Faith Home Healthcare, Inc.

“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 02/21/24 between 11:00 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.”

“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, the agency failed to include a training and testing program which included a full-scale community-based emergency preparedness exercise. During an interview on 02/21/24 between 11:00 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.”

“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 interview the Home Health Agency (HHA) failed to provide the patient and/or caregiver with a copy of written instruction outlining the visit schedule for 5 (Patients 1-5) of 17 sample patients. Failure to provide clear written communication with patient regarding scheduled visits does not allow the patient to identify when to expect each discipline or how often they will receive service. Findings Include: Patient 1 Review of Patient 1’s record showed an admission date of 07/09/23 with a primary diagnosis of malignant neoplasm of the corpus uteri (uterine cancer). Review of Patient 1’s plan of care (POC) for the certification period of 01/25/24 to 03/04/24 showed Patient 1 was to receive skilled nurse (SN) visits 3 times weekly for 8 weeks then decrease SN visits to 1 time weekly for 1 week with 3 as needed visits, and physical therapy (PT) visits 1 time weekly for 7 weeks. A physician order effective on 02/17/24 stated a change in visit frequencies to SN visits 1 time weekly for 1 week, then increase SN visits on 02/18/24 to 3 times weekly for 3 weeks, then decrease SN visits on 03/03/24 to 1 time weekly for 1 week. The 02/17/24 physician order also stated a change in PT visits to 1 time a week for 2 weeks. Observation during a home visit on 02/21/24 at 9:35 AM, revealed there was no HHA folder found with written discipline visit schedules in Patient 1’s home. During an interview at the time of the home visit, Patient 1 stated that she did not know where the folder was since moving. Patient 2 Review of Patient 2’s record showed an admission date of 03/12/23 with a primary diagnosis of encounter for fitting and adjustment of urinary device. Review of Patient 2’s POC for the certification period of 01/06/24 to 03/05/25 showed SN visits 1 time weekly for 8 weeks and 3 as needed visits. Observation during a home visit on 02/21/24 at 2:10 PM, revealed the folder provided to Patient 2 by the HHA had an incomplete “In Home Patient Calendar” showing initial admission date 03/12/23 with listed SN frequency but no updated “In Home Patient Calendar” to reflect the visit schedule changes for the current certification period or any other certification periods. Patient 3 Review of Patient 3’s record showed an admission date of 12/07/23 with a primary diagnosis of type 2 diabetes mellitus. Review of Patient 3’s POC for the certification period of 02/05/24 to 04/04/24 showed SN 1 time weekly and PT 2 times a week for 2 weeks, then decrease PT to 1 time a week for 2 weeks, then increase PT to 2 times a week for 1 week, then decrease PT to 1 time a week for 4 weeks. Observation during a home visit on 02/21/24 at 10:20 AM, revealed the folder provided to Patient 3 by the HHA had an “In Home Patient Calendar” that had no date, and it only had the physical therapy (PT) schedule. There were no other discipline schedules documented on the “In Home Patient Calendar”. During an interview at the time of the home visit, Patient 3 and his spouse stated that they did not have a written calendar and waited for a phone call from HHA to know when their next visit would be. Patient 4 Review of Patient 4’s record showed and admission date of 02/04/24 with a primary diagnosis of hypertensive heart disease with chronic kidney disease. Review of Patient 4’s POC for the certification period of 02/04/24 to 04/03/24 showed SN 1 time weekly for 6 weeks and 3 as needed visits, PT 1 time weekly for 8 weeks, and Occupational Therapy (OT) 1 time weekly for 6 weeks. Observation during a home visit on 02/21/24 at 3:25 PM, revealed the folder provided to Patient 4 by the HHA had an “In Home Patient Calendar” that did not reflect of all disciplines the patient was currently receiving. There was no schedule for OT or SN written on the “In Home Patient Calendar”. Patient 5 Review of Patient 5’s record showed and admission date of 02/02/24 with a primary diagnosis of displaced bimalleolar (inner and outer ankle) fracture of the right lower leg. Review of Patient 5’s POC for the certification period of 02/02/24 to 04/01/24 showed SN visits 1 time weekly for 6 weeks and 3 as needed visits, PT visits 1 time weekly for 6 weeks, and OT visits 1 time weekly for 4 weeks. Observation during home visit on 02/22/24 at 9:00 AM, revealed the folder provided to Patient 4 by the HHA had an “In Home Patient Calendar” that was not reflective of all disciplines the patient was currently receiving. There was no schedule for OT or SN written on the HHA provided “In Home Patient Calendar”. During an interview on 02/22/24 at 3:45 PM, Staff A, HHA Administrator/ Director of Nursing, stated that all materials within the patient folder should be completed at time of admission or with care plan update by all patient care staff performing visits to home. In review of findings, Staff A stated that every patient is to have a folder and all forms are to be filled out at time of admission. Staff A stated that there is no specific policy in place regarding completion of the “In Home Patient Calendar”, but each staff is trained during orientation to fill out each form when admitting patients or updating plan of care.”

