Ahc Hhc, LLC

“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 development of an episodic certification Plan of Care for one (Patient #3) of nine patients. The failed practice had the potential to affect the ability of the agency to identify and address a patient’s health care needs and interventions to achieve health improvements and outcomes for all patients. See Tag #G572. Based on record review and interview, the agency failed to ensure an individualized patient POC included required content four (Patients #1, 3, 5 and #7) of nine patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. See Tag #G574. Based on record review and interview, the agency failed to ensure ongoing discharge planning for six (Patients #1, 3, 4, 5, 6 and #7) of nine patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. See Tag #G598. Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for three (Patients #4, 6 and #7) of nine patients. The failed practice had the potential to impact the coordination of follow up care needs and services affecting patient outcomes for all patients. See Tag #G602. .”

“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 ensure evidence of a patient centered QAPI Program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services, and operations. See Tag G642. Based on record review and interview, the agency failed to ensure utilization of OASIS quality indicator source data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See Tag #G644 Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes, and implemented actions to identify problems to improve care, services and operations for all patients and employees. The failed practice had the potential to place the agency, its patients, and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See Tag #G654. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2023 and 01/01/24 to 10/22/24 for all patients and employees. The failed practice had the potential to place the agency, its patients, and all employees at risk for no improvement in identified performance improvement projects. See Tag #G658. Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities which included sources of data, analysis of data and implementation of actions which tracked efforts toward improvement of care and services for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See Tag G660. .”

“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 governing body oversite of management and operations of the agency for provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. See Tag #G942. Based on record review and interview, the agency failed to ensure governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees. The failed practice effected the agency’s ability to effectively operate and provide services to its patients and the community at large. See Tag #G988. .”

“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 ensure review of the Emergency Preparedness program for the agency annually for all patients and employees. Findings: A review of administrative records showed no annual review of the Emergency Preparedness program for the agency. On 10/23/24 at 3:00 p.m., Staff A stated the agency did not show documentation of an annual review of the Emergency Preparedness program.”

“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 a facility and community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees. Findings: A review of administrative records showed no facility and community-based risk assessment for the agency, its patient population, or its employees. On 10/23/24 at 3:00 p.m., Staff A stated the agency did not show evidence of an All-Hazards Risk Assessment.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure development, implementation and maintenance of processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients and employees. Findings: A review of administrative records showed no administrative processes and/or resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the agency. On 10/23/24 at 3:00 p.m., Staff A stated the agency did not have an Emergency Preparedness Plan with administrative processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials.”

“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 ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and employees. Findings: A review of emergency preparedness records showed no updated Emergency Preparedness Communication Plan which included current staff contact information for the agency. On 10/23/24 at 3:15 p.m., Staff A stated the Emergency Preparedness Communication Plan did not include documentation of contact information for current employees of the agency.”

“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: 1. An emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees and; 2. An after-action report was documented after each drill, exercise or plan activation event for all patients and employees. Findings: A review of administrative records showed no documentation an emergency preparedness plan testing and training program was developed, implemented, and reviewed/updated at least annually. Documentation showed no after-action reports were documented after each drill, exercise or plan activation event that summarized and evaluated the agency’s responses. On 10/23/24 at 3:00 p.m., Staff A stated: 1. The agency had no emergency preparedness plan testing and training program and; The agency showed no after-action reports were documented after each drill, exercise or plan activation event that summarized and evaluated the agency’s responses.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a transfer/discharge summary was completed at the time of patient transfer/discharge for four (Patients #3, 4, 6 and #7) of nine patients. Findings: Patient #3 A review of the clinical record showed no documentation the patient was transferred to inpatient hospital provider services on 08/22/24. Documentation showed no transfer with discharge summary was completed, provided to the physician of record or the inpatient hospital service provider. Patient #4 A review of the clinical record showed no documentation the patient was transferred to inpatient hospital provider services on 01/25/24. Documentation showed no transfer with discharge summary was completed until 03/13/24 and was provided to the physician of record or the inpatient hospital service provider. Patient #6 A review of the clinical record showed no documentation the patient was discharged on 12/31/23. Documentation showed no discharge summary was completed or provided to the physician of record. Patient #7 A review of the clinical record showed no documentation the patient was transferred to inpatient hospital provider services on 02/16/24. Documentation showed no transfer with discharge summary was completed until 03/11/24 and was provided to the physician of record or the inpatient hospital service provider. On 10/23/24 between 2:15 to 2:55 p.m., Staff A stated: 1. Patients #3, 4 and #7 had no transfer summary completed or provided to the physician of record or the inpatient hospital service provider at the time of transfer and; 2. Patients #6 had no discharge summary completed or provided to the physician of record at the time of discharge.”

