Care Home Health Agency, LLC

“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 must be reviewed, and updated at least every 2 years (See E 0004); failed to develop an emergency preparedness plan that was based on both a facility and community-based all-hazards risk assessment (See E 0006); failed to 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 (See E 0029); and failed to ensure all staff including contracted staff, received initial training and training at least every two years in the agency’s Emergency Preparedness Plan for X of X (Staff X, Y, and Z) personnel files reviewed (See E 0037). The cumulative effect of these systemic problems resulted in the potential of having staff not being properly prepared and negatively affecting all future patients that will be serviced by this Agency in the event of an actual emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.”

“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 must be reviewed and updated at least every two years, resulting in Agency personnel not having updated and approved emergency procedures in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all future patients that will be serviced by this Agency in the event of an emergency or disaster. Findings include: On 9/3/24, review of the Agency’s Emergency Preparedness (EP) plan/binder revealed that the Agency’s Administration (Staff-A and Staff-B), had last reviewed and approved its Emergency Preparedness (EP) plan on 1/5/2022. However, further review noted the EP plan’s last authenticated Hazzard Risk Assessment (HRA) occurred on 12/1/2021. In addition, no evidence was found within the EP program that its Communication Plan had ever been utilized or tested. During an interview on 9/3/24 at 1:40 PM., the findings were reviewed with and acknowledged by the Administrator (Staff-A). Staff A was queried how an EP program could be reviewed and approved when its fundamental components were missing. Staff A stated the Agency has had no patients for over 2 years and that he didn’t keep up on the requirements needed for compliance.”

“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 develop an Emergency Preparedness Plan that was based on both a facility and community-based all-hazards risk assessment, resulting in the potential to negatively affect the health and safety of all future patients that will be serviced by this Agency in the event of an emergency or disaster. Findings include: On 9/3/24, review of the Agency’s Emergency Preparedness (EP) plan/binder revealed the last authenticated Hazzard Risk Assessment (HRA) occurred on 12/1/2021. In addition, authenticated and dated documentation of collaborative efforts with other entities within the community to promote an integrated response concerning community-based risks were not evidenced. The Agency failed to develop, review and update its HRA within the last two years as required. The above findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Alternate Administrator (Staff-C) during an interview on 9/4/24 at 1:10 PM.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to 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, resulting in the Agency’s inability to ensure the coordination of patient care in the event of an actual emergency. These practices could negatively affect the health and safety of all future patients that will be serviced by this Agency in the event of an emergency or disaster. Findings include: On 9/3/24, the Agency’s Emergency Preparedness (EP) communication plan was reviewed concerning its staff/employee phone triage tree used during EP drills or in the event of an actual emergency. No evidence was found which detailed by name and title, how the Agency would interact and coordinate with staff and patients during an emergency. In addition, evidence of incorporating and utilizing Federal, State, and local emergency resources within its communication plan was not found. The findings were reviewed with the Administrator (Staff-A) and the Alternate Administrator (Staff-C) during an interview on 9/4/24 at 1:10 PM.”