“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/or caregiver a copy of written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel for 5 (Patients 1-5) of 17 sample patients. The HHA failure to provide a written medication list and instruction regarding administration increases the risk of adverse medication events to occur and inadequate management of symptoms for patients. Findings Include: Review of HHA policy titled “Medication Management- Patient Information” dictates “The patient/family/caregiver is instructed about the patient’s medications verbally or in written format understandable to the patient/family/caregiver.” … “The patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient’s response to the medications are conveyed to the ordering physician.” … “Agency will mail out updated medication list as indicated.” Patient 1 Review of Patient 1’s record showed an admission date of 07/09/23 with a primary diagnosis of malignant neoplasm of the corpus uteri (uterine cancer) with a current certification period of 01/25/24 to 03/04/24. Observation during home visit on 02/21/24 at 9:35 AM, revealed there was no HHA folder found in the patient home with written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel. During an interview at the time of the home visit, Patient 1 stated that she did not know where the folder was since moving. Patient 2 Review of Patient 2’s record showed an admission date of 03/12/23 with a primary diagnosis of encounter for fitting and adjustment of urinary device with a current certification period of 01/06/24 to 03/05/25. Observation during home visit on 02/21/24 at 2:10 PM, revealed the folder provided by the HHA had no HHA written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel. A blank in-home medication form was noted in the HHA folder. A medication list in the folder was noted to be a discharge list from the prior hospitalization that did not reflect the current POC medication list. During an interview at the time of the home visit, Patient 2’s caregiver stated that there were no other medication lists provided by the HHA since the care for her mother had started. Patient 3 Review of Patient 3’s record showed an admission date of 12/07/23 with a primary diagnosis of type 2 diabetes mellitus with a current certification period of 02/05/24 to 04/04/24. Observation during home visit on 02/21/24 at 10:20 AM, revealed the folder provided by the HHA had no written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel. A blank in-home medication form was noted in HHA folder. A medication list in folder noted to be a discharge list from prior hospitalization that did not reflect the current POC medication list. During an interview at the time of the home visit, Staff C Registered Nurse, stated that an HHA medication list was provided to patient at time of admission and then asked Patient 3’s spouse where the list was. Patient 3’s spouse stated that if a list had been provided by HHA at time of admission and restart of care it would be in his folder where she puts all his documents related to the HHA. Patient 4 Review of Patient 4’s record showed and admission date of 02/04/24 with a primary diagnosis of hypertensive heart disease with chronic kidney disease with a current certification period of 02/04/24 to 04/03/24. Observation during home visit on 02/21/24 at 3:25 PM, revealed the folder provided by the HHA had no written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel. A blank in-home medication form was noted in HHA folder. A medication list in folder noted to be a discharge list from the prior hospitalization matching the current POC medication list. During an interview at the time of the home visit, Patient 4 stated that all the information that she has received from the HHA would be in her folder. Patient 5 Review of Patient 5’s record showed and admission date of 02/02/24 with a primary diagnosis of displaced bimalleolar (inner and outer ankle) fracture of the right lower leg with a current certification period of 02/02/24 to 04/01/24. Observation during home visit on 02/22/24 at 9:00 AM, revealed the folder provided by the HHA had no written instructions outlining medication schedule and instructions, including medication name, dosage, frequency, and which medications would be administered by HHA personnel. A blank in-home medication form was noted in HHA folder. A medication list found in the folder noted to be a discharge list from the prior hospitalization matching the current POC medication list. During an interview at the time of the home visit, Patient 5 stated that the current hospital medication list is her most current copy of her medications. During an interview on 02/22/24 at 3:45 PM with Staff A, HHA Administrator/ Director of Nursing, stated that all medications are reviewed at time of admission or resumption of care and a HHA in-home medication list is to be filled out and a carbon copy left with patient/caregiver at that time. Then after the medication review is finished by the primary care provider a copy of the HHA medication list is sent by mail with a copy of the care plan to each patient according to the HHA medication management policy. In review of findings, Staff A stated that every patient is supposed to have a carbon copy of the medication list left in home at time of admission followed by fully reviewed copy by mail.”