Avanti Home Health Care

“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 record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of updated direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients serviced by this Agency in the event of a facility emergency or disaster (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency (E0006); failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared (E0013); failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency as a result of lack of effective communication in the event of an actual emergency (E0030); failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services (E0037); failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all patients currently serviced by this Agency (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §484.102, Emergency Preparedness.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on policy review and interview, it was determined the home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (G-642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (G-644); failed to document the quality improvement projects and document the reasons for conducting these projects and the measurable progress achieved each year (G-658). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care for all the patients the Home Health Agency serves for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure standard precautions were used to prevent the spread of infections and communicable diseases for 1 of 3 (P-3) joint surveyor home visits (see G682); failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program (see G684).Findings include: The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.70 Infection prevention and control.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years, resulting in lack of updated direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients actively serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 9/26/24 at 9:00 am, review of the Agency’s Emergency Preparedness Plan failed to provide any evidence that a review or updates had been documented. This deficient practice was confirmed during an interview with the Director of Nursing (Staff A) at 11:30 am., on 9/26/24. Staff A stated, “We have not updated the Emergency preparedness program since our last survey.” The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed, and updated at least annually as required.”

“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 record review and interview, the Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 9/26/24 at 11:30 am, the Director of Nursing (Staff A) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.” Upon review of the presented documentation, there was no evidence that the facility conducted a risk assessment utilizing an all-hazards approach with regards to natural, man-made, facility and geographic related emergencies.”

“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 record review and interview, the agency failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared. Findings include: On 9/26/24 at 9:00 am, during a review of the Agency’s Emergency Preparedness documents, it was noted that there was no documented evidence that the agency’s Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years. On 9/26/24 at 11:30 am, the Director of Nursing (Staff A) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency as a result of lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency’s emergency preparedness documents on 9/26/24 at 9:00 am, it was noted that there was no updated contact information for all current staff, patient’s physicians, or volunteers as appropriate. On 9/26/24 at 11:30 am, the Director of Nursing (Staff A) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of trainings, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 9/26/24 at 9:00 am, the Director of Nursing (Staff A) was asked to provide documented evidence of initial and ongoing training in Emergency Preparedness policies and procedures, for all staff employed by the agency, and all contracted staff, yet was unable to do so. There was no documented evidence of initial and ongoing training in Emergency Preparedness. The Agency failed to provide the required training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of trainings. These findings were reviewed with and acknowledged by the Staff A at the time of discovery.”

