Heritage Home Health Care Services, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on 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 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 an 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, that had been updated at least every 2 years, 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 policies and procedures were updated at least every 2 years, resulting in the potential for lack of direction and guidance in the event of an actual emergency (E0013); failed to develop an Emergency Preparedness Communication Plan that had been reviewed and updated at least every 2 years, resulting in the potential for lack of effective communication amongst staff, patients and local officials in the event of an actual event (E0029); failed to develop and maintain an emergency preparedness communication plan that had been updated at least every 2 years and included contact information for all staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency (E0030); failed to ensure its training and testing program, based on the Emergency Preparedness Plan and Risk Assessment, had been updated at least every 2 years, resulting in staff not being adequately prepared in the event of an actual disaster (E0036); failed to provide documented evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, 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 (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by this home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care was established, periodically reviewed, and signed timely by the physician in 3 of 7 records reviewed (P-5, 6, 7) resulting in patient’s receiving services that were not reviewed and approved by the physician (G572); failed to ensure the Plan of Care included patient-specific measurable outcomes and goals to determine the patients progress towards achieving the goals in 3 of 7 records reviewed (P-5, 6, 7) resulting on lack of information of the patient’s progress during the certification period (G574); failed to ensure that all care and services were provided only in accordance with the Physician’s orders for 1 (P-2) of 1 patient admitted to the agency’s services, from a total of 7 sampled records reviewed, resulting in the provision of unauthorized unsafe care and services and the potential for poor patient outcomes (G580); failed to ensure the Physician was promptly notified of a patient’s change in condition for 1 (P-2) patient who was transferred/admitted to an inpatient facility, from a total of 7 sampled patients reviewed, resulting in the Physician no being aware of the patient’s health status, lack of continuity of care and unmet care needs (G590). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.60 Care Planning, Coordination, Quality of Care.”

“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 record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2022, 2023 and 2024 (see G642); failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program (see G644); failed to ensure to conduct performance improvement projects in 2022 through 2024 (see G658); and the governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2021 through 2024 (see G660). 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 484.65, Quality Assessment and Performance Improvement.”

“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 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 in 2022 through 2024 (see G684) and failed to provide annual infection control education to staff in 2022 thru 2024 (see G686). 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 at 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 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 an emergency or disaster. Findings include: On 4/2/24 at 2:45 p.m., the Clinical Manager (CM #1) was asked for permission to review the agency’s Emergency Preparedness plan and documents. During the review, it was noted that the agency’s plan had not been updated since 2021. When queried about the plan not being updated and current, CM #1 responded, “We had a waiver, so it wasn’t required for that time.” When asked if the plan had been reviewed and updated in 2023, CM #1 acknowledged that it (Emergency Preparedness Plan) had not been updated for the calendar year of 2023. The agency failed to ensure their Emergency Preparedness Plan had been updated at least every 2 years, as per this requirement.”

“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, that had been updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 4/2/24 at 2:45 p.m., during a review of the agency’s Emergency Preparedness Plan, it was noted that the Risk Assessment was undated. The agency’s Emergency Preparedness Plan was dated for the calendar year 2021. When queried about the agency’s Risk Assessment not being dated or updated, the Clinical Manager (CM #1) reported that it was her understanding that an update was not required for calendar year 2022. When asked if the plan had been updated, based on an updated Risk Assessment, CM #1 acknowledged that there had been no updates since 2021. The agency failed to ensure the agency’s Emergency Preparedness Plan was updated, based on an updated Risk Assessment from an all hazards approach.”

“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 policies and procedures were updated at least every 2 years, resulting in the potential for lack of direction and guidance in the event of an actual emergency. Findings include: On 4/2/24 at 2:45 p.m., the Clinical Manger (CM #1) was asked for permission to review the agency’s Emergency Preparedness Plan and Policy. Upon receipt and review of the requested documents, it was noted that none of the documents had been updated since 2021. When queried about the last update, CM #1 said it was assumed there was no requirement to do so in 2022 due to the Covid-19 pandemic. When asked if the policies were updated in 2023, CM #1 acknowledged there had been no additional updates to the agency’s Emergency Preparedness policies and procedures since 2021.”