“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, the Agency’s Emergency Preparedness Plan failed to ensure all staff including contracted staff, received initial emergency preparedness (EP) training for 5 (Staff A, C, D, E, and F) of 6 personnel files reviewed, and failed to ensure EP training was provided at least every two years for 4 (Staff A, C, D, and F) of 6 personnel files reviewed, resulting in the Agency’s inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of all future patients serviced by this Agency. Findings include: The Agency’s EP documentation and personnel files were reviewed on 9/4/24. Review of the documents indicated that there was no evidence that the Agency ‘s field Staff A (Administrator, date of hire 3/1/2008), Staff C (Alt.-Administrator, date of hire 12/28/2021), Staff D (Physical Therapy Assistant, date of hire 9/18/2010), Staff E (Home Health aide, date of hire 11/10/2009), and Staff F (Physical Therapist, date of hire 4/8/2022) had received initial training in the Agency’s Emergency Preparedness Plan. There was no evidence that these same field Staff A, C, D, and F had received EP training at least every 2 years. The findings were reviewed with and acknowledged by Staff A (Administrator) and Staff C (Alt. Administrator) during an interview on 9/4/24 at 3:30 PM.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure the agency had an ongoing and functioning Quality Assessment and Performance Improvement (QAPI) program, resulting in the potential to adversely affect the quality of care for all patients serviced by this agency. Findings include: On 9/3/24, the agency binder titled, “Quality Assessment Performance Improvement (QAPI) was reviewed. QAPI meeting minutes dated 1/12/23 failed to include participant names/titles of those in attendance. Governing body meeting minutes dated 1/25/23 included QAPI monitoring and summary of 2022 findings. There was no evidence of QAPI or Governing body meeting minutes after January 2023. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C), who stated, “no additional data was obtained after 2022 when we no longer accepted patients. We should have had a meeting in 2024,” during an interview on 9/4/24 at 11 a.m.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure annual infection control education was provided to all staff employed or contracted by the agency, resulting in the lack of knowledge and training regarding current infection prevention/treatment practices in the home setting. Findings include: On 9/4/24 at 3 p.m., the alternate director of nursing (Staff C) was queried about documentation of staff training, education, and in-services regarding Infection Control, and replied, “no infection control education has been provided since 2021.” The agency failed to ensure annual infection control education was provided to all staff employed or contracted by the agency.”

“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 1 (P-3) of 7 records reviewed, were included in the planning of their care, including the disciplines that will furnish the care and the frequency of visits, resulting in the lack of participation in planning, the potential for missed visits, and unmet care needs. Findings include: P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the admission consent failed to include the disciplines that would be furnishing care or the frequency of visits. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the measurable outcomes and goals instituted in the plan of care (POC) had been achieved and failed to ensure blood oxygen safety parameters were obtained and assessed before discharging the patient from home care in 1 (P-7) of 7 closed records reviewed in total, resulting in the potential for unmet patient care needs and poor clinical outcomes. Findings included: P-7: The admit date to the Agency was on 11/19/2022 diagnoses which included hypertensive heart disease with unspecified failure, COPD, and low back pain. Record review on 9/3/24 noted the POC ordered physical therapy (PT) to evaluate and treat the patient. The ordered PT visit frequency was 1w1 (once weekly for one week), 2w4, and 1w3. The comprehensive assessment performed by PT on 11/19/22 documented under “Respiratory Status” that P-7 was “dyspneic or noticeably short of breath (SOB) with minimal exertion (for example, while eating, talking... walking distances less than 20 feet)” but no oxygen saturation was obtained/evidenced in the medical record while P-7 was SOB during the assessment. Also, P-7’s pain was documented as severe (8/10 - highest possible) during the assessment. PT also documented the goals to be achieved before discharge were as follows: Pain reduced to 2/10, ambulation to 100 feet with walker. The following represent PT’s home visit documentation (9 of 9 visits) concerning ambulation, pain level, oxygen saturation (O2 sat) before therapy (BT), after therapy (AT), and physical assistance/support needed by P-7 (Transfer Support). Date: Ambulation: Pain Level: O2 sat: BT - AT: Transfer Support SOB 11/19/22 0 ft. 8 None taken for both. Mod-Max Assist < (less) 20 ft. 11/26/22 0 ft. due to pain 8 None taken for both. Max Assist Not assessed 11/28/22 0 ft. due to pain 8 None taken for both. Max Assist Not assessed 12/6/22 10 ft. 7 None taken for both. Max Assist Not assessed 12/8/22 10 ft. 7 None taken for both. Max Assist Not assessed 12/14/22 10 ft. 6 None taken for both. Max Assist Not assessed 12/16/22 50 ft. 5 Not assessed. Max Assist Not Assessed 12/23/22 10 ft. 4 None taken for both. Max Assist Not Assessed 12/26/22 