Miranda Home Health Care

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on Staff interview, and a review of the Agency’s Emergency Preparedness Plan, it was determined the Agency failed to ensure the Plan included the alternate site in the event of an emergency. This has the potential to affect all Pts. that receive services from the Agency. Findings include: 1. On 09/23/24 at 10:35 AM, arrived onsite at the address the Agency has on record with the Department of Public Health. The door was locked, no response after knocking on the suite door. At 10:40 AM, a call was placed to the Agency and spoke with Intake that stated the Agency temporarily relocated to a different address (2604…). During the entrance interview with the Administrator on 09/23/24 at 11:05 AM, the Administrator stated 2 weeks ago the Agency began experiencing electrical issues with the phone and fax lines, and the Agency relocated to this location which is the alternate site for the Agency. 2. The Emergency Preparedness Plan dated 02/27/23 was reviewed on 09/24/24 and included, “If it is determined that an alternate site is needed, the alternate site will be: 50…”. The Plan lacked the correct address for the Agency’s alternate site. 3. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 at 11:05 AM, the Administrator confirmed the above findings.”

“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 establish policies based on its risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 02/27/23 was reviewed on 09/24/24. The Plan contained an undated risk assessment form titled “Hazard Vulnerability Assessment”. The form contained different types of potential hazards/emergencies that included “Ice snow, flooding, earthquake, hurricane, hazardous material accident, fire, tornado, volcano, civil disturbance, mass causality event, terrorist attacks, severe winter weather, pandemic/infections, extreme high heat, electrical failure, communications failure, information system failure, water failure, transportation interruption, and environmental/altered air quality pollution”. The Plan lacked policies based on the hazards/emergencies that were identified above. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 at 11:05 AM, both confirmed the Plan lacked policies based on potential hazards/emergencies identified in the risk assessment.”

“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 Emergency Preparedness Plan, Staff In-Service binder, personnel files, and Staff interview, it was determined in 7 of 7 (Employees #1, 2, 3, 4, 5, 6, and 7) 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 all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness Plan dated 02/27/23 was reviewed on 09/24/24. The Plan lacked any documentation of Emergency Preparedness staff training. 2. The Staff In-Service binder was reviewed on 09/25/24. The binder lacked any documentation of Emergency Preparedness staff training. 3. The following personnel files were reviewed on 09/25/24 and lacked documentation of Emergency Preparedness staff training upon orientation: Employee #2. Date of hire 06/20/24. Employee #3. Date of hire 05/20/24. Employee #4. Date of hire 06/03/24. Employee #5. Date of hire 07/23/24. Employee #6. Date of hire 06/01/24 Employee #7. Date of hire 07/01/24. Employee #1. Director of Nursing. Date of hire 12/15/12. The Agency was unable to provide a personnel file for Employee #1. 4. During an interview with the Administrator, and Alternate Director of Nursing on 09/25/24 at 11:05 AM, both confirmed the Agency failed to ensure Staff received training pertaining to the Agency’s Emergency Preparedness Plan.”

“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 Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan dated 02/27/23 was reviewed on 09/24/24. The plan lacked documentation that the Agency conducted or participated in any exercises in 2021, 2022, 2023 and 2024 (as of 09/24/24). 2. During an interview with the Administrator, and Alternate Director of Nursing on 09/25/24 at 11:05 AM, the Administrator confirmed the Agency failed to conduct the required testing of its Emergency Preparedness Plan.”

“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 interview, it was determined that in 5 of 17 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 09/2023 to 08/2024 (12 months), was reviewed on 09/25/24. The report included a warning for Error # -3330. The Error included 5 (29.41%) of 17 assessments that were submitted late. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 at 2:45 PM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.”

“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 a review of the Agency’s Pt. admission folder, clinical records and Staff interviews, it was determined in n 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 09/24/24 and lacked documentation of the Agency’s transfer and discharge policies. 2. The following clinical records were reviewed from 09/24/24 to 09/25/24: Pt. #1 SOC 08/08/24 Pt. #2 SOC 07/02/24 Pt. #3 SOC 08/12/24 Pt. #4 SOC 08/09/24 Pt. #5 SOC 08/06/24 Pt. #6 SOC 10/26/23 Pt. #7 SOC 07/11/24 The records lacked documentation the Agency provided Pts. information, regarding the Agency’s transfer and discharge policies. 3. During interviews with the Administrator and Alternate Director of Nursing on 09/25/24 between 11:05 AM and 3:40 PM, 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 clinical records and Staff interviews, it was determined that in 6 of 7 (Pts. #2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1.The following clinical records were reviewed from 09/24/24 to 09/25/24: Pt. #2 SOC 07/02/24 Pt. #3 SOC 08/12/24 Pt. #4 SOC 08/09/24 Pt. #5 SOC 08/06/24 Pt. #6 SOC 10/26/23 Pt. #7 SOC 07/11/24 The records contained the form titled: “Admission consent” and included a section requiring the SN to write the proposed frequency for each discipline in the space provided, this section was left blank for Pts. #2, 3, 4, 5 and 7. Pt. #6’s clinical record lacked the Admission consent to document if the Pt. and/or representative was informed of the proposed frequency for each discipline. 2. During interviews with the Administrator and Alternate Director of Nursing on 09/25/24 between 11:05 AM to 3:40 PM, the Administrator confirmed the above findings.”

