Holistic Health Partners, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Operations Plan and staff interview, it was determined that the Agency failed to review and update its Emergency Operation Plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 10/21/24. The Plan included “UPDATED 10/15/2021”. The Agency failed to update the plan every 2 years. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/23/24 at 4:30 PM, the Administrator confirmed the Agency’s Emergency Operations Plan was last updated on 10/15/21.”

“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 Operations Policies and Procedures and staff interview, it was determined that the Agency failed to review and update its Emergency Operations Policies and Procedures biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan was reviewed on 10/21/24. The Emergency Operations Policies and Procedures lacked the date indicating when it was last reviewed. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/23/24 at 4:30 PM, the Administrator stated the Emergency Operations Policies and Procedures were last reviewed on 10/15/21. The Agency failed to update the Policies and Procedures biennially. During the same interview, the Administrator 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 789 of 2176 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 10/21/24. The report included error # -3330 for 789 of 2176 late submissions, which was 32.26 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator, Director of Nursing, and Administrative Assistant on 10/24/24 at 11:45 AM, the administrative team confirmed that the error occurred.”

“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 clinical record review and staff interviews, it was determined for 4 of 17 (Pts. #14, #7, #9 and #15) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician and as indicated in the POC. 2. Pt. #7 was admitted for home health services on 7/9/24 with the diagnosis of Hypertensive Chronic Kidney disease with Stage 1 through Stage 4 Chronic Kidney disease. The clinical record was reviewed on 10/22/24. The clinical record contained a POC effective 7/9/24 to 9/6/24 and effective 9/7/24 to 11/5/24, required PT “Orders for Discipline and Treatment….Vital Sign Parameters….Weight gain more than 5 lbs or weight loss of less than 5 lbs in 1 week Notify MD….” The clinical records contained weekly PT notes from 8/27/24 to 10/16/24 and lacked weight assessments as ordered. 3. Pt. #9 was admitted for home health services on 8/15/24 with the diagnosis of Type 2 Diabetes Mellitus and Encounter for Attention to Cystostomy. The clinical record was reviewed on 10/23/24. The record contained a POC effective 8/15/24 to 10/13/24 and 10/14/24 to 12/12/24, required “….Interventions:….SN to re-assess suprapubic catheter….”. The clinical record contained SN assessments dated 8/31/24 and 9/28/24, and lacked suprapubic catheter assessments as ordered. The POC effective 8/15/24 to 10/13/24, required: SN frequency 1 time per month and “….Vital Sign Parameters….Systolic BP…. Notify MD….Diastolic BP….Notify MD….Weight gain more than 5 lbs or weight loss of less than 5 lbs in 1 week Notify MD…. FBS less than 60 mg/dl or above 200 mg/dl or RBS less than 60 mg/dl or above 300 mg/dl Notify MD….” The SN assessment note dated 8/23/24, lacked a blood sugar assessment and a weight assessment as ordered. The SN assessment note dated 10/12/24, lacked a blood sugar assessment as ordered. The OT note dated 9/6/24, lacked a blood pressure assessment as ordered. 4. Pt. #15 was admitted for home health services on 1/19/24 with the diagnosis of Pressure Ulcer of Sacral Region. The clinical record was reviewed on 10/23/24. The clinical record contained a POC effective 3/19/24, that required SN frequency of “1 WK 9”. The record lacked a SN visit for the week 4/17/24 as ordered. 5. During interviews with the Administrator, Director of Nursing and Administrative Assistant on 10/23/24 at 3:30 PM and with Administrator and Director of Nursing on 10/24/24 at 9:30 AM, the above findings were confirmed. Findings include: 1.. Pt. #14 is admitted for home health services with the diagnosis of Pressure Ulcer of Sacral Region. The clinical record was reviewed on 10/23/24.The POC for the certification period of 11/13/23 to 1/11/24 required, “SN 1WK 9.” The record also included a Physician discharge order from Home Health Services on 1/3/24. The clinical record lacked documentation of SN visits for the weeks of 12/24/24 to 12/30/24 and 12/31/23 to 1/3/24.”

“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 for 9 of 17 (Pts. #1, 4, 7, 9, 10, 11, 12, 15 and 16 ) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines. Findings include: 1. As of 10/24/24, the following clinical records reviewed lacked documentation of Influenza and/or Pneumococcal Pneumonia inquiry: Pt. #1. SOC 5/26/24 – lacked Influenza immunization assessment. Pt. #4. SOC 9/9/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #7. SOC 7/9/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #9. SOC 8/15/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #10. SOC 8/26/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #11. SOC 10/3/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #12. SOC 6/26/24 – lacked Influenza and Pneumococcal Pneumonia immunization assessment. Pt. #15. SOC 1/09/24 – lacked Pneumococcal Pneumonia immunization assessment. Pt. #16. SOC 04/11/24 – lacked Influenza immunization assessment. 2. During an interview with the Administrator, Director of Nursing and Administrative Assistant on 10/23/24 at 3:30 PM, and on 10/24/24 from 9:30 AM to 11:45 AM, the Administrator stated that the Influenza immunization status inquiry is done during the flu season from October to March and documented in the clinical record. The Pneumococcal Pneumonia immunization status inquiry is conducted at SOC and documented in the SOC OASIS. During the same interviews, the above findings were confirmed.”