20 ft. 3 None taken for both. Max Assist Not Assessed On 1/4/23, nine days with no therapy, P-7 was discharged with a documented ambulation of 50ft. with mod. assistance and pain at a 3/10. P-7 also went from max assist with transfers throughout the entire certification period to independent, again with no therapy since 12/26/22. No blood oxygen level was performed throughout home care admission despite PT’s documentation that P-7 was SOB during admission and discharge when walking greater than 20 feet, well short of his ambulation goal of 100 feet. The above findings were reviewed and acknowledged by the Administrator (Staff A) and the Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:45 PM. Both agreed that P-7 was discharged before his ambulation goals were met and further acknowledged that PT’s documentation was questionable concerning how P-7 went from a max assist on 12/26/22, to independent with no therapy provided in the 9 days leading up to his discharge from the Agency on 1/4/23. The Agency failed to ensure that P-7 had obtained clinical findings that supported”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was completed within 48 hours of the referral in 2 (P-3, P-4) of 7 records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the physician order for home care was dated 12/3/22. The start of care assessment was conducted on 12/17/22, 14 days after the date of the referral. There was no evidence that the physician had been notified for the reason for the delay. P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the physician order for home care was dated 10/13/22. The start of care assessment was conducted on 10/20/22, 7 days after the date of the referral. There was no evidence that the physician had been notified for the reason for the delay. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status at the time of admission, including the events that led to the need for home care referral for 2 (P-4, P-7) of 7 records reviewed in total, resulting in incomplete clinical information in determining the needs of patients. Findings include: P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the start of care assessment, dated 10/20/22, completed by the registered nurse, indicated “long term use of insulin” under diagnoses (section M1021/1023); while the blood sugar section stated, “the client is not prescribed insulin.” This finding was reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m. P-7: The start of care (SOC) admit date to the Agency was on 11/19/2022, with diagnoses which included hypertensive heart disease with unspecified heart failure, COPD, and low back pain. On 9/3/24, review of P-7’s initial comprehensive assessment noted sections M1021 and M1023 (Primary and Other diagnoses) had 8 of 8 listed diagnoses as having dates of onset as 11/19/22 or date of admission. These dates were found to be inaccurate when crossed referenced with P-7’s medical history found in the rest of the medical record. Further, history of severity, exacerbating (worsening) symptoms or alleviating measures concerning any of the listed diagnoses were not found within the initial assessment. Also, a narrative concerning the onset, prior treatments, outcomes, or history of how these diagnoses led to the need for a home care referral were not evidenced during record review. In addition, PT documented the patient’s pain was severe (8/10 being the worst possible) but left blank the questions concerning current pain relief measures and failed to provide any potential pain-relieving measures for P-7’s severe pain during the assessment. The findings were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:50 PM. Both were in agreement this did not meet Agency expectations, or its policy referenced below. Agency Policy: “Initial Assessments/Comprehensive Assessments” 9.6.1 (Revised October 2017) stated, “Each patient will receive a comprehensive assessment. The assessment will reflect the patient’s current health status... will identify the patient’s need for home health care.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, it was determined the agency failed to perform a comprehensive drug review in 7 records (P-1, 2, 3, 4, 5, 6, and 7) from a total of 7 records reviewed, resulting in the potential for harmful medication effects for the agency’s patients. Findings include: P-6: This patient was admitted to the Agency on 8/3/2022 with diagnoses which included COPD (chronic obstructive pulmonary disease), hypertensive heart disease with unspecified failure, and depression. During record review on 9/3/24, it was noted the Agency’s electronic medical record (EMR) software upon drug review documented, “No drug interactions found. We could not verify all the medications in the list, please check manually for any drug interactions!” There was no documented evidence in the record that a manual medication interaction check had been completed. In addition, when a manual review of P-6’s medication list was entered into a professional on-line pharmaceutical medication checker “Drugs.com”, the following was found. There were 7 major/severe (highest level of safety concerns) and 30 moderate level interactions along with 2 duplicative drug therapies noted. No evidence was found in the medical record that the physician was made aware of the above drug interactions. The findings were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:20 PM. The Agency failed to adhere to its policy referenced below. P-7: The admit date to the Agency was on 11/19/2022 diagnoses which included hypertensive heart