“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 an Emergency Preparedness Communication Plan that had been reviewed and updated at least every 2 years, resulting in the potential for lack of effective communication amongst staff, patients and local officials in the event of an actual event. Findings include: On 4/2/24 at 2:45 p.m., the agency’s Emergency Preparedness Communication Plan was reviewed and noted to have last been updated in 2021. The Clinical Manager was queried as to why the plan had not been updated and responded, there was no requirement to do so in 2022 in light of the global pandemic. When asked if the Communication Plan had been updated in 2023, CM #1 acknowledged that there were no updates to the overall Emergency Preparedness Plan in 2023. Upon review of the Communication Plan, there were computer printouts regarding forms of communication such as radio stations. When asked where staff would meet in the event of a disaster, CM #1 stated, “We don’t have a meeting point. Our meeting point is here (the office). If that changed, we would just call the staff and tell them where to meet.” The agency failed to establish an effective Communication Plan that had been updated at least every 2 years. These findings were reviewed with and acknowledged by CM #1 at the time of discovery.”

“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 had been updated at least every 2 years and included contact information for all staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency’s Emergency Preparedness documents on 4/2/24 at 2:45 p.m., it was noted that there was no contact information for staff, patient’s physicians, or volunteers as appropriate. Additionally, the plan had not been updated since 2021. These findings were reviewed with the Clinical Manager (CM #1) at the time of discovery, who reported there was no requirement to update the overall Emergency Preparedness Plan for the calendar year 2022. When asked if there was any documented evidence that the Communication Plan was updated in 2023 to include the required contact information, CM #1 acknowledged there had been no updates to the overall plan since 2021. The agency failed to ensure the Communication Plan included the forementioned contact information as per this requirement.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its training and testing program, based on the Emergency Preparedness Plan and Risk Assessment, had been updated at least every 2 years, resulting in staff not being adequately prepared in the event of an actual disaster. Findings include: On 4/2/24 at 2:45 p.m., the agency’s Emergency Preparedness Training and Testing documents were reviewed. Upon review, it was noted that all documents had not been updated since 2021. These findings were reviewed with the Clinical Manager (CM #1) at the time of discovery, who reported there was no requirement to update the plan in 2022 in light of the recent Covid-19 pandemic. When asked if the Training program had been updated in 2023, CM #1 confirmed that there had been no additional updates to the overall Emergency Preparedness Plan since 2021.”

“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 documented evidence of initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: The agency’s Emergency Preparedness documents were reviewed on 4/2/24 at 2:45 p.m. The Clinical Manager (CM #1 provided a document titled “Emergency Preparedness Education” which was dated 3/12/21 and 3/19/21. When asked if there were any additional trainings provided, CM #1 acknowledged that there were no additional trainings available for review. The agency failed to provide documented evidence of initial and ongoing trainings in Emergency Preparedness policies and procedures, every 2 years, as per this requirement.”

“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 serviced by this Agency. Findings include: On 4/2/24/at 2:45 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that there was no evidence that the agency conducted the required community/facility-based drills. The Clinical Manager (CM #1) presented a document titled “Emergency Preparedness Education.” The word “Drill” was crossed out. The document was dated for 3/12/21 and 3/19/21 and had signatures from Physical Therapists and Registered Nurses. CM #1 was queried about any additional drills and stated that no additional drills were required in light of the CMS waiver that was granted due to Covid-19 pandemic. When asked to review any documentation of efforts made and any attendees of the reported events during the crisis, CM #1 was unable to do so and acknowledged there was no documentation available for review. CM #1 then submitted online printouts of information pertaining to the Covid-19 crisis, however, again, there was no documented evidence of staff participation or roles played. Additionally, there was no tabletop discussion available for review. The agency failed to conduct the required drills as per this requirement.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care was established, periodically reviewed, and signed timely by the physician in 3 of 7 records reviewed (P-5, 6, 7) resulting in patient’s receiving services that were not reviewed and approved by the physician. Findings included: P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. The patient was receiving Physical Therapy Services. This patient was discharged from Home Care Services for this agency on 11/25/23 by the Physical Therapist. Upon further review of the Plan of Care, it was noted the POC was signed by the physician on 12/15/2023, 20 days after the patient was discharged. The agency failed to ensure the physician established, periodically reviewed, and signed the patient’s Plan of Care timely. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-6: The Start of Care was dated 7/29/2023. The Plan of Care for the certification period 7/29/23 to 9/26/2023 identified diagnoses of Spondylosis without myelopathy or radiculopathy of lumbar region, Hypertensive Heart Disease without Heart Failure, Abnormalities of Gait and Mobility, Polyneuropathy, Lack of Coordination, and Generalized Muscle Weakness. This patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. This patient was discharged from Home Care Services for this agency on 9/8/2023 by the Physical Therapist. Upon further review of the Plan of Care, it was noted the POC was signed by the physician on 12/15/2023, 98 days after the patient was discharged. The agency failed to ensure the physician established, periodically reviewed, and signed the patient’s Plan of Care timely. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-7: The Start of Care was dated 9/22/2023. The Plan of Care for the Certification period 9/22/2023 to 11/20/2023 identified diagnoses of Polyarthritis, Muscle Weakness, Low back pain, and Abnormalities of Gait and Mobility. The patient was receiving Physical Therapy Services. This patient was discharged from Home Care Services on 11/08/2023. Upon further review of the record, it was noted the POC was signed by the physician on 12/15/2023, 37 days after the patient was discharged from Home care services. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m.”

