Phoenix Home Health Agency, LLC

“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 the emergency preparedness testing and training program was followed for all employees. Findings: A review of administrative records for calendar year 2023 showed no emergency preparedness plan training for employees. On 01/07/25 at 11:00 a.m., Staff C stated the agency did not do emergency preparedness plan training employees in calendar year 2023.”

“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 ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events from 05/12/23 to 12/31/23 for all patients and employees. Findings: A review of administrative records for emergency preparedness showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events from 05/12/23 to 12/31/23. On 01/07/25 at 11:00 a.m., Staff C stated the emergency preparedness program for the agency showed no table-top exercises, drills, community drills or plan activation events for from 05/12/23 to 12/31/23.”

“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 ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative QAPI records for 07/01/23 to 03/31/24 showed no data collection sources or activities utilized in the analysis of data in the agency’s QAPI Program. On 01/07/25 at 11:00 a.m., Staff C stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no program improvement data or analysis of collected data that showed improved quality of patient care from 07/01/23 to 03/31/24.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI activities included follow-up for self-monitoring for outcomes, improved care, services and operations for all patients and employees. Findings: A review of administrative QAPI records for 07/01/23 to 03/31/24 showed no documentation of patient centered QAPI Program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services, and operations. On 01/07/25 at 11:00 a.m., Staff C stated: 1. All QAPI program documentation for the agency was provided in its entirety; and 2. Documentation showed no patient centered QAPI Program activities that included self-monitoring efforts (follow up) that identified and evaluated outcomes to improve care, services, and operations for 07/01/23 to 03/31/24.”

“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 governing body oversite of the conduction of a patient centered QAPI program for 01/30/23 to 01/03/25 for all patients and employees. Findings: A review of governing body meeting minute records showed no governing body oversite of the conduction of a patient centered QAPI program for 01/30/23 to 01/03/25 for the agency. On 01/07/25 at 11:00 a.m., Staff C stated administrative governing body meeting minute records showed no documentation of governing body oversite of the conduction of a patient centered QAPI program for 01/30/23 to 01/03/25.”

“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 ensure the Infection Control Program surveillance data was included in QAPI program activities for all patients and employees. Findings: A review of QAPI administrative records showed no documentation of infection control surveillance data through the QAPI program for calendar year 2023, and 01/01/24 to 11/14/24. On 01/07/25 at 11:00 a.m., Staff C stated infection surveillance activities were not reported through the agency’s QAPI program for calendar years 2023 and 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 governing body oversite of the agency’s program evaluations, operating budgets, and capital expenditure plans for calendar years 2023 and 2024 for all patients and employees. Findings: A review of administrative records (governing body meeting minutes) showed no governing body oversite for agency program evaluations, operating budgets, and capital expenditure plans for calendar years 2023 and 2024. On 01/07/25 at 11:00 a.m., Staff C stated documentation showed no governing body oversite for the agency’s program evaluations, operating budgets, and capital expenditure plans for calendar years 2023 and 2024.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice was provided to one (Patient #7) of 20 patients. Findings: Patient #7 A review of the clinical record showed no advance notice of discharge or home health change of care notice or physician communications prior to discharge from the agency on 09/26/24 for no payer source for services. On 01/07/25 at 10:32 a.m., Staff C stated there were no ABN or HHCOC notices in the clinical record or physician communications prior to the patient being discharged from the agency for no payer source for services (no insurance authorization).”