“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 a review of clinical records, and Staff interviews, it was determined in 5 of 7 (Pts. #3, 4, 1, 5 and 6) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service, or the initial assessment visit was done within 48 hours of receipt of the referral. Findings include: 1. Pt. #3 was admitted to Home Health Services on 08/12/24 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 09/24/24. The clinical record contained the SOC OASIS completed by the SN and dated 08/12/24. As of 09/24/24, the Agency lacked a referral to initiate service prior to or on 08/12/24. 2. Pt. #4 was admitted to Home Health Services on 08/09/24 with the diagnoses of Bilateral Primary Osteoarthritis of Hip, and Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 09/24/24. The clinical record contained the SOC OASIS completed by the SN and dated 08/09/24. As of 09/24/24, the Agency lacked a referral to initiate service prior to or on 08/09/24. 2. Pt. #1 was admitted to Home Health Services on 08/08/24 with the Diagnosis of Gastrointestinal Stromal Tumor of Large Intestine. The clinical record was reviewed on 09/24/24. The SOC OASIS dated 08/08/24 was completed by the RN and lacked documentation of a referral, or that the Pt. was discharged from an inpatient facility or that the physician ordered a specific SOC date. The record lacked documentation that the Agency initiated service within 48 hours of receiving the referral. 3. Pt. #5 was admitted to Home Health Services on 08/06/24 with Diagnoses of Wedge Compression Fracture of First Lumbar Vertebrae, Sequela, Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. The clinical record was reviewed on 09/25/24. The clinical record lacked documentation of a referral, or that the Pt. was discharged from an inpatient facility or that the physician ordered a specific SOC date. 4. Pt. #6 was admitted to Home Health Services on 10/26/23 with the Diagnoses of Hemiplegia following Cerebral Infarction affecting Left nondominant side. The clinical record was reviewed on 09/25/24. The clinical record lacked documentation of a referral, discharge from an inpatient facility or that the physician ordered a specific SOC date. 5.The Agency policy titled: “Admission Criteria and Process” was reviewed on 09/25/24 and required: “….Procedure….1. ….If the patient’s physician does not make the request for service, he/she will be consulted prior to the evaluation visit and initiation of services…..2. The Clinical Supervisor will assign clinical agency personnel to conduct assessments of eligibility for services within 48 hours of acceptance of referral and/or discharge from a referring facility….” 6. During interviews with the Administrator and Alternate Director of Nursing on 09/25/24 between 11:45 AM to 3:40 PM, the Administrator 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, Agency policy and Staff interview, it was determined that in 1 of 2 (Pts. #7) discharged records reviewed, the Agency failed to ensure that a comprehensive assessment was updated at discharge. Findings include: 1. Pt. #7 was admitted to Home Health Services on 07/11/24 with the Diagnosis of Unspecified Open Wound Right Great Toe without Damage to the Nail. The clinical record was reviewed on 09/25/24. The record documented that the last visit by the RN was on 01/04/24. The clinical record included a form titled: “Beneficiary Elected Transfer Form” dated 08/02/24, indicated Pt. #7 was transferred to another Agency. The clinical record lacked documentation that a comprehensive assessment was updated at discharge. 2. The Agency policy titled: “Initial and Comprehensive Assessment”, required: “...The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS). This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter:....6. At discharge....” 3. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 between 2:45 PM to 3:40 PM, the Administrator confirmed that Pt. #7 was discharged and confirmed the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. 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 7 (Pts. #2 and 4) clinical records reviewed, the Agency failed to ensure the POC contained interventions specific for pain control and management. Findings include: 1. Pt. #2 was admitted to Home Health Services on 07/02/24 with the diagnoses of Right-Side Lumbago with Sciatica, and Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 09/24/24. The clinical record contained the “OASIS-E Start of Care” form completed by the SN and dated 07/02/24 that included the Pt. experienced “continuous” knee and back pain, rated 4 out of 10 (Pain scale rating: 0 = no pain to 10 = severe pain); and weekly SN visit notes from 07/02/24 to 09/10/24 that included the Pt. experienced pain “daily” with a pain rating of 4 to 7 out of 10. The POC for the certification period of 07/02/24 to 08/30/24 lacked interventions pertaining to therapeutic measures to decrease and/or manage the pain. 2. Pt. #4 was admitted to Home Health Services on 08/09/24 with the diagnoses of Bilateral Primary Osteoarthritis of Hip, and Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 09/24/24. The clinical record contained the “OASIS-E Start of Care” form completed by the SN and dated 08/09/24 that included the Pt. experienced intermittent aching pain daily to both knees, rated 4 out of 10; and weekly SN visit notes from 08/16/24 to 09/14/24 that included the Pt. experienced pain “daily” with a pain rating of 5 to 7 out of 10. The POC effective 08/09/24 lacked interventions pertaining to therapeutic measures to decrease and/or manage the pain. 3. During an interview with the Administrator and the Alternate Director of Nursing on 09/25/24 at 11:05 AM, both confirmed the POC lacked interventions specific for pain control and management.”

