Green Country Home Care, Inc.

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body provided oversight of the agency’s Quality Assessment and Performance Improvement Program for all patients and staff. This failed practice placed all employees and 38 current patients at risk for unidentified health and safety issues. See G0942 Based on record review and interview, the governing body failed to ensure professional direction was provided in the agency’s daily functions by an appointed administrator for all patients and staff. This failed practice placed all employees and 38 current patients at risk of poor oversight of their health care needs. See G0946 Based on record review and interview, the governing body failed to ensure a pre-designated person was available, in the absence of the administrator, to provide continuity to the agency for all employees and patients. This failed practice placed all employees and 38 current patients at risk of necessary services not being available or provided. See G0954 .”

“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 maintain a patient centered Emergency Preparedness Program for all current patients and employees. Findings: A review of emergency preparedness records showed no maintenance of the Emergency Preparedness Program. No updated documents were found in the record for 2023, 2024 or 9:00 am - February 25, 2025. On 2/25/25 at 1:50 pm Staff A stated the Emergency Preparedness Program records did not reflect updates in several years.”

“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, the agency failed to update the Communication Plan for the Emergency Preparedness Program for all current patients and employees. A review of emergency preparedness records showed no updates for staff or patients. On 2/25/25 at 1:50 pm Staff A stated the Communication Plan was not updated and did not contain all current patients or updated employee information.”

“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 emergency drills were completed at least bi-annually for all current patients and all employees. Findings: A review of Emergency Preparedness and administrative records showed no annual Emergency Preparedness Tabletop Exercise, no community-based exercise and no full-scale exercise to demonstrate staff knowledge of emergency procedures. On 02/25/25 at 1:50 pm, Staff A stated they did not have documented drills since 2019.”

“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 document/create a PIP for 2024 through their QAPI Program for all employees and 38 current patients. Findings: A review of records showed no PIP initiated or documented for 2024. On 02/25/25 at 2:16 pm, Staff A stated they were unable to provide a PIP for 2024.”

“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 agency failed to ensure the QAPI program was approved by the governing body for all current patients and all employees. Findings: A review of administrative records showed no governing body documentation and no ongoing governing body oversight of the QAPI Program for 2024. On 02/25/25 at 2:55 pm, Staff A stated, they had no Governing Body records for 2024.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure two (Staff E and F) of two CHHAs had a competency evaluation. Findings: Staff E A review of personnel records showed no competency evaluation in the personnel record. Staff F A review of personnel records showed no competency evaluation in the personnel record. On 02/25/25 at 1:45 pm, Staff A stated there was no competency evaluation in the personnel records for Staff E and F.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure CHHA completion of 12 hours of annual training for two (Staff E and F) of two CHHAs. Findings: Staff E A review of personnel records showed six hours of training in 2024. Staff F A review of personnel records showed six hours of training in 2024. On 02/25/25 at 1:45 am, Staff A stated Staff E and F had not completed the 12 hours of required training for 2024.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body provided oversight of the agency’s Quality Assessment and Performance Improvement Program for all patients and staff. This failed practice placed all employees and 38 current patients at risk for unidentified health and safety issues. Findings: A review of administrative records showed no governing body documentation and no ongoing governing body oversight of the QAPI Program for 2024. On 02/25/25 at 1:55 pm, Staff A stated they had no Governing Body records for 2024.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the correct wound care orders for one (Pt #2) of seven patients. Findings: A review of the POC dated 12/02/24 - 01/30/25 showed orders on page 3 under Medical Necessity for wound care three times a week. On Page 4 under patient centered Intervention documentation showed orders for the caregiver to perform wound care daily and prn. On 02/25/25 at 2:15 pm, Staff A stated the orders should have read three times a week not daily.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a skilled nurse completed clinical notes for one (Pt. #3) of seven patients. Findings: Pt #3 A review of the POC dated 01/23/25 - 03/23/25 showed orders for skilled nurse visits once a week for eight weeks effective 01/27/25. Clinical records showed skilled nurse visits made on 02/04/25, 02/13/25, and 02/17/25 were “not started” (undocumented). On 02/25/25 at 2:40 pm, Staff A stated the nurses notes for 02/04/25, 02/13/25, and 02/17/25 were not completed for Pt #3 at the time of record review.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the governing body failed to ensure professional direction was provided in the agency’s daily functions by an appointed administrator for all patients and staff. This failed practice placed all employees and 38 current patients at risk of poor oversight of their health care needs. Findings: A review of the governing body records showed no appointment of an administrator. 02/25/25 at 2:45 pm Staff A stated she thought a new administrator had been appointed by the governing body.”

“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 governing body failed to ensure a pre-designated person was available to provide continuity to the agency, in the absence of the administrator, for all employees and patients. This failed practice placed all employees and 38 current patients at risk of necessary services not being available or provided. Findings: A review of governing body documents showed no appointment of an agency administrator. 02/25/25 at 2:45 pm Staff A stated there is no current administrator.”