“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, the agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program in 2022, 2023 and 2024. Resulting in no documented evidence of the agency’s efforts to monitor agency processes and improve patient outcomes for the 24 patients admitted to the agency in the past 12 months. Findings include: On 4/2/24, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation indicates the agency did not have an active QAPI program in 2022, 2023, and 2024. There was no documented evidence of the agency’s efforts in 2022 thru 2024 to coordinate an agency-wide, data driven QAPI program. During an interview on 4/2/24 at 2:30 p.m., the clinical manager (CM #1) reviewed the findings and explained that QAPI activities were not required during the COVID Public Health Emergency in 2022 and 2023. This is an inaccurate statement by CM #1. During the Public Health Emergency CMS modified the requirements for QAPI to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events.”

“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, the agency failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 24 patients admitted to the agency in the past 12 months. Findings include: On 4/2/24, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation indicates the agency did not have an active QAPI program in 2022, 2023, and 2024. There was no documented evidence of the agency’s efforts in 2022 thru 2024 to collect and utilize quality indicator data and other relevant agency data in the design of its QAPI program. Documentation indicates the agency collected some iQIES (Internet Quality Improvement and Evaluation System) outcome reports in 2022 however there is no indication the agency utilized the data along with other relevant agency data in its QAPI program. During an interview on 4/2/24 at 2:30 p.m., the clinical manager (CM #1) reviewed the findings and explained that QAPI activities were not required during the COVID Public Health Emergency in 2022 and 2023.”

“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 record review and interview, the agency failed to ensure to conduct performance improvement projects in 2022 through 2024, resulting in no coordinated efforts to improve patient outcomes for the 24 patients admitted to the agency in the past 12 months. Findings include: On 4/2/24, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation indicates the agency did not have an active QAPI program in 2022, 2023, and 2024. There was no documented evidence of the agency’s efforts in 2022 thru 2024 to conduct performance improvement projects (PIPS). The last documented PIP was started October 1, 2020, and revised in January 2021. During an interview on 4/2/24 at 2:30 p.m., the clinical manager (CM #1) reviewed the findings and explained that QAPI activities were not required during the COVID Public Health Emergency in 2022 and 2023.”

“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 developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2021 through 2024. Resulting in a lack of oversight by the governing body to ensure patient safety and quality of care improvements for the 24 patients admitted to the agency in the past 12 months. Findings include: On 4/2/24, the agency provided for review, a binder titled Governing Board Book, which contained documents pertinent to the Governing Body. The Governing Board Meeting Minutes dated 1/18/2021, states that current annual QAPI (quality assessment and performance improvement) projects are deferred as part of the Medicare waivers in response to the Covid pandemic restrictions impacting our industry. The meeting minutes dated 1/6/22, states the annual QAPI project 2022 is still deferred as per Medicare waiver during Covid pandemic. The meeting minutes dated 1/9/23 states, that current annual QAPI projects are deferred as part of the Medicare waivers in response to the Covid pandemic restrictions impacting our industry. During an interview on 4/2/24 at 2:30 p.m., the clinical manager (CM #1) reviewed the findings and explained that QAPI activities were not required during the COVID Public Health Emergency in 2022 and 2023. The governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven QAPI program from 2021 through 2024.”