disease with unspecified failure, COPD, and low back pain. Record review on 9/3/24 found only 3 listed medications for P-7 which were entered by the PT (physical therapist). However, further review of the referral for home care (dated 7/28/22) revealed P-7 was prescribed Albuterol to treat his diagnosis of COPD. No evidence was found in the medical record that PT had included Albuterol into the P-7’s medication profile. The findings were reviewed with and acknowledged by Staff A and Staff C during an interview on 9/4/24 at 1:45 PM. The Agency failed to ensure PT had comprehensively reviewed all of P-7’s prescriptions and failed to adhere to the Agency’s policy referenced below. Agency Policy: “Medication Reconciliation” 8.15.1 (Revised October 2017) stated, “At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Any discrepancies will be reconciled by a RN with the patient’s physician.” P-1: The patient was admitted on 8/9/22, with diagnoses of dysphagia, abnormal weight loss, and ataxic gait. During record review on 9/3/24, it was discovered that the agency’s electronic medical record (EMR) systems medication drug review displayed a message, “No medication interactions found. We could not verify all the medications in the list, please check manually for any interactions.” There was no documented evidence in the record that a manual medication interaction check had been completed. P-2: The patient was admitted on 7/28/22, with diagnoses of atopic dermatitis, and unspecified heart disease. During record review on 9/3/24, it was discovered that the agency’s electronic medical record (EMR) systems medication drug review displayed a message, “No medication interactions found. We could not verify all the medications in the list, please check manually for any interactions.” There was no documented evidence in the record that a manual medication interaction check had been completed. P-5: The patient was admitted on 9/10/22, with diagnoses of intertrochanteric fracture, and anxiety. During record review on 9/4/24, it was discovered that the agency’s electronic medical record (EMR) systems medication drug review displayed a message, “No medication interactions found. We could not verify all the medications in the list, please check manually for any interactions.” There was no documented evidence in the record that a manual medication interaction check had been completed. During an interview on 9/4/24 at 3:30 p.m., the administrator (Staff-A) acknowledged the above findings. P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the start of care assessment, dated 12/17/22, completed by the registered nurse, indicated under the Drug Regimen Review (section M2001), “no issues found during review.” A drug interaction report was generated through the electronic medical record software that indicated ten moderate interactions and one major interaction between Oxycodone and Neurontin. There was no evidence the physician was notified. P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the plan of care indicated the principal diagnosis of essential (primary) hypertension and listed one current medication (Januvia, for diabetes). A history and physical from the primary care physician, dated 10/13/22, included an ambulatory current medication list that included Cogentin 0.5mg, Dulcolax 10mg, Wellbutrin XL 150mg, Dupixent 300mg/2ml, Lexapro 5mg, Glucotrol 10mg, Haldol 100mg/ml, Lidoderm 5% topical patch, lisinopril 20mg, nifedipine 30mg, Prilosec 20mg, Invega 3mg, Miralax 17g, and Senokot 8.6mg. There was no evidence these medications were evaluated for potential interactions. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“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, it was determined the Agency failed to ensure the goals on the Plan of Care (POC) were measurable in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, and failed to incorporate safety parameters in which to notify the physician regarding clinical results that would be considered potentially dangerous, resulting in the potential for a plan of care not meeting the patient’s needs. Findings include: P-6: This patient was admitted to the Agency on 8/3/2022 with diagnoses which included COPD (chronic obstructive pulmonary disease), hypertensive heart disease with unspecified failure, and depression. On 9/3/24, review of P-6’s plan of care (POC) noted no safety parameters concerning pertinent clinical values obtained during home visits used to monitor the patient’s current health status such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. In addition, 6 of 6 listed goals failed to be measurable, examples include: “The Client will gain an understanding of the importance of a low sodium diet due to her high blood pressure; Patient/Caregiver will demonstrate knowledge of medication and diet by 11/3/2022; Patient/Caregiver demonstrates correct use of medication by 11/3/2022.” The findings above were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:20 PM. P-7: The admit date to the Agency was on 11/19/2022 diagnoses which included hypertensive heart disease with unspecified failure, COPD, and low back pain. On 9/4/24, review of P-7’s POC noted no safety parameters concerning pertinent clinical values such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. In addition, 5 of 5 listed goals failed to be measurable, examples include: “Patient/Caregiver verbalize measures to protect skin integrity by 11/5/2022; Patient/Caregiver competence in following emergency plan by 12/10/2022; Patient/Caregiver reports patient’s pain within comfort