Visiting Nurse Group, Inc.

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on a review of clinical records (CR), the home health agency’s (HHA) emergency preparedness documents, and an interview with the administrator and supervising registered nurse (SRN), the HHA failed to provide evidence that an individualized emergency preparedness plan was included in the comprehensive assessment and/or documented in the clinical record for seven (7) of seven (7) CR’s reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CF#7. Findings include: The HHA’s Emergency Management Plan reviewed on October 22, 2024 at 3 PM reads in part, “Those patients who must have home visits performed will be considered as top priority patients and every effort will be made by staff to perform home visits during the emergency. At the time of admission, each patient’s acuity level is determined. Level I patients are high priority patients and include patients who require daily or more frequent skilled nursing visits. Visiting Nurse Group will maintain a list of patients acuity established. The list will be updated weekly.” The HHA’s Emergency Preparedness Program (EPP) included a document titled, “Emergency Preparedness Packet for Home Health Agencies” which was written by The National Association for Home Care and Hospice. The document, reviewed on October 22, 2024 at 3:15 PM was a template document which contained the following priority classifications: Level 1 - High Priority (defined as patients needing uninterrupted services); Level 2 - Moderate Priority (defined as services which may be postponed with telephone contact); Level 3 - Low Priority (defined as stable patients with access to informal resources to help); and Level 4 - Lowest Priority (defined as visits that may be postponed 72 hours or more with little or no adverse effects).” A review of the active patient list (HHA’s patient roster) conducted on October 22, 2024 at 2:45 PM found that the roster contained a column to document the “acuity levels” of each patient, which ranged from 1 to 4. In an interview held with the clinical director (ICD) on October 23, 2024 at 10:00 AM, it was unclear as to the method used to classify the priority level of the patients despite the information contained in the EPP program as noted above, and who was responsible for classifying the patients. A review of CR’s was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC) and Certification Period (CP) are indicated below. CR#1 SOC 03/29/2016, CP 08/14/2024 to 10/12/2024. The Plan of Care (POC) included skilled nursing (SN) services twenty-four (24) hours per day on Saturday, Sunday and Monday, and twelve (12) hours per day on Tuesday, Wednesday, Thursday and Friday. The patient also had home health aide (aide) services (frequency unknown). The patient was completely dependent, non-verbal, and had tracheostomy and gastrostomy tubes as evidenced by a home visit conducted on October 21, 2024 at 1 PM. There was no documentation in the completed nursing assessments and/or the clinical record of the priority level/triage classification of the patient. The HHA’s roster contained an acuity level of 4 for the patient which appeared to be incongruent with the status and subsequent needs of the patient in an actual or potential disaster/hazardous situation. It was unclear as to who determined the triage classification and how it was determined. CR#2 SOC 12/31/2016, CP 09/02/2024 to 10/31/2024. The POC included SN services 24 hours/day Monday through Friday and on weekends when dad is working, and 16 hours/day pm weekends when dad is not working. The patient was completely dependent, non-verbal, and had tracheostomy and gastrostomy tubes as evidenced by a home visit conducted on October 22, 2024 at 9:10 AM. There was no documentation in the completed nursing assessments and/or clinical record of the priority level/triage classification of the patient. The HHA’s roster contained an acuity level of 3 for the patient which appeared to be incongruent with the status and subsequent needs of the patient in an actual or potential disaster/hazardous situation. It was unclear as to who determined the triage classification and how it was determined. CR#3 SOC 01/03/2015, CP 08/14/2024 to 10/12/2024. The POC included SN services 24 hours/day, 7 days per week, and aide services 8 hours/day, 3 days/week. The patient was completely dependent, non-verbal, and had a gastrostomy tube as evidenced by a home visit conducted on October 22, 2024 at 10:15 AM. There was no documentation in the completed nursing assessments and/or clinical record of the priority level/triage classification of the patient. The HHA’s roster contained an acuity level of 2 for the patient. It was unclear as to who determined the triage classification and how it was determined. CR#4 SOC 03/04/2024, CP 03/04/2024 to 05/02/2024, Discharge (DC) 03/22/2024. The POC included SN services 10 hours/day, 5 days per week. There was no documentation in the completed nursing assessment and/or clinical record of the priority level/triage classification of the patient. CR#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024, Discharge (DC) 07/26/2024. The POC included SN services 6 hours/day, Monday, Thursday, and Friday, and 16 hours/day Tuesday and Wednesday. There was no documentation in the completed nursing assessments and/or clinical record of the priority level/triage classification of the patient. CR#6 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024. The POC included SN services 18 hours/day Monday through Friday, and 8 hours overnight Saturday and Sunday. There was no documentation in the completed nursing assessment and/or clinical record of the priority level/triage classification of the patient. The HHA’s roster contained an acuity level of 2 for the patient. It was unclear as to who determined the triage classification and how it was determined. CR#7 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024. The POC included SN services 9 hours/day Monday through Friday during the day, and 10 hours per night, 7 days per week. There was no documentation in the completed nursing assessment and/or clinical record of the priority level/triage classification of the patient. The HHA’s roster contained an acuity level of 2 for the patient. It was unclear as to who determined the triage classification and how it was determined. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“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 a review of the home health agency’s (HHA) emergency preparedness plan and documents, and an interview with the administrator, the HHA failed to conduct testing of the emergency preparedness plan annually. Findings include: The HHA’s Emergency Preparedness Plan (EPP) reviewed on October 22, 2024 at approximately 3 PM reads in part, “The plan will be tested and evaluated annually, either in response to an actual emergency or in a planned exercise.” A review of the HHA’s EPP found that the plan was last tested on 10/08/2021. There was no evidence of annual testing of the EPP in 2022 or 2023. An interview conducted with the administrator, clinical director, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on a review of clinical records (CR), the home health agency’s (HHA) admission packet, and an interview with the administrator, the HHA failed to provide the criteria for transfer and discharge of patients from the HHA for seven (7) of seven (7) records reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: The HHA’s Patient Admission Packet reviewed on October 21, 2024 at 10:00 AM, which contained a template of a document titled “Home Health Patient Rights,” included information that a patient could be discharged or transferred at patient request, or if the agency could no longer meet the needs of the patients, but the agency failed to include additional information that a patient could be discharged from the HHA when goals are met, when there is no longer a payment source, and for cause. A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 03/29/2026, CP 08/14/2024 to 10/12/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CR#2 SOC 12/31/2026, CP 09/02/2024 to 10/31/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CR#3 SOC 01/03/2015, CP 08/14/2024 to 10/12/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CR#4 SOC 03/04/2024, CP 03/04/2024 to 05/02/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CR#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CR#6 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. CF#7 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024 did not contain evidence that the patient received information that discharge could occur under the following circumstances: when goals were met, when there was no longer a payment source, and for cause. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on a review of clinical records (CR), home health agency (HHA) admission documents, and an interview with the administrator, the HHA failed to provide the patient with the names, addresses and telephone numbers of federally-funded and state-funded entities that service the area where the patient resides for seven (7) of seven (7) CR’s reviewed; CR#1, CR#2, CR#3, CR#4, CR#5, CF#6, and CR#7. Findings include: The HHA’s Patient Admission Packet reviewed on October 21, 2024 at 10:00 AM did not contain the names, addresses and telephone numbers of the following federally funded and state-funded entities that service the area where the patient resides: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 03/29/2026, CP 08/14/2024 to 10/12/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#2 SOC 12/31/2026, CP 09/02/2024 to 10/31/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#3 SOC 01/03/2015, CP 08/14/2024 to 10/12/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#4 SOC 03/04/2024, CP 03/04/2024 to 05/02/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#6 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CF#7 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024 did not contain evidence that the patient received the names, addresses, and telephone numbers for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of clinical records (CR), the home health agency’s (HHA) policy, and an interview with the administrator and supervising registered nurse, the completion of the initial assessment was not evident within 48 hours of referral for two (2) of seven (7) records reviewed: CR#5 and CR#7. Findings include: The HHA’s Policy Admission/Readmission To Agency Services reviewed on October 21, 2024 at 11:00 AM states in part, “All patients are admitted by an RN within 24 to 48 hours of referral unless the referral source or patient requests a delay in initiation of service.” A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024 contained a referral date of 01/23/2024. The initial/comprehensive assessment was completed on 01/29/2024, six (6) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. CF#7 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024 contained a referral date of 08/29/2024. The initial/comprehensive assessment was completed on 09/09/2024, eleven (11) days after the referral date. There were no orders to otherwise indicate a physician-specific start of care date. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on a review of clinical records (CR), the home health agency’s (HHA) field nursing supervisor position description, and an interview with the administrator and supervising registered nurse, the HHA failed to ensure that a reassessment occurred within the last five (5) days of every sixty (60) day recertification period for three (3) of seven (7) CR’s reviewed: CR#1, CR#2, and CR#3. Findings include: The HHA’s Position Description for Field Nursing Supervisor reviewed on October 21, 2024 at 11:45 AM reads in part, “Reviews and corrects plan of care and ensures the submission in 5 days prior to re-certification date.” A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 03/29/2026, CP 08/14/2024 to 10/12/2024. The recertification assessment was not completed within 5 days prior to the start of the recertification period. The recertification period began 08/14/2024. The reassessment was not completed until 08/19/2024. CR#2 SOC 12/31/2026, CP 09/02/2024 to 10/31/2024. The recertification assessment was not completed within 5 days prior to the start of the recertification period. The recertification period began 09/02/2024. The reassessment was not completed until 09/17/2024 CR#3 SOC 01/03/2015, CP 08/14/2024 to 10/12/2024. The recertification assessment was not completed within 5 days prior to the start of the recertification period. The recertification period began 08/14/2024. The reassessment was not completed until 08/21/2024. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency (HHA) policy, and an interview with the administrator and supervising registered nurse, the home health agency failed to ensure that the plan of care (POC) included the duration of visits to be made for seven (7) of seven (7) CR’s reviewed: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: The HHA’s Policy Plan of Care - CMS#485 and Physician Orders reviewed on October 22, 2024 at 2:00 PM reads in part, “The Plan of Care includes....frequency of visits and duration.” A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#1 SOC 03/29/2026, CP 08/14/2024 to 10/12/2024 contained a plan of care (POC) that included physician orders for skilled nursing (SN) 24 hours/day Saturday, Sunday and Monday, and 12 hours/day Tuesday through Friday. There was no duration of service indicated in the order. The patient was also receiving home health aide (aide) services as evidenced 1) by a home visit whereby an aide was present during the visit, and 2) a physician’s order stating supervision every 14 days of the aide by the SN. However, there were no orders pertaining to the frequency or duration of aide visits. CR#2 SOC 12/31/2026, CP 09/02/2024 to 10/31/2024 contained a POC that included physician orders for SN 24 hours/day Monday through Friday and on weekends when dad is working, and 16 hours/day on weekends when dad is not working. There was no duration of service indicated in the order. CR#3 SOC 01/03/2015, CP 08/14/2024 to 10/12/2024 contained a POC that included physician orders for SN 24 hours/day, 7 days/week, and aide services 8 hours/day, 3 days per week. There was no duration of service indicated in the order for SN or aide services. CR#4 SOC 03/04/2024, CP 03/04/2024 to 05/02/2024 contained a POC that included physician orders for SN 10 hours/day, 5 days per week. There was no duration of service indicated in the order. CR#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024 contained a POC that included physician orders for SN 6 hours/day Monday, Thursday, and Friday, and 16 hours/day Tuesday and Wednesday. There was no duration of service indicated in the order. CR#6 SOC 09/09/2024, CP 09/09/2024 to 11/07/2024 contained a POC that included physician orders for SN 18 hours/day Monday through Friday during the day, and 8 hours/day overnight Saturday and Sunday. There was no duration of service indicated in the order. CF#7 SOC 09/12/2024, CP 09/12/2024 to 11/10/2024 contained a POC that included physician orders for SN 9 hours/day Monday through Friday, and 10 hours/night, 7 nights per week. There was no duration of service indicated in the order. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of personnel files (PF), home health agency policies, the CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, and an interview with the administrator, the agency failed to ensure that competency and performance evaluations and tuberculosis education were completed annually and emergency preparedness training was conducted every two (2) years for one (1) of seven (7) PF’s reviewed: PF#7, and failed to provide evidence of tuberculosis screening for one (1) of seven (7) PF’s reviewed: PF#3. Findings include: The HHA’s Policy Competency Assessment Program reviewed on October 22, 2024 at 3:30 PM reads in part, “The agency will assess the competency of each clinical employee during the orientation process and at least on an annual basis.” The HHA’s Policy Performance Evaluation reviewed on October 22, 2024 at 3:15 PM reads in part, “Annual performance evaluations will be conducted for all staff.” The Centers for Disease Control and Prevention (CDC) and the National TB (Tuberculosis) Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019 which were reviewed on October 18, 2024 at 4 PM. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19). A review of personnel files (PF) was conducted on October 22, 2024 starting at 1:10 PM. The date of hire (DOH) is indicated below. PF#3 DOH 08/28/2023 contained a document signed by a physician on 08/19/2022 stating that a “PPD” (TB test) on 08/19/2022 was negative. There was a second internal HHA document in the PF, dated 10/18/2024, which stated “Date of most recent TB Skin Test 06/30/2023.” There were no TB results contained in the PF. PF#7 DOH 12/26/2017 contained no evidence that competency evaluations, performance evaluations, and TB education were completed annually. There was no evidence of emergency preparedness training every two years since 2018. The last noted date of EP training was 09/16/2018. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”

“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 a review of clinical records (CR), home health agency policy, position description for field nursing supervisor, and an interview with the administrator and supervising registered nurse, the agency failed to complete a discharge summary for two (2) of two (2) discharged CR’s reviewed: CR#4 and CR#5. Findings include: The HHA’s Policy Discharge From Agency Services reviewed on October 21, 2024 at 11:30 AM reads in part, “A copy of the discharge summary is sent to the physician’s office.” The HHA’s RN Field Nursing Supervisor position description reviewed on October 21, 2024 at 11: 45 AM states in part, “Discharges chart and completes documentation in 48-72 hour period.” A review of CR’s clinical records (CR) was conducted on October 21, 2024 starting at 11:00 AM, and continued at various times on October 22, 2024. The Start of Care (SOC), and Certification Period (CP) are indicated below. CR#4 SOC 03/04/2024, CP 06/02/2024 contained a discharge date of 03/22/2024. There was no evidence that a discharge summary was completed and sent to the physician. CF#5 SOC 01/29/2024, CP 05/28/2024 to 07/26/2024 contained a discharge date of 07/26/2024. There was no evidence that a discharge summary was completed and sent to the physician. An interview conducted with the administrator, supervising registered nurse, and clinical coordinator on October 23, 2024 starting at 12:30 PM confirmed the above findings.”