“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 individualized patient POC included: 1. SN catheter treatment/interventions or last changed/treatment due date for suprapubic catheter management for one (Patient #1) of 20 patients; 2. Identified a wound site for wound care management for one (Patient #7) of 20 patients; 3. Misidentified medication (EMR medication profile was appropriately updated) for one (Patient #11) of 20 patients; 4. SN intervention for medication administration (intramuscular injection) with last competed or intervention due date related to medication administration (intramuscular injection) for 11 (Patients #9, 10, 11, 12, 13, 15, 16, 17, 18, 19 and #20) of 20 patients; and 5. SN intervention for venipuncture/lab draw with last competed or intervention due date related to venipuncture/lab draw for three (Patients #13, 17 and #19) of 20 patients. Findings: Patient #1 A review of the POC dated 11/13/24 to 01/11/25 showed orders for SN to perform monthly suprapubic catheter changes using a 18/10 French catheter. POC documentation showed no urinary catheter treatment intervention last changed or monthly change due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:08 a.m., Staff C stated the POC should have included catheter treatment interventions last changed or monthly change due date related to urinary catheter management. Patient #7 A review of the POC dated 08/29/24 to 10/27/24 showed orders for SN wound care management every visit. POC documentation identified no wound site. Documentation showed no physician notifications and no change in orders. On 01/07/25 at 10:32 a.m., Staff C stated the POC identified no wound site. Patient #9 A review of the POC dated 11/12/24 to 01/10/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:39 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #10 A review of the POC dated 11/12/24 to 01/10/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:40 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #11 A review of the POC dated 11/12/24 to 01/10/25 showed orders for SN to administer Haldol (a psychiatric use medication) 200 milligrams intramuscular injection every two weeks. The medication profile and SN visit notes showed no documentation of Haldol injection every two weeks but documented Invega (a psychiatric use medication) 234 milligram intramuscular injection monthly was administered. POC showed no orders for Invega (a psychiatric use medication) intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date of either medication. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:41 a.m., Staff C stated the POC documented the wrong medication (Haldol) and should have included medication treatment intervention for Invega and showed the last administered or monthly due date. Patient #12 A review of the POC dated 11/11/24 to 01/09/25 showed orders for SN to administer Invega (a psychiatric use medication) 156 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:42 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #13 A review of the POC dated 11/11/24 to 01/09/25 showed orders for SN to perform interventions to perform venipuncture lab draw for CBC (complete blood count) and Clozaril levels (laboratory tests for medical management of health conditions) every month. POC documentation showed no last conducted or due date for venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:43 a.m., Staff C stated the POC should have included last conducted or due date for venipuncture lab draw for CBC and Clozaril levels. Patient #15 A review of the POC dated 11/11/24 to 01/09/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:45 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #16 A review of the POC dated 11/18/24 to 01/16/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:46 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #17 A review of the POC dated 11/18/24 to 01/16/25 showed orders for SN to administer Prolixin (a psychiatric use medication) 50 milligrams intramuscular injection every two weeks. The POC showed orders for SN to perform interventions to perform venipuncture lab draw for CMP (comprehensive metabolic profile) and Hgb A1C (hemoglobin glucose level, laboratory tests for medical management of health conditions) every 120 days. POC documentation showed no last conducted or due date for medication administration or venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:47 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date and last conducted or due date for venipuncture lab draw. Patient #18 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:48 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date. Patient #19 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. The POC showed orders for SN to perform interventions to perform venipuncture lab draw for CMP (comprehensive metabolic profile) and Hgb A1C (hemoglobin glucose level, laboratory tests for medical management of health conditions) every 120 days. POC documentation showed no last conducted or due date for medication administration or venipuncture lab draw. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:49 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date and last conducted or due date for venipuncture lab draw. Patient #20 A review of the POC dated 12/04/24 to 02/01/25 showed orders for SN to administer Invega (a psychiatric use medication) 234 milligrams intramuscular injection every month. POC documentation showed no medication treatment intervention last administered date or monthly due date. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:51 a.m., Staff C stated the POC should have included medication treatment intervention last administered or monthly due date.”