level by 12/24/2022.” The findings were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:50 PM. Staff A and Staff C noted the findings did not meet Agency expectations or its policy referenced below. Agency Policy: “Plan of Care-CMS #485 and Physician Orders” 9.10.1 (Revised October 2017) stated, “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and ling range needs and resources... Each patient must receive... plan of care that identifies patient-specific measurable outcomes and goals.” P-1: The patient was admitted on 8/9/22, with diagnoses of dysphagia, abnormal weight loss, and ataxic gait. During record review on 9/3/24, it was discovered that the goals on the POC were not measurable, for example, “Patient/Caregiver demonstrates ability to follow home exercise program by..., and Patient/Caregiver cardiac/respiratory status will remain stable by 8/31/22.” P-2: The patient was admitted on 7/28/22, with diagnoses of atopic dermatitis, and unspecified heart disease. During record review on 9/3/24, it was discovered that the goals on the POC were not measurable, for example, “Patient/Caregiver cardiac/respiratory status will remain stable by..., and Patient/Caregiver will demonstrate knowledge of medication and diet by 9/29/22.” P-5: The patient was admitted on 9/10/22, with diagnoses of intertrochanteric fracture, and anxiety. During record review on 9/4/24, it was discovered that the goals on the POC were not measurable, for example, “Patient/Caregiver verbalizes information about community resources and how to obtain assistance by 10/8/22, and Able to walk with decreased pain in right leg.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 9/4/24 at 3:30 p.m., the administrator (Staff-A) acknowledged the above findings. P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the plan of care failed to include parameters for reporting vital signs, blood sugar levels, or pain to the physician. It was also noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient/caregiver cardiac/respiratory status will remain stable.” [sic] Another goal stated, “patient/caregiver will demonstrate knowledge of medication and diet.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the plan of care failed to include parameters for reporting vital signs, blood sugar levels, or pain to the physician. It was also noted that the plan of care failed to include measurable nursing goals that were individualized to address patient needs. For example, one goal stated, “patient/caregiver cardiac/respiratory status will remain stable.” [sic] Another goal stated, “patient/caregiver will demonstrate knowledge of medication and diet.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure treatments were provided in accordance with a physician’s order in 1 (P-4) of 7 records reviewed, resulting in the potential for unmet care needs. Findings include: P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the plan of care ordered skilled nursing visits once a week for six weeks. The nurse documented a missed visit note during week six, however there was no evidence the physician was notified. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“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 speech language pathology (SLP) services were provided as ordered by the physician in the plan of care (POC) for 1 of 7 (P-1) records reviewed, resulting in the potential for physical decline and negative patient outcomes. Findings include: P-1: The patient was admitted on 8/9/22, with diagnoses of dysphagia, abnormal weight loss, and ataxic gait. During record review on 9/3/24, it was discovered that the POC ordered SLP services to evaluate and treat the patient. There were no documented visits by SLP services in the record. There was no documentation to indicate the patient had declined SLP services, and no documentation that the physician was informed that SLP services were not provided as ordered in the plan of care. During an interview on 9/4/24 at 3:30 p.m., the administrator (Staff-A) acknowledged the above findings.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing communicated assessment findings with the physician for 2 (P-3, P-4) of 7 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the registered nurse indicated the patient’s blood pressure on admission was 179/100 and on discharge was 180/70. The record failed to include evaluation of potential symptoms (i.e., headache) or evidence that the physician was notified. P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the registered nurse indicated the patient’s blood pressure on admission was 166/93, on 10/26/22 blood pressure was 190/96, on 11/2/22 blood pressure was 163/85, on 11/11/22 blood pressure was 170/80, and on 11/18/22 blood pressure was 180/75. The record failed to include evaluation of potential symptoms (i.e., headache) or evidence that the physician was notified. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on record review and interview, it was determined the agency failed to have all agency staff, participate in agency sponsored in-services, resulting in the potential for poor patient outcomes. Findings include: During review of the agency’s employee files on 9/3/24, it was discovered that from a sample of 6 agency employees, 3 of the employees had no yearly in-services documented in their record. 2 of the employees had in-services documented for 2021 but did not have any yearly in-services documented for 2022 or 2023. The findings were acknowledged by the administrator (Staff-A) during an interview on 9/4/24 at 3:30 p.m.”