“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 in 2022 through 2024, resulting in the potential development and spread of infections between staff and the 24 patients admitted to the agency in the past 12 months. Findings include: On 4/2/24, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation indicates the agency has not had an active QAPI program in 2022, 2023, and 2024. There was no documented evidence of the agency’s efforts in 2022 thru 2024 to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their QAPI program. During an interview on 4/2/24 at 2:30 p.m., the clinical manager (CM #1) reviewed the findings and explained that QAPI activities were not required during the COVID Public Health Emergency in 2022 and 2023. This is an inaccurate statement by CM #1. During the Public Health Emergency CMS modified the requirements for QAPI to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events.”

“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 provide annual infection control education to staff in 2022 thru 2024, resulting in a lack of education regarding current infection prevention and treatment practices in the home setting. Findings include: The agency’s binder titled Infection Control Program was reviewed with the clinical manager (CM #1) on 4/2/24 at 3:00 p.m. The last documented infection control education provided to staff was on 3/19/21. CM #1 acknowledged the findings and confirmed that there was no infection control education for staff in 2022, 2023, and 2024.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the Agency terminating on-going care for 7 (P#’s 1, 2, 3, 4, 5, 6, 7) of 7 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. During clinical record review on 4/2/24, it was noted that there was no documented evidence the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to discharge. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-6: The Start of Care was dated 7/29/2023. The Plan of Care for the certification period 7/29/23 to 9/26/2023 identified diagnoses of Spondylosis without myelopathy or radiculopathy of lumbar region, Hypertensive Heart Disease without heart failure, Abnormalities of Gait and Mobility, Polyneuropathy, Lack of Coordination, and Generalized Muscle Weakness. During clinical record review on 4/2/24, it was noted that there was no documented evidence the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to discharge. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-7: The Start of Care was dated 9/22/2023. The Plan of Care for the Certification period 9/22/2023 to 11/20/2023 identified diagnoses of Polyarthritis, Muscle Weakness, Low back pain, and Abnormalities of Gait and Mobility. During clinical record review on 4/2/24, it was noted that there was no documented evidence the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to discharge. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-3: This patient was admitted to home care on 5/24/23. The patient was discharged from the agency on 7/5/23. During clinical record review on 4/2/24, it was noted that there was no documented evidence the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to discharge. The finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23. The patient was discharged from the agency on 9/21/23. During clinical record review on 4/2/24, it was noted that there was no documented evidence the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to discharge. The finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. P-1: The patient’s start of care (SOC) was 6/2/23 with diagnoses that included Polyarthritis and Bilateral Knee Pain. During the record review on 4/1/24 at 1:05 p.m., it was noted that the patient was discharged from the agency on 7/13/23. Further review of the clinical record revealed no documented evidence that the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to being discharged from the agency’s services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 4/2/24 at 1:25 p.m. P-2: The patient’s SOC was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure and Chronic Obstructive Pulmonary Disease. On 4/2/24 at 9:20 a.m., during the clinical record review, it was noted that the patient was discharged from the agency’s services on 8/29/23. Upon further review, there was no documented evidence that the patient was provided with the Notice of Medicare Provider Non-Coverage information prior to being discharged. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 1:50 p.m. to which CM #1 replied, “We don’t have any evidence that it was given to the patient. The discipline is supposed to have it (form) signed and bring it back to the office.” When asked if the patient is provided with a copy, CM #1 was unable to answer.”