“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 development of an episodic certification Plan of Care for one (Patient #5) of nine patients. The failed practice had the potential to affect the ability of the agency to identify and address a patient’s health care needs and interventions to achieve health improvements and outcomes for all patients. Findings: Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POCs) for POC certification periods of 08/05/24 to 10/03/24. Documentation showed no physician notifications and no recertification OASIS assessments conducted between 07/30/24 and 08/03/24 (days 55 through 60 of each 60-day certification period) and documented no physician orders. The last documented POC for the patient’s Home Health Agency episodic certification period was 06/06/24 to 08/04/24. On 10/23/24 from 2:25 p.m., Staff A stated: 1. Patient #5 did not have POCs (physician orders) for the certification period of 08/05/24 to 10/03/24; and 2. The patient was discharged from agency services on 08/16/24 to rehabilitation services.”

“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 ensure evidence of a patient centered QAPI Program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services, and operations. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services, and operations. Findings: A review of QAPI Program documents showed no QAPI program meeting activities which showed measurements, analysis, tracking or evaluation of data (scope) for the agency’s improvement in calendar year 2023 and 01/01/24 to 10/22/24. On 10/23/24 at 3:30 p.m., Staff A stated: 1. The agency had no quarterly reports based on identified data sources (clinical patient record chart audits, etc.) during calendar year 2023 and 01/01/24 to 10/22/24; and 2. Administrative record documentation showed no improvement measurements, analysis, tracking or evaluation of data (program scope) by the agency.”

“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 OASIS quality indicator source data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: A review of QAPI records for calendar year 2023 and 01/01/24 to 10/22/24 showed no data collection sources based on OASIS quality indicator data or activities utilized in the analysis of that data in the agency’s QAPI Program. On 10/23/24 at 3:30 p.m., Staff A stated: 1. All available QAPI program documentation for the agency was provided in its entirety and; 2. Documentation showed no program improvement data or analysis of collected data based on OASIS quality indicator data for calendar year 2023 and 01/01/24 to 10/22/24.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes, and implemented actions to identify problems to improve care, services and operations for all patients and employees. The failed practice had the potential to place the agency, its patients, and all employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: A review of QAPI Program documents showed no program activities for calendar year 2023 and 01/01/24 to 10/22/24 that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes, and implemented actions to identify problems to improve care, services, and operations. On 10/23/24 at 3:30 p.m., Staff A stated QAPI program documentation for calendar years 2023 and 01/01/24 to 10/22/24 showed no ongoing QAPI program activities that included self-monitoring efforts and opportunities that tracked adverse events, analyzed causes, and implemented actions to identify problems to improve care, services, and operations.”

“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 the initiation and review of a PIP through their QAPI Program for calendar years 2023 and 01/01/24 to 10/22/24 for all patients and employees. The failed practice had the potential to place the agency, its patients, and all employees at risk for no improvement in identified performance improvement projects. Findings: A review of QAPI Program documents showed no PIP activities for calendar year 2023 and 01/01/24 to 10/22/24. Documentation showed no intervention activities, analysis of data and showed no follow up or PIP status designation. On 10/23/24 at 3:30 p.m., Staff A stated the agency had no QAPI PIP records for calendar year 2023 and 01/01/24 to 10/22/24 which showed intervention activities, analysis of data, follow up or PIP status designation.”