“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 a review of clinical records, and Staff interviews, it was determined for 6 of 7 (Pts. #3, 4, 1, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure Staff provided services in accordance with the POC, and as indicated by the Physician. Findings include: 1. Pt. #3 was admitted to Home Health Services on 08/12/24 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 09/24/24. The clinical record contained the POC effective 08/12/24 that included “Orders: SN Frequency: 1wk9.” A home visit was conducted on 09/24/24 at 3:30 PM with Employee #2. During the home visit, an interview was conducted with the family/caregiver that stated the Pt. did not receive a SN visit last week (09/15/24 to 09/21/24), and that no one from the Agency called to cancel the visit. During the same interview, asked Employee #2 whether a visit was made last week, Employee #2 replied “No”. During an interview with the Administrator on 09/25/24 at 11:05 AM, asked who was assigned to visit Pt. #3 last week, the Administrator replied Employee #2. The SN failed to provide service as required on the POC effective 08/19/24. The POC effective 08/12/24 required “SN to notify MD of: temperature greater than (>) 100.0 or less than () 24 or less than () 160 or less than () 90 or less than ( The clinical record was reviewed on 09/25/24. The POC effective 10/26/23, required: “Notify physician of….pulse….less than ()90….” The SN notes dated 11/03/24 and 11/11/24, indicated a pulse rate of 58. The SN note dated 12/02/24, indicated a Diastolic BP of 107. The SN notes lacked documentation that the physician was notified, as ordered in the POC. 6. Pt. #7 was admitted to Home Health Services on 07/11/24 with the Diagnosis of Unspecified Open Wound Right Great Toe without Damage to the Nail. The clinical record was reviewed on 09/25/24. The POC effective 07/11/24, required: “….SN to perform complete physical assessment each visit with emphasis on the open wound right toe….” The SN notes dated 07/18/24, 07/25/24 and 08/01/24, lacked documentation of wound assessment on the right toe, as ordered in the POC. 7. During interviews with the Administrator and Alternate Director of Nursing on 09/25/24 between 11:45 AM to 3:40 PM, both confirmed the above findings.”

“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 a review of clinical records, Agency policy and Staff interviews, it was determined that in 3 of 7 (Pts. #2, 3, and 5) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines. Findings include: 1. Pt. #2 was admitted to Home Health Services on 07/02/24 with the diagnoses of Right-Side Lumbago with Sciatica, and Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 09/24/24. The clinical record contained the “OASIS-E Start of Care” form completed by the SN and dated 07/02/24. The “OASIS-E Start of Care” form lacked documentation that the SN assessed the patient’s need for the Pneumonia and Influenza (Flu) vaccines, as required by the Agency. 2. Pt. #3 was admitted to Home Health Services on 08/12/24 with the diagnosis of Unspecified Atrial Fibrillation. The clinical record was reviewed on 9/24/24. The clinical record contained the “OASIS-E Start of Care” form completed by the SN and dated 08/12/24. The “OASIS-E Start of Care” form lacked documentation that the SN assessed the patient’s need for the Pneumonia and Influenza (Flu) vaccines, as required by the Agency. Pt. #5 was admitted to Home Health Services on 08/06/24 with Diagnoses of Wedge Compression Fracture of First Lumbar Vertebrae, Sequela, Type 2 Diabetes Mellitus with Hyperglycemia and Essential (Primary) Hypertension. The clinical record was reviewed on 09/25/24. The SOC assessment dated 08/06/24, included: “Pneumonia…Yes….”, with the date section, left blank. The record lacked documentation of a complete assessment of Influenza and Pneumonia vaccination status, as required by the Agency. The Agency policy titled: “Vaccinations” was reviewed on 09/25/24 and required: “....Upon initiation of home health services, the admitting clinician will complete an assessment to determine the paient’s influenza and pneumococcal vaccination status...A form shall be completed indicating the need, patient response, arrangement, and follow-up activities and included in the patient’s medical record....” During interviews with the Administrator and Alternate Director of Nursing on 09/25/24 between 11:45 AM to 3:40 PM, the Alternate Director of Nursing stated that if the Pt. or representative don not know vaccination status, the SN should inquire vaccination status with the physician. During the same interview, both confirmed the above findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on a review of clinical records, and Staff interview, it was determined that in 1 of 2 (Pt. #2) clinical record reviewed for services provided more than 60 days, the Agency failed to ensure a POC was reviewed by the Physician every 60 days, beginning with the SOC. Findings include: 1. Pt. #2 was admitted to Home Health Services on 07/02/24 with the diagnoses of Right-Side Lumbago with Sciatica, and Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 09/24/24. The clinical record contained the initial POC for the certification period of 07/02/24 to 08/30/24,and SN visit notes dated 9/3/24 and 9/10/24. As of 09/24/24, the record lacked a POC effective 08/31/24 for the Physician to review. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 at 11:05 AM, both confirmed the Agency had not completed a POC effective 08/31/24 for Pt. #2. .”

