Good Shepherd Homecare and Hospice, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on review of agency documents, and interview it was determined the Home Health agency (HHA) failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP). The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1. The Home Health agency failed to develop and maintain an emergency preparedness program plan (EPP) based on a facility and community-based all hazards risk assessment, that addressed patient population and included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials (Refer to tag E0006, E0007 and E0009) 2. The Home Health agency failed to develop and implement policies and procedures, based on the emergency plan, individual plans for patients during a natural or man-made disaster, homebound patients, follow-up with on duty staff and patients, medical documentation and the use of volunteers. (Refer to E0013, E0017, E0019, E0021, E0023 and E0024) 3. The Home Health agency failed to have a communication plan that included methods for sharing information and information about the agency’s occupancy, needs, and its ability to provide assistance. (Refer to E0033 and E0034) 4. The Home Health agency failed to develop and maintain an emergency preparedness program training and testing program that is based on the emergency plan, its risk assessment and the communication plan and failed to participate in a full-scale community-based emergency preparedness program (EPP) exercise or conduct an annual facility-based functional exercise in the past 2 years. (Refer to E0036 and E0039)”

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review, document review and interview, it was determined the Home Health Agency (HHA) failed to ensure patients and or their representatives were provided and informed of all patient rights. Failure to provide and inform patients and or their representatives of all their rights places patients at risk for unmet needs and services. Findings Include: 1. The Home Health agency (HHA) failed to ensure the patient’s right to receive the contact information for the HHA’s administrator, including the administrator’s name, business address, and business phone number in order to receive complaints for 7 of 7 sample patients. (Refer to G0414) 2. The Home Health agency (HHA) failed to ensure the patient’s right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 7 of 7 sample patients. (Refer to G0434) 3. The Home Health agency (HHA) failed to ensure the patient’s right to receive the state toll-free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs for 7 of 7 sample patients. (Refer to G0444) 4. The Home Health agency (HHA) failed to ensure the patient’s right to be informed of the HHA’s policies for transfer and discharge for 7 of 7 sample patients. (Refer to G0452)”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, record review, and interview, it was determined the Home Health agency (HHA) failed to meet the condition of participation (CoP) requirements for care planning, coordination, and quality of care when the HHA failed to provide visit schedules, written medication instructions, and the clinical coordinators contact information. This deficient practice places patients at risk for missed visits, medication errors, unmet care needs and the inability to contact the clinical manager for needs or concerns. Findings Include: 1.The Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedule including frequency of visits by HHA personnel for 7 of 7 Patients (Patients 1-7). (Refer to G0614) 2. The Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule/instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 7 of 7 Patients (Patients 1 - 7). (Refer to G0616) 3. The Home Health agency skilled staff failed to provide contact information of the HHA’s clinical manager, including the telephone number and e-mail address to 7 of 7 sample patients (Patients 1-7). (Refer to G0622)”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and staff interview it was determined the Home Health agency (HHA) failed to meet the condition of participation (CoP) requirements for clinical records when the HHA failed to ensure comprehensive assessments were performed and maintained, discharge summaries were completed and provided to the inpatient facilities for 5 of 7 patient (Patients 1-5) records reviewed and failed to include an individual emergency preparedness plan as part of the comprehensive assessment for 7 of 7 patients (Patients 1-7) reviewed. This deficient practice places patients at risk for missed assessments, discontinuity of care across health care providers and harm or injury during an emergency or disaster. Findings Include: 1. The Home Health agency (HHA) skilled staff failed to ensure that all Comprehensive Assessment including OASIS were performed and maintained in the clinical record for 5 of 7 sample patients (Patients 1 - 5). 2. The Home Health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 5 of 7 sample patients (Patients 1 - 5). (Refer to G1022) 3. The Home Health agency (HHA) failed to develop and implement individual EPP plans for each of the HHA’s patients as a part of the comprehensive assessment for 7 of 7 sampled patients (Patients 1-7) reviewed. (Refer to the Emergency Preparedness Program - E0017)”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and maintain an EPP that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include evidence of a facility and community-based risk assessment. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was no Risk Assessment for the Emergency Preparedness Program.”

“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 review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and maintain an EPP that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to address the Patient Population in the Emergency Preparedness Program. During an interview on 12/05/23 between at 10:00 AM and 12:00 PM, the Administrator stated that there was no program in place which addresses the Patient Population in the Emergency Preparedness Program.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to include information addressing the process for cooperation and collaboration with local, regional, state and federal emergency preparedness officials in their EPP. This affects all residents and could result in a delayed response to an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to provide a process for cooperation and collaboration with local, regional, state and federal emergency preparedness officials. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was no process in place which provides a process for cooperation and collaboration with local, regional, state and federal emergency preparedness officials in the Emergency Preparedness Program.”