“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 patient centered QAPI Program activities which included sources of data, analysis of data and implementation of actions which tracked efforts toward improvement of care and services for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: A review of administrative records showed no governing body oversite for the conduction of a comprehensive patient centered QAPI Program for calendar year 2023 and 01/01/24 to 10/22/24. On 10/23/24 at 3:30 p.m., Staff A stated administrative record documentation showed no governing body oversite of the conduction of a comprehensive patient centered QAPI Program in calendar year 2023 and 01/01/24 to 10/22/24.”

“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 its infection control program included surveillance monitoring and reporting; and was included in QAPI program activities for all patients and staff. The failed practice placed the agency at risk for missed opportunities to identify and reduce the incidence and occurrence of infection throughout the agency and effect the health and well-being of all patients and employees. Findings: A review of QAPI and Infection Control Program administrative records showed no infection control program surveillance monitoring and reporting as a part of QAPI program activities for calendar year 2023 and 01/01/24 to 10/22/24. On 10/23/24 at 3:30 p.m., Staff A stated: 1. The agency did not provide the infection surveillance logs and; 2. Infection surveillance was not a part of QAPI program reporting.”

“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 certified home health aides received twelve hours of in-service (continuing education) per calendar year or per cyclic 12-month periods from 05/12/23 to 10/22/24 for two (CHHA D and F) of two reviewed CHHAs. Findings: CHHA D A review of the personnel records for CHHA D showed no documentation of per calendar year or per cyclic 12-month periods of in-service (continuing education) from 05/12/23 to 10/22/24. CHHA F A review of the personnel records for CHHA D showed no documentation of per calendar year or per cyclic 12-month periods of in-service (continuing education) from 05/12/23 to 10/22/24. On 10/23/24 at 3:00 p.m., Staff A stated personnel records for CHHA D and F were presented in their entirety and documentation of in-service (continuing education) from 05/12/23 to 10/22/24 were not available for review.”

“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 management and operations of the agency for provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees. This failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. Findings: A review of administrative records showed no governing body over-site and responsibility for the agency’s provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24. On 10/23/24 at 3:15 p.m., Staff A stated documentation showed no administrative records which showed evidence of ongoing governing body oversite and responsibility for governing body over-site and responsibility for the agency’s provisions of care and services, patient safety, allocation of resources, and annual agency program evaluation for calendar year 2023 and 01/01/24 to 10/15/24.”

“Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar year 2023 and 01/01/24 to 10/15/24 for all patients and employees. The failed practice effected the agency’s ability to effectively operate and provide services to its patients and the community at large. Findings: A review of administrative records showed no governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar year 2023 and 01/01/24 to 10/15/24. On 10/23/24 at 3:15 p.m., Staff A stated documentation showed no administrative records which showed evidence of ongoing governing body fiscal planning and oversite of an operating budget and capital expenditure plan for calendar year 2023 and 01/01/24 to 10/15/24.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge oasis was completed by the agency for two (Patients #3 and 6) of nine patients. Findings: Patient #3 A review of the clinical record showed no documentation the patient was discharged on 08/22/24. Documentation showed no discharge OASIS assessment was completed. On 10/23/24 at 2:15 p.m., Staff A stated the patient was discharged on 08/22/24 and had no discharge OASIS assessment completed at the time of discharge. Patient #6 A review of the clinical record showed no documentation the patient was discharged on 12/31/23. Documentation showed no discharge OASIS assessment was completed. On 10/23/24 at 2:42 p.m., Staff A stated the patient had no discharge OASIS assessment completed at the time of discharge.”