“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 record review and interview, the Agency failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all patients currently serviced by this Agency. Findings include: During the review of the agency’s Emergency Preparedness documents on 9/26/24 at 9:00 am, it was noted that there was no evidence the agency had conducted any training or exercises to test the agencies emergency plan. Further, there was no documentation of an actual event that would qualify as an emergency, no community based full-scale exercise, no second full-scale exercise or a table-top exercise that would satisfy this requirement. On 9/26/24 at 11:30 am, the Director of Nursing (Staff A) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 8 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: The agency’s Quality Assessment and Performance Improvement (QAPI) documentation was reviewed on 9/26/24. There was no documentation to support the agency’s performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and instructions for a QAPI program, but had no additional data added, thus unable to quantitively demonstrate improvements. The Director of Nursing (Staff A) was questioned regarding QAPI indicators and process to measure on 9/26/24 at 8:30 am and stated, “We have not done anything with QAPI since the last survey.” The agency failed to ensure their QAPI program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program, which had the potential to negatively affect all patients serviced by the agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: During an interview with the Director of Nursing (Staff A) on 9/26/24 at 8:30 am a request was submitted to review the QAPI (quality assessment performance improvement) documents for 2022, 2023 and 2024. There was no documentation to support the agency’s performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and instructions for a QAPI program, but had no additional data added, thus unable to quantitively demonstrate improvements.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2022, 2023 and 2024 calendar years, resulting in the Agency’s inability to improve in patient care, health outcomes, patient safety, quality of care and the agency’s performance. Findings include: On 9/26/24 at 8:30 am during an interview, the Director of Nursing (Staff A) was queried about documentation of the Agency’s QAPI (Quality Assessment Performance Improvement) program and Performance Improvement Projects, reasons for conducting the projects along with measurable progress achieved. ADM#1 was unable to provide the requested data and stated, “We do not have any improvement projects.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review and interview, the agency failed to follow accepted standards of practice for infection control in 1 (P-3) of 3 records reviewed with home visits, resulting in the potential for transmission of infections and communicable disease. Findings include: **Agency Policy: “Standard Precautions,” (Revised April 2018). The policy states, “Gloves: C. Gloves are to be changed: 1. Between tasks and procedures on the same patient.” P-3: The Start of Care (SOC) was dated 8/9/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Bilateral Osteoarthritis and Chronic Obstructive Pulmonary Disease. During record review on 9/24/24, the plan of care documented, “SN (Skilled Nurse) to perform wound care to cellulitis to BLE (Bilateral Lower Extremity). Cleanse wound with wound cleanser, apply xeroform, cover ABD pads and wrap with kerlix and secure with tape…” This surveyor completed an in-home observation visit on 9/25/24 with the Registered Nurse (RN). It was observed during the wound care that the RN cleansed the wound, applied the xeroform dressing and covered the wounds with ABD pad and wrapped the dressing with the same gloves. The staff member failed to follow agency policy. This finding was reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 10:55 am.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program, resulting in the potential development and spread of infections between staff and the 8 patients currently admitted to the agency. Findings include: On 9/26/24 at 8:30 am, the Director of Nursing (Staff A) was interviewed regarding the agency’s quality assessment and performance improvement (QAPI) program. When queried to review an infection tracking binder, Staff A replied, “We have not yet kept track of staff and patient illnesses.” There was no documented evidence for review to indicate the agency had coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the Registered Nurse (RN) prepared complete written instructions for patient safety needs in 1 (P-3) of 1 record in which aide services were provided, resulting in the potential for unsafe, substandard care and unmet care needs. Findings include: **Agency Policy: “Home Health Aide Plan of Care,” (Revised April 2018). The policy states, “Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. 1. The patient’s Case manager or other appropriate skilled professional (physical therapist, speech-language pathologist, or occupation therapist), upon initialization of aide services, will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician (or other authorized licensed independent practitioner) orders. 2. The home health aide plan of care will be individualized to the specific patient…” P-3: The Start of Care (SOC) was dated 8/9/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Bilateral Osteoarthritis and Chronic Obstructive Pulmonary Disease. During record review on 9/24/24, it was noted that the POC ordered Home Health Aide (HHa) services at a frequency of 1w4 (1 time a week for 4 weeks). The HHa completed visits on 9/2/24, 9/10/24, 9/16/24 and 9/23/24. The EMR (Electronic Medical Record) failed to contain a home health aide plan of care. The agency failed to generate a home health aide plan of care per policy. This finding was reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 10:45 am.”