“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 review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to review and update policies and procedures at least every 2 years and failed to develop EPP policies and procedures for all hazards identified within the facility’s risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include policies and procedures which were inclusive of all hazards identified within the HHA risk assessment, as a risk assessment was not used in creating the EPP. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no policies and procedures which were inclusive of all hazards identified within the HHA risk assessment, as a risk assessment was not used in creating the EPP.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP), record review and interview the Home Health agency (HHA) failed to develop and implement individual EPP plans for each of the HHA’s patients as a part of the comprehensive assessment for 7 of 7 sampled patients (Patients 1-7) reviewed. Failure to develop individual EPP plans for each patient places patients at risk for harm during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include plans for the HHA’s individual patients during a natural or man-made disaster. Review or Patient records 1 through 7 lacked documented evidence by agency professional staff of an individual emergency preparedness plan as part of the comprehensive assessment for each patient. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no plans for the HHA’s individual patients during a natural or man-made disaster.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and implement EPP policies and procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This deficient practices places patients at risk for harm during an emergency. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include plans which addressed the procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no plans which addressed the procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to provide procedures to follow up with on-duty staff and patients to determine services that are need, in the event that there is an interruption in services during or due to an emergency. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include written policies or procedures in place to facilitate following-up with on-duty staff and patients to determine services that are needed, in the event of an emergency. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no written policies or procedures in place to facilitate following-up with on-duty staff and patients to determine services that are needed, in the event of an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and implement policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records for the Emergency Preparedness Program. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records for the Emergency Preparedness Program.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and implement policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include policies or procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for the Emergency Preparedness Program. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there were no policies or procedures for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for the Emergency Preparedness Program.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and implement an EPP communication plan that included method of sharing information and medical documentation. This deficient practice has the potential to place patients at risk for the loss of continuity of care and services during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include a communication plan that included method of sharing information and medical documentation. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was no communication plan that included method of sharing information and medical documentation.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and implement an EPP communication plan that includes a means of providing information about the HHA’s needs, and its ability to provide assistance to the authority having jurisdiction. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include a communication plan that includes a means of providing information about the HHA’s needs, and its ability to provide assistance to the authority having jurisdiction. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was no communication plan that includes a means of providing information about the HHA’s needs, and its ability to provide assistance to the authority having jurisdiction.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to develop and maintain an EPP training and testing program that is based on the emergency plan, its risk assessment and the communication plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include a training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was not a training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program.”

“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 review of the agency’s Emergency Preparedness Program (EPP) and interview the Home Health agency (HHA) failed to conduct or participate in exercises to test the EPP. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include a training and testing program which included a full-scale community-based emergency preparedness exercise. During an interview on 12/05/23 between 10:00 AM and 12:00 PM, the Administrator stated that there was no full-scale community-based emergency preparedness program or exercise which was conducted in the past 2 years for the Emergency Preparedness Program.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on record review, document review and staff interview the Home Health agency (HHA) failed to ensure the patient’s right to be informed of the HHA’s policies for transfer and discharge for 7 of 7 sample patients (Patients 1-7). The HHA’s failure to ensure the patient’s right to receive information regarding the agency’s transfer and discharge policies placed all patient currently on services for risk of unmet needs due to not having all needed information regarding agency policies. Findings Include: Review of all admission documents for Patients 1 through 7, showed the agency failed to provide any evidence of written information regarding the HHA’s policies for transfer and discharge being given to patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, failed to provide any evidence of written information regarding the HHA’s policies for transfer and discharge being given to patients during the admission process or thereafter. During an interview on 12/06/23 at 2:30 PM, the Administrator confirmed that the agency had not been providing the patients with the information regarding the transfer and discharge policies.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review, document review and staff interview the Home Health agency (HHA) failed to ensure the patient’s right to receive the contact information for the HHA’s administrator, including the administrator’s name, business address, and business phone number in order to receive complaints for 7 of 7 sample patients (Patients 1-7). The home health agency’s failure to ensure the patient’s right to receive the contact information for the administrator, placed all patients currently on service, at risk for unmet needs due to not being able to contact the home health agency’s administrator. Findings Include: Review of all admission documents for Patients 1 through 7, showed the agency failed to document any evidence the Agency’s Administrator contact information was provided to the patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, the agency failed to provide any evidence of written information regarding the Agency’s Administrator contact information being given to patients during the admission process or thereafter. During an interview on 12/06/23 at 2:30 PM, the Administrator confirmed that the agency had not been providing the patients with her contact information.”