“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 an individualized patient POC included required content three (Patients #1, 3 and #7) of nine patients. The failed practice had the potential to affect a patient’s response to health care interventions to achieve functional and physical health improvements for all patients. Findings: Patient #1 A review of the POC dated 09/23/24 to 11/21/24 showed orders for SN to conduct assessment, instruction/teaching anticoagulation precautions, oxygen use, orthopedic safety, seizure precautions, cardiac precautions, ambulation safety. Documentation included orders for certified home health aide for personal care services and instructions to assist with related activities of daily living tasks. POC documentation showed no related care goals for SN and CHHA services, no physician notifications, and no change in orders. On 10/23/24 at 1:40 p.m., Staff A stated the POC for patient #1 did not include goals for SN and CHHA services. Patient #3 A review of the POC dated 09/23/24 to 11/21/24 showed orders for SN to conduct assessment and provide and instruction/teaching on medication regimen. POC documentation showed no medication profile, no physician notifications, and no change in orders. On 10/23/24 at 1:55 p.m., Staff A stated the POC for patient #3 did not include a medication profile (list), including cross referencing medications for allergies, side effects and untoward reactions/medication compatibility. Patient #7 A review of the POC dated 01/10/24 to 03/09/24 showed no primary diagnosis for home health services, showed orders for wound care materials, identified no wound site, and directed no SN to perform wound site care. POC documentation showed no physician notifications, and no change in orders. On 10/23/24 at 2:25 p.m., Staff A stated the POC for patient #5 showed no primary diagnosis for home health services, showed orders for wound care materials, identified no wound site, and directed no SN to perform wound site care.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure ongoing discharge planning for six (Patients #1, 3, 4, 5, 6 and #7) of nine patients. The failed practice had the potential to affect the health and health care outcomes of all patients that required skilled care interventions to improve their health status. Findings: Patient #1 A review of the clinical record showed a SOC date of 10/14/20. Documentation showed subsequent episodic certification period of 09/23/24 to 11/21/24. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. Patient #3 A review of the clinical record showed a SOC date of 07/08/24. Documentation showed subsequent episodic certification period of 09/06/24 to 11/04/24. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. Patient #4 A review of the clinical record showed a SOC date of 01/17/23. Documentation showed subsequent episodic certification period of 09/08/24 to 11/06/24. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. Patient #5 A review of the clinical record showed a SOC date of 01/17/23. Documentation showed subsequent episodic certification period of 06/06/24 to 08/04/24. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. Patient #6 A review of the clinical record showed a SOC date of 11/01/23. Documentation showed an episodic certification period of 11/01/23 to 12/31/23. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. Patient #7 A review of the clinical record showed a SOC date of 07/27/23. Documentation showed an episodic certification period of 01/10/24 to 03/09/24. Documentation showed no communication notes or case conference notes related to discharge planning and showed no physician notification and no change in orders. On 10/23/24 at 1:40 p.m. to 2:55 p.m., Staff A stated documentation showed no communication notes or case conference notes related to discharge planning for patients #1, 3, 4, 5, 6 and #7.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for three (Patients #4, 6 and #7) of nine patients. The failed practice had the potential to impact the coordination of follow up care needs and services affecting patient outcomes for all patients. Findings: Patient #4 A review of a plan of care dated 01/12/24 to 03/11/24 documented the patient was transferred to in-patient hospital services on 01/25/24 and discharged from agency services on 03/13/24. Documentation showed no physician coordination of care communications as follow up to in-patient hospital transfer and subsequent discharge from agency services. Documentation showed no hospital hold services between 01/25/24 and discharge on 03/13/24. On 10/23/24 at 2:15 p.m., Staff A stated the agency documented no follow up coordination of care or physician notification of the patient’s transfer and subsequent discharge to in-patient hospital services. Patient #6 A review of a plan of care dated 11/01/23 to 12/31/23 documented the patient was discharged from agency services on 12/31/23. Documentation showed no physician coordination of care communications related to the patient’s discharge from agency services prior to 03/06/24. On 10/23/24 at 2:42 p.m., Staff A stated the agency documented no coordination of care or physician notification of the patient’s discharge from agency services. Patient #7 A review of a plan of care dated 01/10/24 to 03/09/2 documented the patient was transferred to in-patient hospital services on 02/16/24. Documentation showed no physician coordination of care communications related to the patient’s transfer to in-patient hospital services and showed no hospital hold orders after 01/25/24 transfer date. On 10/23/24 at 2:55 p.m., Staff A stated the agency documented no coordination of care or physician notification of the patient’s transfer to in-patient hospital services.”