“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 interview, the agency failed to ensure that 4 (P-4, 5, 6, 7) of 7 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent and unmet care needs. Findings include: P-4: The Start of Care (SOC) was dated 8/22/24. The Plan of Care (POC) identified diagnoses of Encounter for attention to Gastrostomy and Myasthenia Gravis. During record review on 9/24/24, it was noted that the referral stated, “DC (Discharge) home with HC (Home Care), RN (Registered Nurse), PT (Physical Therapy), OT (Occupational Therapy) and HHA (Home Health Aide). The consent signed by the patient on 8/22/24 and the comprehensive assessment completed by the RN on 8/22/24 were blank under the OT and HHA section and there was no documentation of the patient refusing OT and HHA. P-5: The Start of Care (SOC) was dated 7/22/24. The Plan of Care (POC) identified diagnoses of Stomach Cancer, Hypothyroidism and Hypertension. During record review on 9/24/24, it was noted that the referral stated, “DC home with HC, RN, PT, OT and HHA. The consent signed by the patient on 7/22/24 and the comprehensive assessment completed by the RN on 7/22/24 were blank under the HHA section and there was no documentation of the patient refusing HHA. P-6: The Start of Care (SOC) was dated 7/24/24. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Hypertension and Atrial Fibrillation. During record review on 9/24/24, it was noted that the referral stated, “DC home with HC, RN, PT, OT and HHA. The consent signed by the patient on 7/24/24 and the comprehensive assessment completed by the RN on 7/24/24 were blank under the OT and HHA section and there was no documentation of the patient refusing OT and HHA. P-7: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnosis of Left Fibula Fracture. During record review on 9/26/24, it was noted that the referral stated, “PT/OT Eval and Treat. The consent signed by the patient on 8/27/24 and the comprehensive assessment completed by the PT on 8/27/24 were blank under the OT section and there was no documentation of the patient refusing OT. These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 11:05 am.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included interventions specific to the individualized needs of the patient in 7 records (P-1, 2, 3, 4, 5, 6, 7) resulting in the potential for poor patient outcomes and unmet care needs. Findings include: **Agency Policy: “Care Planning Process,” (Revised April 2018). The policy states, “1. Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline…” P-1: The Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) identified diagnosis of Spinal Stenosis. During record review on 9/23/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-2: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnoses of Transient Cerebral Ischemic attack, Anxiety and Hypertension. During record review on 9/23/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-3: The Start of Care (SOC) was dated 8/9/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Bilateral Osteoarthritis and Chronic Obstructive Pulmonary Disease. During record review on 9/24/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-4: The Start of Care (SOC) was dated 8/22/24. The Plan of Care (POC) identified diagnoses of Encounter for attention to Gastrostomy and Myasthenia Gravis. During record review on 9/24/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-5: The Start of Care (SOC) was dated 7/22/24. The Plan of Care (POC) identified diagnoses of Stomach Cancer, Hypothyroidism and Hypertension. During record review on 9/24/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-6: The Start of Care (SOC) was dated 7/24/24. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Hypertension and Atrial Fibrillation. During record review on 9/24/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( P-7: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnosis of Left Fibula Fracture. During record review on 9/26/24, it was noted that the POC stated, “Notify physician of vital sign parameters out of range: … Blood Sugar, Fasting: Greater than (>) 180 less than () 200 less than ( These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 10:45 am.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, it was determined the agency had failed to promptly notify the physician concerning pain outside of vital sign parameters for 2 (P-1, 7) of 7 records resulting in a potential poor clinical outcome. Findings include: **Agency Policy: “Pain Assessment,” (Revised April 2018). The policy states, “Policy: All patients will receive at least an initial pain assessment. When pain is identified a more comprehensive pain assessment will be completed. Pain assessments will be appropriate to the patient’s age and will be documented to facilitate regular reassessment and follow-up by clinicians… 5. Pain assessments will be documented in the clinical record, and information will be communicated to other caregivers.” P-1: The Start of Care (SOC) was dated 9/11/24. The Plan of Care (POC) identified diagnosis of Spinal Stenosis. During record review on 9/23/24, it was noted that the POC ordered Physical Therapy (PT) at a frequency of 2w6 (two times a week for 6 weeks). The POC had orders to notify the physician of vital sign parameters out of range: … Pain level: Greater than (>) 6. The PT documented a pain level of 9 during the comprehensive assessment on 9/11/24. There was no documented evidence in the clinical record that the physician had been notified of the patient’s pain. P-7: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnosis of Left Fibula Fracture. During record review on 9/26/24, it was noted that the POC ordered PT at a frequency of 2w6. The POC had orders to notify the physician of vital sign parameters out of range: … Pain level: Greater than (>) 6. On 9/2/24, the PT documented a pain level of 8. On 9/4/24 the PT documented a pain level of 6. On 9/9/24 and 9/11/24, the PT documented a pain level of 7. There was no documented evidence in the clinical record that the physician had been notified of the patient’s pain. These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 11:15 am.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that skilled services were administered in accordance with the physician’s orders and the Plan of Care in 3 (P-3, 4, 6) of 7 records reviewed, resulting in the potential for decline in physical functioning, unidentified health concerns and unmet care needs. Findings include: P-3: The Start of Care (SOC) was dated 8/9/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Bilateral Osteoarthritis and Chronic Obstructive Pulmonary Disease. During record review on 9/24/24, it was noted that the POC dated 8/9/24 ordered “Physical Therapy (PT): Evaluate and Treat” The PT evaluation dated 8/14/24 was late by 5 days from the Skilled Nurse (SN) Comprehensive Assessment dated 8/9/24. During the entrance interview on 9/23/24 at 10:30 am, when questioned on the timeframe for additional services to evaluate the patient, Staff A stated, “Within 48 hours.” The agency failed to evaluate the patient within 48 hours. P-4: The Start of Care (SOC) was dated 8/22/24. The Plan of Care (POC) identified diagnoses of Encounter for attention to Gastrostomy and Myasthenia Gravis. During record review on 9/24/24, it was noted that the POC dated 8/22/24 ordered “Speech Therapy (ST): Evaluate and Treat” The ST evaluation dated 9/5/24 was late by 14 days from the SN Comprehensive Assessment dated 8/22/24. During the entrance interview on 9/23/24 at 10:30 am, when questioned on the timeframe for additional services to evaluate the patient, Staff A stated, “Within 48 hours.” The agency failed to evaluate the patient within 48 hours. P-6: The Start of Care (SOC) was dated 7/24/24. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Hypertension and Atrial Fibrillation. During record review on 9/24/24, it was noted that the POC dated 7/24/24 ordered “Physical Therapy (PT): Evaluate and Treat” The PT evaluation dated 7/31/24 was late by 7 days from the SN Comprehensive Assessment dated 7/24/24. During the entrance interview on 9/23/24 at 10:30 am, when questioned on the timeframe for additional services to evaluate the patient, Staff A stated, “Within 48 hours.” The agency failed to evaluate the patient within 48 hours. These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 11:00 am.”

