administrator. 2. On 01/05/24 at 10:30 AM, during an interview with Employee #2, it was stated that she was the co-owner and member of the governing body. It was observed that the Agency lacked an Alternate for the Administrator to direct and organize the Agency’s operations/activities in the absence of the Administrator. 3. The above findings were confirmed with the Acting Administrator and Employee #2 on 01/05/24 at 1:00 PM.”