“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 physician orders were a part of the patients’ POCs for SN to administer medications for two (Patients #11 and #17) of 20 patients. Findings: Patient #11 A review of the POC dated 11/12/24 to 01/10/25 showed no orders for SN to administer Invega (a psychiatric use medication) intramuscular injection. SN visit notes dated 12/02/24 documented Invega (a psychiatric use medication) 234 milligram intramuscular injection monthly was administered on 12/02/24. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:41 a.m., Staff C stated the POC showed no SN orders for Invega medication administration. Patient #17 A review of the POC dated 11/18/24 to 01/16/25 showed no orders for SN to administer Invega (a psychiatric use medication) intramuscular injections times two. SN visit notes dated 12/02/24 and on 12/09/24 documented Invega (a psychiatric use medication) 234 milligram intramuscular injection monthly was administered on 12/02/24 and Invega (a psychiatric use medication) 156 milligram intramuscular injection monthly was administered on 12/09/24. Documentation showed no physician notification and no changes in orders. On 01/07/25 at 10:47 a.m., Staff C stated the POC showed no SN orders for Invega medication administration.”

“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: 1. CHHA conducted visit frequency as ordered on the POC for one (Patient #2) of 20 patients; 2. PT conducted visit frequency as ordered on the POC for one (Patient #3) of 20 patients; 3. SN conducted visit frequency as ordered on the POC for two (Patients #3 and #4) of 20 patients; 4. OT conducted visit frequency as ordered on the POC for one (Patient #6) of 20 patients; 5. SN administered an ordered medication and performed venipuncture for ordered laboratory testing for one (Patient #17) of 20 patients. Findings: Patient #2 A review of the plan of care dated 11/27/24 to 01/25/25 showed orders for CHHA visit frequency of two week one, then three times a week for eight weeks. Documentation showed on 12/30/24 a CHHA visit was not conducted due to the agency not having staff available to cover the visit (three visits ordered, two visits conducted). Documentation showed no patient/caregiver refusal of care, no attempt to make up the visit, and no physician notification or change in orders. On 01/07/25 at 10:11 a.m., Staff A stated SN should have covered the CHHA visit as ordered in the POC. Patient #3 A review of the POC dated 11/24/24 to 01/22/25 showed orders for a PT visit frequency of one time a week for one week, then two times a week for three weeks; and SN visit frequency of one time a week for nine weeks. Documentation showed on 12/04/24 a PT visit was not conducted due to an agency scheduling conflict (three visits ordered, one visit conducted) and no SN visit was verified or documented as conducted on 12/20/24 and on 01/03/24 (two visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, no attempt to make up the visits, and no physician notification or change in orders. On 01/07/25 at 10:22 a.m., Staff A stated: 1. PT should have conducted the visit as ordered in the POC; 2. SN should have either verified the visit upon arrival to the home and/or completed the visit documentation within 24 hours of the visit and; 3. SN documentation does not show the visits were conducted as ordered on the POC. Patient #4 A review of the POC dated 11/03/24 to 01/01/25 showed orders for a SN visit frequency of one time a week for nine weeks. Documentation showed on 12/20/24 no SN visit was verified or documented as conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of care, no attempt to make up the visits, and no physician notification or change in orders. On 01/07/25 at 10:25 a.m., Staff A stated: 1. SN should have either verified the visit upon arrival to the home and/or completed the visit documentation within 24 hours of the visit and; 2. SN documentation does not show the visit was conducted as ordered on the POC. Patient #6 A review of the plan of care dated 07/20/24 to 09/17/24 showed orders for a OT visit frequency of one time a week for one week, then two times a week for three weeks; and SN visit frequency of one time a week for nine weeks. Documentation showed on 11/27/24 an OT visit was not conducted due to not available (two visits ordered, one visit conducted) and no SN visit was verified or documented as conducted on 12/19/24 and on 12/26/24 (two visits ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, no attempt to make up the visits, and no physician notification or change in orders. On 01/07/25 at 10:27 a.m., Staff A stated: 1. OT should have conducted the visit as ordered in the POC; 2. SN should have either verified the visit upon arrival to the home and/or completed the visit documentation within 24 hours of the visit and; 3. SN documentation does not show the visits were conducted as ordered on the POC. Patient #17 A review of the POC dated 11/18/24 to 01/16/25 showed orders for SN to administer Prolixin (a psychiatric use medication) 50 milligrams intramuscular injection every two weeks; and the POC showed orders for SN to perform interventions to perform venipuncture lab draw for CMP (comprehensive metabolic profile) and Hgb A1C (hemoglobin glucose level, laboratory tests for medical management of health conditions) every 120 days. SN visit documentation dated 12/02/24, 12/09/24, 12/16/24, 12/23/24, 12/30/24 and 01/06/25 showed no documentation of Prolixin medication administration or venipuncture lab draw. Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 01/07/25 at 10:47 a.m., Staff C stated the physician should have been notified: 1. The POC showed orders for medication treatment interventions for Prolixin and not for the medication Invega and; 2. The venipuncture lab draw for CMP and Hgb A1C had not been conducted.”