“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 Comprehensive Assessment was conducted within 48 hours of the date of referral for 5 (P#’s 1, 2, 3, 4, 5) of 5 records where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. Upon review of the record, it was noted the referral was dated 10/13/2023 and ordered physical therapy and occupational therapy services. The Start of Care was completed 72 hours after the referral. There was no documentation regarding an explanation for the late Start of Care. These findings were reviewed with and confirmed by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-3: The patient’s initial assessment visit was on 5/24/23. During clinical record review on 4/2/24, it was noted that there was no referral or physician’s order for home care services. On 4/2/24 at 12 noon, CM #1 was interviewed regarding the referral or physician’s order for home care services. CM #1 reviewed the clinical record and acknowledged that there was no referral or physician’s order for home care. It was unable to be determined if the initial assessment visit was conducted within 48 hours of referral or on the physician’s ordered start of care date. P-4: The patient’s initial assessment visit was on 8/15/23. During clinical record review on 4/2/24, it was noted that the referral for home care services was fax stamped as received at the agency on 8/11/23 at 1:22 p.m. There was no documented evidence that the patient had requested a 4-day delay in starting home care services. There was no documentation to indicate the physician was informed of the delay in providing care. The findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. P-1: The patient’s start of care (SOC) was 6/2/23 with diagnoses that included Polyarthritis and Bilateral Knee Pain. On 4/1/24 at 1:05 p.m., during the clinical record review, it was noted that the referral for home care was dated 5/4/23 and ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. The SOC was initiated 29 days after the date of the referral. Upon further review, there was no documented rationale as to why the services were delayed. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 4/2/24 at 1:25 p.m. P-2: The patient’s SOC was 7/17/23 with a diagnosis of Hypertensive Heart Disease without Heart disease. During the record review on 4/2/24 at 9:20 a.m., it was noted that the referral for home care was dated 7/14/23. The SOC was initiated 72 hours after the date of the referral. The Agency failed to ensure the SOC was initiated within 48 hours from the date of the referral as per this requirement. These findings were reviewed with and confirmed by Adm #1 and CM #1 during an interview on 4/2/24 at 1:50 p.m.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Comprehensive Assessment was updated within 48 hours for 1 (P-2) patient who returned home from an inpatient hospital stay, from a total of 7 sampled patients reviewed, resulting the delay in needed services and the potential for unmet care needs. Findings include: P-2: The patient’s start of care was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure, Chronic Obstructive Pulmonary Disease and Muscle Weakness. During the clinical record review on 4/2/24 at 9:20 a.m., it was noted that the Transfer Oasis dated 7/19/23 documented that the patient was transferred and admitted to an inpatient facility on 7/17/23 due to complaints of headache and stomach pains. According to the Clinical Manager (CM #1) during an interview on 4/2/24 at 1:50 p.m., the patient returned to home on 7/21/23. The Resumption of Care Comprehensive Assessment was not initiated until 3 days later, on 7/24/23. The agency failed to ensure the Comprehensive Assessment was updated within 48 hours of the patient’s return home from hospitalization. These findings were discussed with and confirmed by CM #1 during the above interview.”