“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 record review, and staff interview the Home Health Agency failed to ensure the patient’s right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 7 of 7 sample patients (Patients 1 -7). The home health agency’s failure to ensure the patient’s right to consent to frequency of services place all patients currently on service, at risk for unmet needs, care and services. Finding Include: Patient 1 Review of Patient 1’s Admission Consent dated 06/26/23 lacked documented visit frequency or which disciplines would provide services to the patient. Review of the Plan of Care (POC) dated 06/26/23 indicated orders for Skilled Nursing (SN) visits one time per week for 9 weeks. Patient 2 Review of Patient 2’s Admission Consent dated 08/28/23 lacked documented visit frequency for SN or Physical Therapy (PT), which were both marked with a check mark. There was no signature or date found on the Admission Consent. Patient 3 Review of Patient 3’s Admission Consent dated 07/12/23 lacked documented visit frequency for the home health aide, which was marked with a check mark. There was no signature or date found on the Admission Consent. Review of the Plan of Care (POC) dated 07/12/23 indicated orders for home health aide to be 1-2 times per week for 9 weeks. Patient 4 Review of Patient 4’s record lacked evidence of a consent for services for the patient. Review of the Plan of Care (POC) dated 10/11/23 indicated orders for SN one time per week and home health aide two times per week. Patient 5 Review of Patient 5’s Admission Consent dated 10/10/23 lacked documented visit frequencies for SN, Social Work (SW), PT, or home health aide which were all marked with a check mark. There was no signature or date found on the Admission Consent. Review of the Plan of Care (POC) dated 10/10/23 indicated orders for SN one time per week and home health aide two times per week with no other disciplines ordered. Patient 6 Review of Patient 6’s Admission Consent dated 10/11/23 lacked documented visit frequencies or disciplines to provide services to the patient. Review of Plan of Care (POC) dated 10/11/23 indicated orders for SN 3 times per week for 8 weeks and home health aide one time per week for 8 weeks. Patient 7 Review of Patient 7’s Admission Consent dated 08/11/23 lacked documented visit frequencies or disciplines to provide services to the patient. Review of Plan of Care (POC) dated 08/11/23 indicated orders for SN one time per week for 6 weeks. During an interview on 12/06/23 at 2:30 PM, Staff A, Administrator, stated that it is the expectation for the clinician performing the Start of Care Assessment to complete the visit frequency line for each discipline that will visit the patient and not to just document a check mark on the line. She confirmed the above findings of the agency’s failure to ensure the patient’s right to consent to visit frequencies of services.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review, document review and staff interview the Home Health agency (HHA) failed to ensure the patient’s right to receive the state toll-free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs for 7 of 7 sample patients (Patients 1-7). The home health agency’s failure to ensure the patient’s right to receive the contact information and state toll free home health telephone hot line number placed all patient currently on services for unmet needs due to not being able to contact the State Agency with complaints. Findings Include: Review of all admission documents for Patients 1 through 7, showed the agency failed to provide any evidence of written information regarding the State Agency’s toll-free hot line number for complaints being given to patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, the agency failed to provide any evidence of written information regarding the State Agency’s toll-free hot line number for complaints being given to patients during the admission process or thereafter. During an interview on 12/06/23 at 2:30 PM, the Administrator confirmed that the agency had not been providing the patients with the information regarding the state hot line number.”

