Vision Home Health Care, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). 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 that the Agency failed to update the communication plan. This has the potential to affect all patients served. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/15/23 at 1:00 pm. The plan lacked an updated communication plan that included the contact information of staff, entities providing services under arrangement, patients’ physicians and volunteers. 2. During an interview with the Administrator on 11/16/23 at 11:00 am, the Administrator confirmed the above finding.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan, and Staff interview, it was determined the Agency failed to conduct a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. This has the potential to affect all patients served. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/15/23 at 1:00 pm. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted or participated in any testing exercise or drills since 2020. 2. During an interview with the Administrator on 11/16/23 at 10:00 am, the Administrator confirmed that the Agency failed to conduct or participate in a community and or facility-based testing or drill.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on the clinical records review, home visit observations and Staff interview, it was determined the Agency failed to conform to the Physicians’ orders. This was found in 3 of 7 (Pts. #1, 5 and 6) records reviewed. Findings include: 1. Patient #1 was admitted to the Home Health agency on 11/09/23 with diagnoses of Bilateral Primary Osteoarthritis of Knee and Other Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 11/14/23 and included orders for the “SN to perform medication review and reconcile medication …” A home visit was conducted on 11/15/23 with the SN. During an interview with Patient #1, she stated she was taking Prednisone10mg daily, which was not included in the physician’s orders. 2. Patient #5 was admitted to the Home Health agency on 07/06/23 with the diagnoses of Essential Hypertension and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 11/14/23 and included orders for the SN to monitor the patient’s vital signs. The SN visit note dated 10/26/23 lacked the required vital signs. 3. Patient #6 was admitted to the Home Health agency on 04/17/23 with the diagnoses of Chronic Obstructive Pulmonary Disease with (acute) exacerbation and Type 2 Diabetes Mellitus with Polyneuropathy. The clinical record was reviewed on 11/14/23 and required the SN to monitor vital signs 1 time a week for 9 weeks and the “SN to perform blood sugar testing every visit if testing has not been done. Notify MD if FBS greater than 200mg/dl or less than 70mg/dl…” The SN visit note dated 07/10/23 did not include the blood glucose or vital signs. The SN visit notes did not include the blood glucose on 06/26/23, 07/03/23 and 07/10/23. 4.The above findings were confirmed on 11/15/23, between 12:00 PM -1:00 PM, with the Administrator, Owner and Agency Supervisor.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on home visit observations, Agency policy review and Staff interview, it was determined the Agency Staff did not conform to the preventive measures of infection control. This was found in 2 of 3 (Pts. #1 and 2) home visits conducted. Findings include: 1. A home visit was conducted on 11/14/23 at 2:00 PM, with the RN (Employee #20) and Patient #2. Employee #20 left the nursing bag open during the visit and did not put on a mask, per policy. It was observed that the RN dropped his equipment to the floor and did not wipe the equipment with non-aerosol wipes, as required by the Agency’s policy for cleaning and disinfecting. 2. A home visit was conducted on 11/15/23 at 9:30 AM, with the RN (Employee #7) and Patient #1. Employee #7 did not put on a mask. It was observed that the RN did not follow the Agency’s policy. 3.The Agency’s policy titled “Enhanced Visiting Nurse Bag Policy with Detailed Sanitary Procedures” was reviewed on 11/16/23 at 1:00 PM and required “… 3. Infection Control…Handling Contaminated Items: Place items or waste in a separate sealable bag. …4. Usage Guidelines…Minimizing Contamination: Limit the opening of the bag…Close it immediately after use…7. Sanitary Procedures During Visits Before Entering the home : Perform hand hygiene using hand sanitizer. Don a new pair of gloves and a mask. 8. Prohibited Items Aerosol Disinfectants: Do not use any aerosol disinfectant sprays. All disinfections should be done using non-aerosol wipes…” 4. The above findings were confirmed on 11/15/23 between 12:00 PM -1:00 PM with the Administrator, Owner and Agency Supervisor.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on clinical record review, Agency policy review and Staff interview, it was determined the Agency failed to ensure the RN conducts Aide supervision in the patient’s home. This was found in 1 of 1 (Pt. #6) clinical records reviewed with Aide services. Findings include: 1.Patient #6 was admitted to the Home Health agency on 04/17/23, with the diagnoses of Chronic Obstructive Pulmonary Disease with (acute) exacerbation and Type 2 Diabetes Mellitus with Polyneuropathy. The clinical record was reviewed on 11/14/23 and included Aide visits 2 times a week from 06/15/23 through 07/20/23. The record lacked documentation of Aide supervision in the patient’s home, by the RN, from 06/15/23 through 07/17/23. During the interview with the Agency Supervisor, it was stated that the Aide supervision was conducted by telephone. 2. The Agency’s policy was reviewed on 11/15/23 at 1:00 PM and required “…Special instructions 1. When patients are receiving skilled nursing services… the RN will make a supervisory visit to the patient’s residence at least every two (2) weeks.” 3. The above findings were confirmed on11/15/23, between 12:00 PM -1:00 PM, with the Administrator, Owner and Agency Supervisor.”

“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 staff interview and Governing Body minutes review, it was determined that the Governing Body failed to appoint the current Administrator. This has the potential to affect all patients served. Findings include: 1. During the entrance interview with the Administrator on 11/14/23 at 10:30am, the Administrator stated that he was the Agency Administrator since May 2023. 2. The Agency’s Governing Body minutes were reviewed on 11/15/23 at 11:00am. The Governing Body minutes lacked documentation indicating that the Governing Body appointed the Administrator. 3. The finding of the Governing Body failing to appoint the Administrator was confirmed during an interview with the Administrator and Agency Supervisor on 11/16/23 at 10:00am.”