Alpha Home Health, 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 maintain a communication plan with the names and contact information for current Staff. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on10/09/24. The communication plan did not include a communication plan with contact information of the current Agency staff. 2. During an interview with the Director of Nursing on 10/10/24 at 10:30 AM, finding of the Agency not having an updated communication plan was confirmed.”

“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 that the Agency failed to ensure that the Agency conducted / participated in a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 10/09/24. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted / participated in a full-scale exercise or that the Agency implemented the Emergency Preparedness Plan since 2017. 2. During an interview with the Director of Nursing on 10/10/24 at 10:30 AM, the Director of Nursing confirmed that the Agency has not implemented the Emergency Plan and failed to conduct / participate full scale exercise since 2017.”

“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 a review of the Agency’s OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency’s past 12 months (10/01/23 to 10/01/24) OASIS submission report was reviewed on 10/09/24. The report contained information that out of the 220 Agency’s OASIS assessment reports,126 (57.27 %) were submitted beyond the required time frame of 30 days. 2. During an interview with the Director of Nursing on 10/10/24 at 10:00 AM. The Director of Nursing confirmed the Agency’s late OASIS submission.”

“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 records review and staff interviews, it was determined for 3 of 7 (Pts. #6, 1 and 7) 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. # 1 was admitted to home health services on 04/30/24 with Diagnosis of Heart Failure Unspecified. The clinical record was reviewed on 10/08/24. The record contained a POC for certification period 06/29/24 to 08/27/24 that required PT visits 1 time a week for 9 weeks. The clinical record lacked PT visits for week 6 and week 7 of certification period. No modification orders were found in the clinical record. 3. Pt. # 7 was admitted to home health services on 08/05/24 with Diagnosis of Muscle Weakness. The clinical record was reviewed on 10/08/24. The record contained a POC for certification period 08/05/24 to 10/03/24 that required SN visits 1 time a week for 9 weeks. The clinical record lacked SN visits for weeks 5 to week 9 of certification period, no modification orders were found in the record. 4. During interviews with the Director of Nursing on 10/10/24 between 10:00 AM and 12:00 PM, the Director of Nursing confirmed that Agency failed to provide services in the Plans of Care. Findings include: 1. Pt. #6 was admitted for home health services on 03/16/24 with the diagnosis of Fracture of the Rib, right side. The clinical record was reviewed on 10/09/24. The record included a POC for the period of 03/16/24 to 05/07/24 which required, “Notify MD… Pain level >8/10…” The SN notes included documentation of pain level for the following dates: 04/09/24 = 9/10, 04/16/24 = 9/10, 04/23/24 = 9/10, 04/30/24 = 9/10. The record lacked documentation that the Physician was notified that the pain level was greater than 8 out 10 for the above-mentioned dates.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical records review and Staff interview it was determined that in 7 of 7 (Pts # 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to properly inform patients of Agency reducing or terminating on- going care. 1. The following clinical records were reviewed between 10/08 and 10/10/24 P t#1. SOC 04/30/24. Pt #2. SOC 05/28/24. Pt #3. SOC 08/31/24. Pt #4. SOC 04/17/24. Pt #5. SOC 03/06/24. Pt #6. SOC 03/16/24, Pt #7. SOC 08/05/24. The clinical records contained a document titled “Notice of Medicare Non-Coverage” signed by the patient on admission to home health services. The section in the document that states “The effective date of your current home health services will end “ was left blank. 2. During interviews with the Director of Nursing on 10/10/24 between 10:00 AM and 12:00 PM the Director of Nursing confirmed that Agency completes document during Admission and not when ongoing services will end.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on home visit observations, clinical record review, Agency policy reviews, and staff interviews it was determined that for 2 of 7 clinical records reviewed (Pts.# 3 and 2) the Agency failed to ensure that clinical records included all the current medications. 2. Pt. # 2 was admitted to home health services on 05/28/24 with Diagnosis of Chronic Respiratory Failure. A home visit was conducted on 10/08/24 with SN Employee #8. During the home visit it was observed and confirmed by patient the use of Oxygen at 6 liters per nasal cannula continuously. The clinical record of Pt. #2 was reviewed on 10/08/24 and 10/09/24. The clinical record contained a POC for certification period 09/25/24 to 11/23/24, medication profile that did not list oxygen use at home. 3. The Agency policy titled “Medication Profile” was reviewed and required, “Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.” 4. During interviews with the Director of Nursing on 10/10/24 between 10:00 AM and 12:00 PM. The Administrator stated that the Plans of Care did not include all the current medications patients are using. Findings include: 1. Pt. #3 was admitted for home health services on 08/31/24 with the diagnosis of Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 10/09/24. A home visit was conducted on 10/09/24 and the following medications were found at Pt. #3’s home but not listed on the medication profile or on the POC effective 08/31/24: Spironolactone 25 milligrams, ½ tablet by mouth once daily, Trazodone 100 milligrams 1 tablet every night, Levothyroxine 50 micrograms 1 tablet by mouth once daily. During the home visit interview, it was stated that in addition to the medications listed in the medication profile, the above-mentioned medications are currently being taken by Pt. #3.”

“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, Agency’s policy review and staff interview, it was determined that for 3 of 7 (Pts. #3, 5 and 6) clinical records reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines. Findings include: 1. As of 10/10/24, the following clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry: Pt. #3. SOC 08/31/24. Pt. #5. SOC 03/06/24. Pt. #6. SOC 03/16/24. 2. The policy titled, “Home Health Guideline for Standing Order Influenza (Flu) Vaccination of Patients, Staff and Volunteers” was reviewed and required: “A. All home health patients…should receive the influenza vaccine annually unless there is a documented medical contraindication…II. Administration Procedure: …A. The immunization status of each patient…will be determined prior to vaccination and will be documented in their medical record…” 3. The policy titled, “Home Health Guideline for Standing Order Pneumococcal Vaccination (PPV) of Patients” was reviewed and required: “(I) All patients should receive the pneumococcal vaccine if they are 65 years of age or older; or younger than 65 years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications…II. Administration procedure: A. Each’s patient’s pneumococcal immunization status will be determined upon admission or soon afterwards and will be documented in the patient’s medical records. Current patients will have their immunization status determined by reviewing past and present medical records…” 4. During an interview with the Director of Nursing on 10/10/24 at 11:30 AM, it was stated that during the SOC, the patient’s Influenza and Pneumococcal Pneumonia vaccination status is assessed, and this information should be documented in the clinical record. During the same interview, the above findings were confirmed.”

“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 1 of 2 (Pt # 7) discharge clinical records reviewed. the Agency failed to complete and send a discharge summary to the Physician after the patient was discharged from the Agency. Findings include: 1. Pt. #7 was admitted to home health services on 08/05/24 with Diagnosis of Muscle Weakness. During an interview with the Director of Nursing on 10/09/24 at 10:00 AM the Director of Nursing stated that Pt #7 was discharge from services in August 2024. The clinical record was reviewed on 10/09/24, the clinical record lacked a discharge summary and evidence that a summary was sent to the Physician. 2. During an interview with the Director of Nursing on 10/10/24 at 10:00 AM. The Director of Nursing confirmed that the clinical record did not contain a discharge summary.”