“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 record review, and staff interview, it was determined that the Home Health agency (HHA) failed to conduct an initial assessment visit within 48 hours after receiving a referral to provide services for 4 (Patients 2, 4, 5, 6) of 7 patients reviewed. This failure had the potential for the patients not to receive needed assessments and home care services that could have negatively impacted outcomes. Findings Include: Patient 2 Review of Patient 2’s, “Home Health Certification and Plan of Care (POC)”, dated 08/28/23 indicated that the patient was admitted with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and orders for Skilled Nursing (SN) visits one time per week. Review of the Comprehensive Assessment dated 08/28/23, showed, “Physician’s ordered Start of Care (SOC) date” indicated the patient was to be admitted on 08/23/23. Review of faxed referral information indicated the date of receival to be 08/23/23. There was no documented evidence to indicate why there was a delay in the SOC or that the referring physician was notified of the delayed SOC. Patient 4 Review of Patient 4’s, “Home Health Certification and Plan of Care (POC)”, dated 10/11/23 indicated that the patient was admitted with a primary diagnosis of Malignant Neoplasm (cancer) of the Gallbladder and orders for Skilled Nursing (SN) visits one time per week. Review of the Comprehensive Assessment dated 10/11/23, showed, “Physician’s ordered Start of Care (SOC) date” indicated the patient was to be admitted on 10/11/23. Review of faxed referral information indicated the date of receival to be 10/03/23. There was no documented evidence to indicate why there was a delay in the SOC or that the referring physician was notified of the delayed SOC. Patient 5 Review of Patient 5’s, “Home Health Certification and Plan of Care (POC)”, dated 10/10/23 indicated that the patient was admitted with orders for Skilled Nursing visits one time per week and Home Health Aide (HHA) two times per week. Review of the Comprehensive Assessment dated 10/10/23, showed, “Physician’s ordered Start of Care (SOC) date” indicated the patient was to be admitted on 10/10/23. Review of faxed referral information indicated the date of receival to be 10/04/23. There was no documented evidence to indicate why there was a delay in the SOC or that the referring physician was notified of the delayed SOC. Patient 6 Review of Patient 5’s, “Home Health Certification and Plan of Care (POC)”, dated 10/11/23 indicated that the patient was admitted with a Primary Diagnosis of Alzheimer’s and orders for Skilled Nursing visits one time per week. Review of the Comprehensive Assessment dated 10/11/23, showed, “Physician’s ordered Start of Care (SOC) date” indicated the patient was to be admitted on 10/11/23. Review of faxed referral information indicated the date of receival to be 10/06/23. There was no documented evidence to indicate why there was a delay in the SOC or that the referring physician was notified of the delayed SOC. During an interview on 12/06/23 at 2:30 PM, the Administrator confirmed that the agency had not admitted the patient within the 48-hour time frame. She stated that the agency wasn’t aware that the patients had to be admitted within 48 hours of receiving the referral or that the referring physician needed to be made aware of the delay in starting services.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review, and staff interview, the Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedule including frequency of visits by HHA personnel for 7 of 7 Patients (Patients 1-7). The home health agency’s failure to ensure the patients received written instruction regarding planned visits placed all patients, currently on services at risk for unmet needs, care and services. Findings Include: Observation during home visit with Patient 1 on 12/06/23 at 9:30 AM, there were no written instructions regarding visit frequency or home health agency (HHA) instructional documents found in the home. The patient stated that she was unaware if she was given any folder or papers. Observation during home visit with Patient 2 on 12/06/23 at 11:30 AM, there were no written instructions regarding visit frequency or home health agency (HHA) instructional documents found in the home. The patient’s wife stated that she did not know where any of the agency paperwork was but that she was sure they had signed something when home health started. Review or Patient records 1 through 7 lacked documented evidence by agency professional staff regarding giving or delivering written instructions outlining visit frequencies to the patients or caregivers. During an interview on 12/06/23 at 2:30 PM, Staff A, Administrator stated that, the agency had not been giving the patients written information regarding the frequency of visits.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review and interview, the Home Health agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule/instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 7 of 7 Patients (Patients 1 - 7). The home health agency’s failure to ensure the patients received written instructions regarding medication administration placed all patients, currently on service at risk for adverse medication outcomes, and unmet needs. Findings Include: Observation during home visit with Patient 1 on 12/06/23 at 9:30 AM, there were no written instructions regarding patient medication list or home health agency (HHA) instructional documents found in the home. The patient stated that she was unaware if she was given any folder or papers. Observation during home visit with Patient 2 on 12/06/23 at 11:30 AM, there were no written instructions regarding patient medication list or home health agency (HHA) instructional documents found in the home. The patient’s wife stated that she did not know where any of the agency paperwork was but that she was sure they had signed something when home health started. Review or Patient records 1 through 7 lacked documented evidence by agency professional staff regarding giving or delivering written instructions outlining medications to the patients or caregivers. During an interview on 12/06/23 at 2:30 PM, Staff A, Administrator confirmed that, the agency had not been giving the patients written information regarding their medications. She stated that the agency staff had been printing a list of the patient medications but were filling it in the chart.