“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 patient-specific measurable outcomes and goals to determine the patients progress towards achieving the goals in 5 of 7 records reviewed (P-3, 4, 5, 6, 7) resulting in lack of information of the patient’s progress during the certification period. Findings include: P-3: This patient was admitted to home care on 5/24/23 with diagnoses of polyarthritis, muscle weakness, and low back pain. The 5/24/23 plan of care included the following nursing goals: patient will be able to demonstrate pain relief measures to mitigate pain by 3rd week; and patient will demonstrate knowledge of pain medication and proper administration by 3rd week. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards her goals. This finding was reviewed with and acknowledged by the administrator (Adm #1) and the clinical manager (CM #1) during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23 with diagnoses of spondylosis lumbar region and hypertensive heart disease. The 8/15/23 plan of care included the following goals: a physical therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician. This is a goal for the physical therapist, not the patient. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. Policy # C312-Care Planning, approved January 2008. The policy states, “Every patient admitted to Heritage shall have a written Plan of Treatment ...Care decisions and outcome development will be made as a result of the care planning process and analysis of assessment visit including but not limited to reasonable, measurable, and individualized goals and/or outcomes.” P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. The patient was receiving Physical Therapy Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver will be from falls/injury during this episode of care”{sic}; “Patient will demonstrate compliance with energy conservation techniques as evidenced by increased ability to complete transfers, ADLs and ambulate within 5-6weeks.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals.” This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-6: The Start of Care was dated 7/29/2023. The Plan of Care for the certification period 7/29/23 to 9/26/2023 identified diagnoses of Spondylosis without myelopathy or radiculopathy of lumbar region, Hypertensive Heart Disease without heart failure, Abnormalities of Gait and Mobility, Polyneuropathy, Lack of Coordination, and Generalized Muscle Weakness. This patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will receive safe and effective personal care during this episode of care; Patient will be able to demonstrate adequate problem-solving skills, express self and optimism while accepting limitations; Patient will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse, call 911 by 4th week. “These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals.” This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-7: The Start of Care was dated 9/22/2023. The Plan of Care for the Certification period 9/22/2023 to 11/20/2023 identified diagnoses of Polyarthritis, Muscle Weakness, Low back pain, and Abnormalities of Gait and Mobility. The patient was receiving Physical Therapy Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patients activity level will improve due to effective pain control within 5-6-weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. Policy # C312-Care Planning, approved January 2008. The policy states, “Every patient admitted to Heritage shall have a written Plan of Treatment ...Care decisions and outcome development will be made as a result of the care planning process and analysis of assessment visit including but not limited to reasonable, measurable, and individualized goals and/or outcomes.” P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. The patient was receiving Physical Therapy Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver will be from falls/injury during this episode of care”{sic}; “Patient will demonstrate compliance with energy conservation techniques as evidenced by increased ability to complete transfers, ADLs and ambulate within 5-6weeks.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals.” This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-6: The Start of Care was dated 7/29/2023. The Plan of Care for the certification period 7/29/23 to 9/26/2023 identified diagnoses of Spondylosis without myelopathy or radiculopathy of lumbar region, Hypertensive Heart Disease without heart failure, Abnormalities of Gait and Mobility, Polyneuropathy, Lack of Coordination, and Generalized Muscle Weakness. This patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will receive safe and effective personal care during this episode of care; Patient will be able to demonstrate adequate problem-solving skills, express self and optimism while accepting limitations; Patient will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse, call 911 by 4th week. “These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals.” This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-7: The Start of Care was dated 9/22/2023. The Plan of Care for the Certification period 9/22/2023 to 11/20/2023 identified diagnoses of Polyarthritis, Muscle Weakness, Low back pain, and Abnormalities of Gait and Mobility. The patient was receiving Physical Therapy Services. Upon review of the Plan of Care, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patients activity level will improve due to effective pain control within 5-6-weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-3: This patient was admitted to home care on 5/24/23 with diagnoses of polyarthritis, muscle weakness, and low back pain. The 5/24/23 plan of care included the following nursing goals: patient will be able to demonstrate pain relief measures to mitigate pain by 3rd week; and patient will demonstrate knowledge of pain medication and proper administration by 3rd week. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards her goals. This finding was reviewed with and acknowledged by the administrator (Adm #1) and the clinical manager (CM #1) during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23 with diagnoses of spondylosis lumbar region and hypertensive heart disease. The 8/15/23 plan of care included the following goals: a physical therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician. This is a goal for the physical therapist, not the patient. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 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, the Agency failed to ensure that all care and services were provided only in accordance with the Physician’s orders for 1 (P-2) of 1 patient admitted to the agency’s services, from a total of 7 sampled records reviewed, resulting in the provision of unauthorized unsafe care and services and the potential for poor patient outcomes. Findings included: P-2: The patient’s start of care was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure, Chronic Obstructive Pulmonary Disease and Muscle Weakness. During the clinical record review on 4/2/24 at 9:20 a.m., it was noted that the patient was discharged from the agency’s services on 8/29/23. During the course of care, it was noted that the initial plan of care had not been signed until 11/22/23. This date was after the patient’s discharge from care. Further review revealed the patient was transferred to an inpatient facility on 7/19/23 and resumed to care under the agency’s services on 7/24/23. A Physician’s order, dated 7/21/23, transcribed by the Clinical Manager (CM #1) had not been signed by the Physician until 11/17/23, which was 3 months after the patient was discharged from the agency. Additionally, the Resumption of Care Plan of Care had not been signed by the Physician until 12/21/23, which was 4 months after the patient was discharged from the agency’s services. The agency failed to ensure that all services were only provided in accordance with Physician’s orders. These above findings were reviewed with and confirmed by CM #1 during an interview on 4/2/24 at 1:50 p.m.”