“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 SN and OT visit note documentation was completed within 24 hours of the visit for two (Patients #3 and #6) of 20 patients. Findings: Patient #3 A review of the POC dated 11/24/24 to 01/22/25 showed orders for OT visit frequency of two times a week for four weeks, then two times a week for three weeks. Documentation showed OT visits dated 12/31/24 and 01/02/25 showed the visits were ‘not started’ as of the 01/06/25 record review. EMR documentation on 01/07/25 showed the visit note from 12/31/24 was completed on 01/06/25 (6 days from the date of the visit) and the OT visit note from 01/02/24 was completed on 01/06/25 (5 days from the date of the visit) and SN visit frequency of one time a week for nine weeks. Documentation showed SN visits dated 12/20/24, 12/27/24 and on 01/03/25 showed the visits were ‘not started’ as of the 01/06/25 record review. The EMR showed no documentation about why the visit notes were not completed. Patient #6 A review of the POC dated 11/14/24 to 01/25/25 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed SN visits dated 12/19/24 and 12/26/24 showed the visits were ‘not started’ as of the 01/06/25 record review. EMR documentation on 01/07/25 showed the visit notes from 12/19/24 and 12/26/24 remained incomplete (location verified, visit not documented). The EMR showed no documentation about why the visit notes were not completed. On 01/07/25 at 10:22 a.m. to 10:27 a.m., Staff C stated: 1. Visit note documentation is due 24 hours from the time a visit is completed and; 2. OT visit documentation was not completed timely for patient #3; and 3. SN visit documentation was not completed for patient #6.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2023 and 2024. On 01/07/25 at 11:00 a.m., Staff C stated QAPI program activities had no multi-disciplined skilled professional staff participation for the agency.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical visit note documentation was completed for one (Patient # 2) of 20 patients. Findings: Patient #2 A review of the POC dated 11/27/24 to 01/25/25 showed orders for SN to assess and monitor health conditions and perform wound care interventions to multiple wound sites each visit. SN visit note dated 12/26/24 documented no wound site interventions performed during the visit. On 01/07/25 at 10:11 a.m., Staff C stated SN clinical visit note for 12/26/24 did not document wound site interventions.”

“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 reviews and interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving service providers for five (Patients #1, 5, 6, 7 and #8) of 20 patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 12/11/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital service provider. Patient #5 A review of the clinical record documented transfer from the agency on 11/29/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital service provider. Patient #6 A review of the clinical record documented transfer from the agency on 09/10/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital service provider. Patient #7 A review of the clinical record documented discharge from the agency on 09/26/24. Documentation showed no discharge summary was provided to the physician. Patient #8 A review of the clinical record documented transfer from the agency on 10/18/24 to inpatient hospital provider services. Documentation showed no transfer summary was provided to the receiving inpatient hospital service provider. On 01/07/25 at 10:08 a.m. to 10:35 a.m., Staff C stated documentation showed no transfer/discharge summary was sent to the receiving service providers for patients 1, 5, 6, 7 and #8.”