North Shore Healthcare, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan. Findings include: 1. The Agency’s Emergency Preparedness plan was reviewed with the Administrator on 06/05/24 at 11:30 AM. The undated Emergency Preparedness plan lacked a date, indicating when the plan was last reviewed and updated. 2. During an interview with the Administrator on 06/05/24 at 11:45 AM, the Administrator confirmed the Agency failed to review and update the Emergency Preparedness plan.”

“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 program, review of In-service binders and Staff interview, it was determined in 4 of 18 (Employees #11, 12, 14 and 15) Employees, the Agency failed to conduct staff training, relative to the Agency’s Emergency Preparedness plan. Findings include: 1. The Emergency Preparedness program and In-service binders for 2021, 2022 and 2023 were reviewed on 06/05/24. As of 06/05/24, the Agency lacked documentation that the following staff received any Emergency preparedness training: Employee # 11 (Licensed Practical Nurse/Date of Hire 05/01/18) Employee # 12 (Home Health Aide/Date of Hire 08/21/17) Employee # 14 (Intake/Date of Hire 11/19/19) Employee # 15 (Intake/Date of Hire 07/05/23) 2. During an interview with the Administrator on 06/05/24 at 11:45 AM, the Administrator confirmed the Agency was unable to provide documentation that staff received training relative to the Agency’s 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 151 of 476 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 03/2023 to 02/2024 (12 months), was reviewed on 06/04/24. The report included a warning for Error # -3330. The Error included 151 (31.72 %) assessments that were submitted late. 2. During an interview with the Administrator and Director of Nursing on 06/06/24 at 11:45 AM, the Administrator stated that the Agency has an outside biller that submits OASIS reports and should be within 30 days after completion date. During the same interview, the Administrator confirmed the above findings.”

“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 in 5 of 7 (Pts. #6, 3, 4, 5 and 7) clinical records reviewed, the clinical records were not completed as required. 2. The following clinical records were reviewed from 06/04/24 to 06/05/24, and contained the forms titled: “ Beneficiary Elected Transfer, Notice of Medicare Non-Coverage and Medicare Questionnaire.” These forms were signed by the Pt., witness and SN at the SOC. Pt. #3 SOC 06/05/24 Pt. #4 SOC 04/19/24 Pt. #5 SOC 05/07/24 Pt. #7 SOC 12/22/23 The form lacked entries of previous Home Health Agency and date of transfer, the date of coverage that Medicare services will end and answers to Medicare questionnaire. These forms in the clinical records lack complete information as the form required. 3. During interviews with the Administrator and Director of Nursing on 06/05/24 at 1:00 PM and on 06/06/24 at 11:45 AM, both confirmed the above findings. Findings include: 1. Pt. #6 was admitted to the Home Health Services on 08/05/23 with the Diagnosis of: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed 06/04/24. The clinical record contained a POC dated 04/01/24, that required SN to assess the heart rate, respirations, blood pressure and blood glucose each visit. The clinical record lacked the vital signs for the month of April and May 2024.”

“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 the clinical record review and Staff interview, it was determined in 5 of 7 (Pts. #1, 2, 3, 4 and 5) clinical records reviewed, the patient care was not provided as ordered by the physician. 3. Pt. #3 was admitted to Home Health Services on 01/03/24 with Diagnosis of “Parkinsonism, unspecified”. The clinical record was reviewed on 06/05/24. The PsOC effective 03/03/24 to 05/01/24 and 05/02/24 to 06/03/24, included orders to Notify Physician of vital signs parameters out of range: “….Diastolic BP….less ( The SN note dated 04/24/24, indicated an assessment of Diastolic BP of 59, and heart rate/pulse rate of 59. The recertification assessment dated 05/01/24, indicated an assessment of Diastolic BP of 58 and heart rate/pulse rate of 58. The record lacked documentation that the Physician was notified for vital signs falling outside parameters as ordered. The PsOC effective 03/03/24 to 05/01/24 and 05/02/24 to 06/03/24, included orders for HHA services, frequency 1w9. The clinical record lacked HHA visits for the week of 04/22/24 and 04/29/24. The record lacked documentation that HHA provided care as ordered. The signed PT Plan of care required PT frequency of 2wk1, 1wk5. The clinical record contained PT visit notes dated 3/12/24, 3/15/24, 3/18/24, 3/26/24 and 04/02/24. The clinical record lacked PT visits for the week of 04/18/24 and week of 04/15/24. The record lacked documentation that PT provided care as ordered. 4. Pt. #4 was admitted to Home Health Services on 04/19/24 with Diagnosis of Hemiplegia. The clinical record was reviewed on 06/05/24. The POC effective 04/19/24 to 06/17/24, included orders to Notify Physician: “…. Pain Level: Greater than (>)7. The clinical record contained SN visit notes dated 05/18/24 and 05/25/24, lacked documentation of pain assessment as ordered. 5. Pt. #5 was admitted to Home Health Services on 05/07/24 with Diagnosis of Primary Generalized Osteoarthritis. The clinical record was reviewed on 06/04/24. The POC effective 05/07/24 to 07/05/24, required SN frequency 1 wk 9. The clinical record lacked SN visit for the week of 05/13/24. The record lacked documentation that the SN provided care as ordered. 6. During interviews with the Administrator and Director of Nursing on 06/05/24 at 1:00 PM and on 06/06/24 at 11:45 AM, both confirmed the above findings. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 03/06/24 with the Diagnosis of: Urinary Tract Infection, site not specified. The clinical record was reviewed on 06/04/24. The clinical record contained a POC dated 05/05/24, that included notify the Physician of blood sugar greater than 200 or less than 70. The SN visit notes dated 03/06/24 and 04/19/24 lacked documentation of the patient’s blood sugar results. 2. Pt. #2 was admitted to the Home Health Services on 03/28/24 with the Diagnosis of: Primary Generalized (Osteo)Arthritis. The clinical record was reviewed on 06/04/24. The clinical record contained a POC dated 05/14/24, that included Aide services 1 time a week for 9 weeks. As of 06/06/24, the clinical record lacked documentation of any Aide services provided (more than one month).”

“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 the clinical records review and staff interview, it was determined in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the discharge summaries were not complete. 2. Pt. #7 was admitted to Home Health Services on 12/22/23 with Diagnosis of Type 2 Diabetes. The closed clinical record was reviewed on 06/04/24. The record contained the Discharge Assessment, indicating Pt. was discharged on 04/19/24. The record contained a Discharge Summary, completed by the SN and dated 05/29/24 (41 days from discharge) and signed by the Physician on 05/30/24. The discharge summary was not sent within 5 days after discharge. 3. During interviews with the Administrator and Director of Nursing on 06/05/24 at 1:00 PM and on 06/06/24 at 11:45 AM, both confirmed the above findings. Findings include: 1. Pt. #6 was admitted to the Home Health Services on 08/05/23 with the Diagnosis of: Chronic Obstructive Pulmonary Disease, Unspecified. The discharged clinical record was reviewed 06/04/24. The discharged summary lacked the vital signs.”