“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, the agency failed to ensure the Physician was promptly notified of a patient’s change in condition for 1 (P-2) patient who was transferred/admitted to an inpatient facility, from a total of 7 sampled patients reviewed, resulting in the Physician not being aware of the patient’s health status, lack of continuity of care and unmet care needs. Findings include: P-2: The patient’s start of care was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure, Chronic Obstructive Pulmonary Disease and Muscle Weakness. During the clinical record review on 4/2/24 at 9:20 a.m., it was noted that the patient was transferred and admitted to an inpatient facility on 7/19/23. The patient was resumed to care under the agency’s services on 7/24/23. There was no documented evidence that the Physician had been promptly notified of the patient’s status and subsequent hospital admission. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 4/2/24 at 1:50 p.m.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient was advised of the ordered discipline’s visit frequency prior to the provision of care and services for 3 (P-1, 3, 4) patients ordered to receive home health services, from a total of 7 sampled records reviewed, resulting in the patient not having a say in the planning of care. Findings include: P-1: The patient’s start of care was 6/2/23 with a diagnosis of Polyarthritis. During the record review on 4/1/24 at 1:05 p.m., it was noted that the referral for home care ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. A document titled, “Disciplines for Care and Projected Frequency of Visits” dated 6/2/23, included the patient’s name and the discipline’s (nurse) signature. The document was otherwise blank and failed to include the ordered disciplines and with projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 1:25 p.m. P-3: This patient was admitted to home care on 5/24/23 with diagnoses of polyarthritis, muscle weakness, and low back pain. During record review on 4/2/24, it was noted that there was no documentation to support that the patient was informed in writing of the disciplines providing visits and the visit frequency. The clinical record contained a document titled, “Disciplines for Care and Projected Frequency of Visits” dated 5/24/23. The document included the patient’s name and the nurse’s signature. The remainder of the document was blank and failed to include the ordered disciplines and the projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23 with diagnoses of spondylosis lumbar region and hypertensive heart disease. During record review on 4/2/24, it was noted that there was no documentation to support that the patient was informed in writing of the disciplines providing visits and the visit frequency. The clinical record contained a document titled, “Disciplines for Care and Projected Frequency of Visits” dated 8/15/23. The document included the patient’s name and the nurse’s signature. The remainder of the document was blank and failed to include the ordered disciplines and the projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 2:00 p.m. P-1: The patient’s start of care was 6/2/23 with a diagnosis of Polyarthritis. During the record review on 4/1/24 at 1:05 p.m., it was noted that the referral for home care ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. A document titled, “Disciplines for Care and Projected Frequency of Visits” dated 6/2/23, included the patient’s name and the discipline’s (nurse) signature. The document was otherwise blank and failed to include the ordered disciplines and with projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 1:25 p.m. P-3: This patient was admitted to home care on 5/24/23 with diagnoses of polyarthritis, muscle weakness, and low back pain. During record review on 4/2/24, it was noted that there was no documentation to support that the patient was informed in writing of the disciplines providing visits and the visit frequency. The clinical record contained a document titled, “Disciplines for Care and Projected Frequency of Visits” dated 5/24/23. The document included the patient’s name and the nurse’s signature. The remainder of the document was blank and failed to include the ordered disciplines and the projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23 with diagnoses of spondylosis lumbar region and hypertensive heart disease. During record review on 4/2/24, it was noted that there was no documentation to support that the patient was informed in writing of the disciplines providing visits and the visit frequency. The clinical record contained a document titled, “Disciplines for Care and Projected Frequency of Visits” dated 8/15/23. The document included the patient’s name and the nurse’s signature. The remainder of the document was blank and failed to include the ordered disciplines and the projected visit frequencies. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/2/24 at 2:00 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 Occupational Therapy services were provided as ordered by the Physician for 2 (P#’s 1, 2) patient who required therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and unmet activity of daily living needs. Findings include: P-1: The patient’s start of care (SOC) was 6/2/23 with a diagnosis of Polyarthritis. The referral for home care ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. The patient was discharge from this agency on 7/13/23. At the time of this clinical record review on 4/1/24 at 1:05 p.m., no Occupational Therapy services had been provided. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 4/2/24 at 1:25 p.m. P-2: The patient’s SOC was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure and Muscle Weakness. The referral for home care ordered Physical Therapy and Occupational Therapy services to be provided. The patient was discharged from the agency’s services on 8/29/23. At the time of this record review, no Occupational Therapy services had been provided. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 1:50 p.m.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to pre-designate a person who is authorized in writing by the administrator and the governing body to assume the same responsibilities and obligations as the administrator, resulting in no person authorized to assume the responsibilities of the administrator in their absence. Findings included: During a review of the agency Organizational Chart, Staff list, and Governing Body meeting minutes, it was noted that there was no documentation of a staff member who was designated or authorized to assume the responsibilities and obligations of the Administrator during the Administrator’s absence. During an interview with the Clinical Manager and Administrator on 4/3/2024 at 10:30 am, the Administrator stated, “usually when I am not available, my clinical manager is able to fill-in and take over any of my responsibilities that may be needed.” When asked if this information is documented in the organizational chart, agency policies, or governing board meeting minutes, the response was “no.” The Administrator then created and signed a document titled “Designation of Alternate Authority,” to this surveyor, and submitted a copy of the document into the agency policy manual. The Administrator stated, “we will include this information at our next Governing Board Meeting and submit the document into our Governing Board Meeting minutes.””