“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 provide evidence of a discharge summary in the medical record which would be sent to the physician within 5 business days of the patient’s discharge for 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 closed records reviewed out of a total sample of 7 records, resulting in the physician not having knowledge of the patient’s health status at the time of discharge and a summary of the care provided which has the potential to negatively affect these patients through unmet care needs. Findings include: P-6: This patient was admitted to the Agency on 8/3/2022 with diagnoses which included COPD (chronic obstructive pulmonary disease), hypertensive heart disease with unspecified failure, and depression. Record review on 9/3/24 noted a discharge OASIS (outcome and assessment information set) was completed by the physical therapist (PT) on 9/30/2022. However, further review found no documented evidence of a discharge summary with subsequent submission for physician review within 5 business days of the patient’s discharge. The findings were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:20 PM. Staff A was noted that he was under the impression that the discharge OASIS was sufficient for all patient discharges. P-7: The admit date to the Agency was on 11/19/2022 diagnoses which included hypertensive heart disease with unspecified failure, COPD, and low back pain. Record review on 9/3/24 noted a discharge OASIS was completed by PT on 1/4/2022. However, further review found no documented evidence of a discharge summary with subsequent submission for physician review within 5 business days of the patient’s discharge. The findings were reviewed with and acknowledged by the Administrator (Staff A) and Alternate Administrator (Staff C) during an interview on 9/4/24 at 1:45 PM. Staff A again noted that he was under the impression that the discharge OASIS was sufficient for all patient discharges. The Agency failed to adhere to its policy referenced below. Agency Policy: “Discharge Summary” 9.31.1 (undated) stated, “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner... The original Discharge Summary form from each service will be filed in the medical record.” P-1: The patient was admitted on 8/9/22, with diagnoses of dysphagia, abnormal weight loss, and ataxic gait. During record review on 9/3/24, it was discovered that no discharge summary was documented in the record or available to the physician within 5 days of the patient’s discharge date of 10/4/22. P-2: The patient was admitted on 7/28/22, with diagnoses of atopic dermatitis, and unspecified heart disease. During record review on 9/3/24, it was discovered that no discharge summary was documented in the record or available to the physician within 5 days of the patient’s discharge date of 9/24/22. P-5: The patient was admitted on 9/10/22, with diagnoses of intertrochanteric fracture, and anxiety. During record review on 9/4/24, it was discovered that no discharge summary was documented in the record or available to the physician within 5 days of the patient’s discharge date of 10/12/22. During an interview on 9/4/24 at 3:30 p.m., the administrator (Staff-A) acknowledged the above findings. P-3: This 69-year-old patient was admitted to home care on 12/17/22 with diagnoses of type 2 diabetes and hypertension with heart failure. During record review on 9/4/24, it was noted that the patient was discharged from agency services on 1/13/23. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-4: This 68-year-old patient was admitted to home care on 10/20/22 with diagnoses of hypertension, schizoaffective disorder, and type 2 diabetes. During record review on 9/4/24, it was noted that the patient was discharged from agency services on 12/16/22. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate director of nursing (Staff C) during an interview on 9/4/24 at 2:45 p.m.”