“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 SN conducted every month urinary catheter change/management as ordered on the POC for one (Patient #5) of nine patients. Findings: Patient #5 A review of the POC dated 06/06/24 to 08/04/24 showed orders for SN visit frequency one time a week for one week, then two times a week for eight weeks; OT 3-6 times a week (no duration specified); PT (no frequency or duration of services identified); and CHHA 3-6 times a week for nine weeks. Documentation showed no SN visit were conducted (17 visits ordered, no visits conducted); no OT visit were conducted, (3-6 times a week (no duration specified) ordered, no visits conducted); no PT visits were conducted (no frequency or duration of services identified, no visits conducted); and no CHHA visits were conducted, (3-6 times a week for nine weeks ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 10/23/24 from 2:25 p.m., Staff A stated SN, OT, PT and CHHA should have conducted visits as ordered in the POC for patient # 5.”

“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: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar year 2023 and 01/01/24 to 10/22/24. On 10/23/24 at 3:20 p.m., Staff A stated administrative QA record documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency for calendar year 2023 and 01/01/24 to 10/22/24.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure certified home health aide supervisory visits were completed every 14 days for one (Patient #1) of nine patients. Findings: Patient #1 A review of the POC dated 09/23/24 to 11/21/24 showed orders for showed a CHHA visit frequency of three times a week for eight weeks, then one week one. A review of the clinical record showed CHHA supervisory visits were completed on 09/18/24 and showed no further documentation of aide supervision from 09/19/24 to 10/22/24 (date of clinical record review, 20 days). Documentation showed no patient refusal of supervisory visits, physician notification and no change in orders. On 10/23/24 at 2:25 p.m., Staff A stated the CHHA supervisory visits for patient #1 should be conducted every 14 days due on 10/02/24 and again on 10/16/24.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit note documentation was completed for one (Patient #4) of nine patients. Findings: Patient #4 A review of the clinical record showed SN visit was conducted on 01/23/24. Documentation showed no SN visit note documented for 01/23/24. Documentation showed no communications of why the SN visit was not documented and showed no communication to the physician provider for a missed visit or patient/caregiver refusal of visit. On 10/23/24 at 2:15 p.m., Staff A stated there was no SN visit note documented for 01/23/24 and no communication to the physician provider for a missed visit or patient/caregiver refusal of visit.”

“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 skilled professional service visit note documentation was completed for one (Patient #3) of nine patients. Findings: Patient #3 A review of the POC dated 07/08/24 to 10/11/24 showed orders for SN to conduct wound care (Wound Vac management) two times a week. Documentation showed SN visit notes from 07/08/24 to 08/22/24 documented no wound care. On 10/23/24 at 2:15 p.m., Staff A stated SN visit notes from 07/08/24 to 08/22/24 showed no wound care documentation for patient #3.”

“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 interview, the agency failed to ensure a completed transfer/discharge summary was provided for two (Patients #5 and #7) of nine patients. Findings: Patient #5 A review of the clinical record documented discharge from the agency on 08/23/23 for non-compliance. Documentation showed discharge summary was provided to the physician on 09/05/23 (12 days after discharge). On 10/23/24 at 2:25 p.m., Staff A stated the discharge summary for patient #5 was sent to the physician and returned with the physician’s signature on 10/01/24 (44 days after discharge). Patient #7 A review of the clinical record documented transferred to in-patient hospital services on 02/16/24. Documentation showed no transfer summary was provided to the in-patient hospital service provider. On 10/23/24 at 2:25 p.m., Staff A stated no transfer summary for patient #7 was provided to the in-patient hospital service provider.”