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review, document review and staff interview the Home Health agency skilled staff failed to provide contact information of the HHA’s clinical manager, including the telephone number and e-mail address to 7 of 7 sample patients (Patients 1-7). The home health agency’s failure to ensure the patient’s right to receive the contact information for the clinical manager, placed all patients currently on service, at risk for unmet needs due to not being able to contact the home health agency’s administrator. Findings Include: Review of Patients 1 through 7’s medical record admission documents showed the agency failed to provide any evidence of contact information regarding the Agency’s Clinical Manager being given to patients during the admission process or thereafter. Review of Agency Admission packet and all admission documents provided, failed to provide any evidence of contact information regarding the Agency’s Clinical Manager being given to patients during the admission process or thereafter. During an interview on 12/06/23 at 2:30 PM, the Administrator confirmed that the agency had not been providing the patients with contact information for the Clinical Manager.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review, and staff interview the Home Health agency (HHA) skilled staff failed to ensure that all Comprehensive Assessment including OASIS were performed and maintained in the clinical record for 5 of 7 sample patients (Patients 1 - 5). The home health agency’s failure to ensure all Comprehensive Assessment were performed and maintained in the clinical record placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/26/23 and a Certification Period from: 08/25/23 to 10/23/23. Review of visit notes for the current certification period showed a transfer to the hospital on 11/17/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment. Patient 2 Review of Patient 2’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/28/23 and a Certification Period from: 08/28/23 to 10/26/23. Review of visit notes for the current certification period showed a transfer to the hospital, for a fall, on 10/26/23, which was the last day of the current episode. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment. Patient 3 Review of Patient 3’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/12/23 and a Certification Period from: 07/12/23 to 09/09/23. Review of visit notes for the current certification period showed a transfer to the hospital on 07/13/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment. Patient 4 Review of Patient 4’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 10/11/23 and a Certification Period from: 10/11/23 to discharge date of 10/31/23. Review of visit notes showed that the agency discharged the patient on 10/31/23. The home health agency failed to complete a Discharge OASIS/Comprehensive Assessment but, instead completed a Significant Change In Condition (SCIC) OASIS/Comprehensive Assessment. Patient 5 Review of Patient 5’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 10/10/23 and a Certification Period from: 10/10/23 to 12/08/23. Review of visit notes for the current certification period showed a transfer to the hospital on 10/16/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment. During an interview on 12/06/23 at 1:45 PM, Staff A, Administrator, confirmed the agency had not completed the appropriate OASIS/Comprehensive Assessment and maintained the assessments in the clinical records for the above patients.”

“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 record review, and staff interview, it was determined the Home Health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 5 of 7 sample patients (Patients 1 - 5). The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lace of care coordination with other health care services. Findings Include: Patient 1 Review of Patient 1’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 06/26/23 and a Certification Period from: 08/25/23 to 10/23/23. Review of visit notes for the current certification period showed a transfer to the hospital on 11/17/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment and a Transfer Summary. There was no evidence of a Transfer Summary being sent to the receiving facility. Patient 2 Review of Patient 2’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 08/28/23 and a Certification Period from: 08/28/23 to 10/26/23. Review of visit notes for the current certification period showed a transfer to the hospital, for a fall, on 10/26/23, which was the last day of the current episode. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment and a Transfer Summary. There was no evidence of a Transfer Summary being sent to the receiving facility. Patient 3 Review of Patient 3’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/12/23 and a Certification Period from: 07/12/23 to 09/09/23. Review of visit notes for the current certification period showed a transfer to the hospital on 07/13/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment and a Transfer Summary. There was no evidence of a Transfer Summary being sent to the receiving facility. Patient 4 Review of Patient 4’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 10/11/23 and a Certification Period from: 10/11/23 to discharge date of 10/31/23. Review of visit notes showed that the agency discharged the patient on 10/31/23. The home health agency failed to complete a Discharge OASIS/Comprehensive Assessment but, instead completed a Significant Change In Condition (SCIC) OASIS/Comprehensive Assessment. There was no evidence of a Discharge Summary being sent to the physician. Patient 5 Review of Patient 5’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 10/10/23 and a Certification Period from: 10/10/23 to 12/08/23. Review of visit notes for the current certification period showed a transfer to the hospital on 10/16/23. The home health agency failed to complete a “Transfer to In-Patient Facility” (TIF) OASIS/Comprehensive Assessment and a Transfer Summary. There was no evidence of a Transfer Summary being sent to the receiving facility. During an interview on 12/06/23 at 1:45 PM, Staff A, Administrator, confirmed the agency had not provided Transfer/Discharge Summaries for the above patients.”