“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 onsite observation, review of the Agency’s Pt. admission folder, observation during a home visit, Agency policy review, and staff interview, it was determined that the Administrator failed to ensure information provided to the Department of Public Health, and Pts. was accurate; and retain personnel records. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. On 09/23/24 at 10:35 AM, arrived onsite at the address provided by the Agency (2644…) and on record with the Department. The door was locked, no response after knocking on the door. At 10:40 AM, a call was placed to the Agency and spoke with Agency Staff that stated the Agency temporarily relocated to a different address (2604…). During the entrance interview onsite with the Administrator on 09/23/24 at 11:05 AM, the Administrator stated 2 weeks ago the Agency began experiencing electrical issues with the phone and fax line, and the Agency relocated to the Agency’s alternate site (2604...). As of 09/23/24, the Agency failed to notify the Department that the Agency was operating from an alternate site. 2. On 09/23/24, a request was made to review the personnel file of Employee #1 / Director of Nursing. As of 9/25/24, the Administrator was unable to provide Employee #1’s personnel file. 3. The Patient’s admission folder was reviewed on 09/23/24. The folder contained the 2 different addresses (19150… and 2644…) for this Agency. The folder also included 2 different names for the Agency’s Administrator. The Agency provided conflicting information to Pts. and/or their representatives. 4. A home visit was conducted on 09/24/24 at the residence of Pt. #2 (SOC 07/02/24). During the home visit, the Patient’s admission folder was observed and contained 2 different addresses for the Agency, and 2 different names for the Agency Administrator. Home visits were also conduct on Pt.#1 (SOC 08/08/24), and Pt. #3 (SOC 08/12/24). During the home visits, the Pt. admission folder was not available for review. 5. The Agency’s policy titled “Administrator” was reviewed on 9/25/24. The policy required, “…The Administrator shall have the following responsibilities…8. Have the authority for the management of the… overall operation of the agency… 10. Maintain appropriate personnel records… 11. Ensure the accuracy of public information materials…” 6. During an interview with the Administrator and Alternate Director of Nursing on 9/25/24 at 11:05 AM, the Administrator confirmed the above findings. .”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on review of the Agency staff list, Agency license and Staff interview, it was determined that the Agency failed to ensure that the Administrator employed qualified Staff to provide Home Health Aide services. Findings include: 1. On 09/24/24, the Agency Staff list was reviewed and lacked a Home Health Aide. The current Home Health Agency license number 1012268 was reviewed and indicated the Agency can provide Home Health Aide services. As of 09/26/24, the Agency lacked a Home Health Aide to provide personal care for Pts. 2. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 at 2:45 PM, the Administrator stated that if Pts. need a home health aide, then a home health aide can be hired. During the same interview, the Administrator confirmed the above findings.”

“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 that in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure a discharge summary was completed and sent to the Physician. Findings include: 1. Pt. #6 was admitted to Home Health Services on 10/26/23 with the Diagnosis of Hemiplegia following Cerebral Infarction affecting Left nondominant side. The clinical record was reviewed on 09/25/24. The clinical record documented a discharge assessment and discharge summary dated 01/03/24, the Agency lacked documentation that a copy of the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 07/11/24 with the Diagnosis of Unspecified Open Wound Right Great Toe without Damage to the Nail. The clinical record was reviewed on 09/25/24. The clinical record documented that the last visit by the RN was on 08/01/24. The form titled: “Beneficiary Elected Transfer Form” dated 08/02/24, indicated that Pt. #7 was transferred to another Agency. The clinical record lacked documentation that a discharge summary was completed and a copy was sent to the Physician. 3.. During an interview with the Administrator and Alternate Director of Nursing on 09/25/24 between 2:45 PM to 3:40 PM, the Administrator confirmed that Pts. #6 and #7 are closed/discharged Pts. and confirmed the above findings.”