“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/transfer summary was completed and sent to the receiving facility within 2 days, and sent to the physician within 5 days of the patient’s discharge for 7 (P#’s 1, 2, 3, 4, 5, 6, 7) of 7 records reviewed in which the patient was either transferred, or discharged from the agency, resulting in the physician or receiving facility not having knowledge of the patient’s health status at the time of transfer/discharge and the potential for unidentified, unmet care needs. Findings include: P-5: The Start of Care was dated 10/17/2023. The Plan of Care for the certification period 10/17/2023 to 12/15/2023 identified diagnoses of Hemiplegia following Cerebral Infarction of right dominant side, Paralytic Gait, Muscle Contractures, Hypertensive Heart Disease without heart failure, and Lack of Coordination. A Discharge OASIS was completed by the Physical Therapist on 11/25/2023, however, there was no indication found in the record that the PT discharge summary was sent to the physician or completed within 5 days after the patient was discharged from services. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-6: The Start of Care was dated 7/29/2023. The Plan of Care for the certification period 7/29/23 to 9/26/2023 identified diagnoses of Spondylosis without myelopathy or radiculopathy of lumbar region, Hypertensive Heart Disease without heart failure, Abnormalities of Gait and Mobility, Polyneuropathy, Lack of Coordination, and Generalized Muscle Weakness. A Discharge OASIS was completed by the Physical Therapist on 9/7/2023. However, there was no evidence found in the record that the PT discharge summary was sent to the physician or completed within 5 days after the patient was discharged from services. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-7: The Start of Care was dated 9/22/2023. The Plan of Care for the Certification period 9/22/2023 to 11/20/2023 identified diagnoses of Polyarthritis, Muscle Weakness, Low back pain, and Abnormalities of Gait and Mobility. The patient was receiving Physical Therapy Services. A Discharge OASIS was completed by the Physical Therapist on 11/8/2023. However, there was no evidence found in the record that the PT discharge summary was sent to the physician or completed within 5 days after the patient was discharged from services. This finding was reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/3/24 at 11:30 a.m. P-3: This patient was admitted to home care on 5/24/23 with diagnoses of polyarthritis, muscle weakness, and low back pain. During record review on 4/2/24, it was noted that the patient was discharged from the agency on 7/5/23. There was no documented evidence that the discharge summary was sent to the physician within 5 days of discharge from agency services. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. P-4: This patient was admitted to home care on 8/15/23 with diagnoses of spondylosis lumbar region and hypertensive heart disease. During record review on 4/2/24, it was noted that the patient was discharged from the agency on 9/21/23. There was no documented evidence that the discharge summary was sent to the physician within 5 days of discharge from agency services. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 2:00 p.m. P-1: The patient’s start of care (SOC) was 6/2/23 with diagnoses that included Polyarthritis and Pain Bilateral Knees. The referral for home care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. During the record review on 4/1/24 at 1:05 p.m., it was noted that the patient was discharged from SN services on 6/12/23. There was no SN discharge Summary available for review. The patient was discharged from PT services on 7/13/23. There was no documented evidence that the summary was sent to the Physician within 5 days of discharge from the discipline or the agency’s services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 4/2/24 at 1:25 p.m. P-2: The patient’s SOC was 7/17/23 with diagnoses that included Hypertensive Heart Disease without Heart Failure, Chronic Obstructive Pulmonary disease and Muscle Weakness. The referral for home care ordered PT and OT services to be provided. During the record review on 4/2/24 at 9:20 a.m., it was noted that the patient was transferred to an inpatient facility on 7/19/23. There was no documented evidence that the Transfer Summary was sent to the receiving facility or the Physician. Additionally, the patient was discharged from SN on 8/18/23 and was discharged from the agency’s services by PT on 8/29/23. There was no SN Discharge Summary available for review and no documented evidence that the PT or SN Discharge summaries were forwarded to the Physician as per this requirement. These findings were reviewed wit and acknowledged by Adm #1 and CM #1 during an interview on 4/2/24 at 1:50 p.m.”