“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 observation, record review and interview, the agency failed to ensure clinical notes were accurate for 3 (P-2, 3, 7) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: **Agency Policy: “Entries into the Clinical Record,” (Revised April 2018). The policy states, “Procedure: 1. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: 6. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned into the office at the end of the workday. 7. The clinical note will include: A. Care that was provided. B. Treatment and/or invasive procedures performed. C. Patient response to treatment and/or procedures. D. The date the service was provided. E. Signature of clinician and his/her credentials.” P-2: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnoses of Transient Cerebral Ischemic attack, Anxiety and Hypertension. During record review on 9/23/24, it was noted that Physical Therapy (PT) was ordered at a frequency of 2w6 (2 times a week for 6 weeks). The last two PT visit notes dated 9/17/24 and 9/19/24 are blank. The agency failed to document visits timely. P-3: The Start of Care (SOC) was dated 8/9/24. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Bilateral Osteoarthritis and Chronic Obstructive Pulmonary Disease. During record review on 9/24/24, it was noted that Skilled Nursing (SN) was ordered at a frequency of 1w8 and PT was ordered at a frequency of 2w4. The following SN visits were blank: 8/15/24, 8/23/24, 8/30/24, 9/5/24 and 9/13/24. The following PT visits were blank: 8/23/24, 8/26/24, 8/30/24, 9/2/24, 9/6/24, 9/9/24, 9/13/24, 9/16/24, 9/18/24. The agency failed to document visits timely. P-7: The Start of Care (SOC) was dated 8/27/24. The Plan of Care (POC) identified diagnosis of Left Fibula Fracture. During record review on 9/26/24, it was noted that PT was ordered at a frequency of 2w6. The last three PT visit notes dated 9/17/24, 9/20/24 and 9/24/24 are blank. The agency failed to document visits timely. These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 11:20 am.”

“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 interview, the Agency failed to ensure a discharge summary was completed, provided the patient’s current health status at the time of discharge, progress toward goals in 3 (P-4, 5, 6) of 3 closed records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: **Agency Policy: “Discharge Summary,” (Revised April 2018). The policy states, “Policy: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. Procedure: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged…2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service.” P-4: The Start of Care (SOC) was dated 8/22/24. The Plan of Care (POC) identified diagnoses of Encounter for attention to Gastrostomy and Myasthenia Gravis. During record review on 9/24/24, it was noted that Speech Therapy (ST) was ordered at a frequency of 1w1 (1 time a week for 1 week), 2w1, 1w1. The ST completed their last visit on 9/9/24. The Electronic Medical Record (EMR) failed to contain a ST discharge summary per policy. P-5: The Start of Care (SOC) was dated 7/22/24. The Plan of Care (POC) identified diagnoses of Stomach Cancer, Hypothyroidism and Hypertension. During record review on 9/24/24, it was noted that Skilled Nursing (SN) was ordered at a frequency of 1w6. On 8/26/24 the SN documented a “Missed Visit” stating, “Type of Visit: SN Discharge Summary. Reason: No answer to Phone Call. Comments: SN called the patient and left messages but did not return phone calls.” The EMR failed to contain a SN discharge summary per policy. P-6: The Start of Care (SOC) was dated 7/24/24. The Plan of Care (POC) identified diagnoses of Cellulitis of Left Lower Limb, Hypertension and Atrial Fibrillation. During record review on 9/24/24, it was noted that Physical Therapy was ordered at a frequency of 2w7. The PT Outcome and Assessment Information Set (OASIS) Discharge dated 9/11/24 is blank, the PT failed to complete the discharge per policy. These findings were reviewed with and acknowledged by the Staff A (Director of Nursing) and during an interview on 9/26/24 at 11:30 am.”