Kindest Care Healthcare LLC

“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 a review of agency policy, and an interview with the administrator and director of nursing, the agency failed to provide documentation that a facility-based and community-based risk assessment was completed. Findings include: A review of the agency’s policy titled Emergency Preparedness Plan 6.1 conducted on December 13, 2023 at approximately 10:00 AM reads in part, “The agency has a risk assessment to identify the potential disasters from natural and man-made causes most likely to occur in the agency’s service area.” A review of the Emergency Preparedness Plan conducted on December 13, 2023 at 9:45 AM found no evidence of a hazard vulnerability analysis (HVA)/risk assessment completed at any time. An interview held with the administrator and director of nursing on December 13, 2023 starting at 3:45 PM confirmed the above findings.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on a review of personnel files (PF), agency policy, and an interview with the administrator and director of nursing, the agency failed to demonstrate that initial training in emergency preparedness (EP) policies and procedures was provided to newly hired employees for one (1) of nine (9) PF: PF#1, and that EP training was conducted at least every two (2) years for four (4) of nine (9) PF reviewed: PF#1, PF#2, PF#4, and PF#7. Findings Include: A review of the agency’s policy titled Emergency Preparedness – Training and Testing Plan conducted on December 13, 2023 at approximately 9:45 AM reads in part, “Initial training in emergency preparedness policies and procedures to all new and existing agency staff…the agency will endeavor to provide emergency preparedness training at least every 2 years….the agency shall maintain documentation of the training and shall demonstrate staff knowledge of emergency procedures.” A review of the agency’s policy titled Emergency Preparedness Plan 6.1 reads in part, “the agency must maintain documentation of compliance with emergency preparedness.” A review of personnel files (PF) was conducted on December 12, 2023 starting at 1:05 PM. The date of hire (DOH) is indicated below. PF#1 DOH 09/04/2020 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire or any time thereafter. PF#2 DOH 02/21/2014 did not contain evidence that training in emergency preparedness policies and procedures was conducted at least every 2 years. PF#4 DOH 11/05/2010 did not contain evidence that training in emergency preparedness policies and procedures was conducted at least every 2 years. PF#7 DOH 08/09/2007 did not contain evidence that training in emergency preparedness policies and procedures was conducted at least every 2 years. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 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 agency policy, the Emergency Preparedness documents provided by the agency, and an interview with the administrator and director of nursing, the agency failed to provide evidence that the emergency preparedness plan was tested annually. Findings Include: A review of the agency’s policy titled Emergency Preparedness – Training and Testing Plan conducted on December 13, 2023 at approximately 09:50 AM reads in part, “For the Emergency Preparedness Testing Plan, Kindest Care shall conduct exercises to test the Emergency Plan at least annually.” A review of the home health agency’s emergency preparedness documents on December 13, 2023 at approximately 10:00 AM did not contain any evidence that exercises to test the emergency preparedness plan were conducted annually. There was an exercise conducted on June 5, 2023, but no exercises prior to June 5, 2023. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 PM confirmed the above findings.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the administrator and director of nursing, the agency failed to provide care according to the Home Health Certification and Plan of Treatment (POC) for five (7) of seven (7) CR’s: CR#2, CR#3, CR#5, CR#6, and CR#7, and failed to ensure that the most current physician orders were clearly evident in the clinical record for two (2) of seven (7) CR’s: CR#2 and CR#7. Findings include: A review of the agency’s policy titled Patient Visits - Scheduling conducted on December 12, 2023 at approximately 1:00 PM reads in part, “each individual providing care and/or services to the patient should contact the Clinical Supervisor at least weekly to confirm that visits have been conducted as scheduled;” and “the physician is contacted whenever changes to the type and/or frequency of patient visits are required based on patient needs.” A review of clinical records was conducted on December 11, 2023 starting at approximately 11:00 AM. The start of care (SOC) and Certification Period (CP) are indicated below. CR#2 SOC 10/25/2023, CP 10/25/2023 to 12/23/2023 contained a CMS-485 Home Health Certification and Plan of Care (POC) dated 10/25/2023 with orders for Skilled Nursing (SN): one (1) day per week for nine (9) weeks, Physical Therapy (PT) two (2) days per week for 4 weeks, then one (1) day per week for two (2) weeks, and Occupational Therapy (OT) one (1) day per week for six (6) weeks. The POC orders were not timed. There is an additional, separate Physician Order also dated 10/25/2023 and timed 2:00 PM which contains orders for SN two (2) days per week for 2 weeks, then one (1) day per week for seven (7) weeks. The two sets of orders both dated 10/25/2023 are discrepant as it relates to the frequency of the skilled nursing visits. It is unclear as to which set of orders are the most current orders to be followed. There was a one (1) missed visit the week of 12/03/2023 for both PT and OT. There were no clinical or missed visit notes from either discipline for that week, nor any indication that the physician was notified of the missed visits. CR#3 SOC 09/25/2023, CP 11/24/2023 to 01/22/2024 contained a POC dated 11/22/2023 with recertification orders for PT one (1) day per week for nine (9) weeks and OT one (1) day per week for nine (9) weeks. There is an additional, separate Physician Order dated 11/22/2023 with recertification orders for PT one (1) day per week for nine (9) weeks and OT one (1) day per week for nine (9) weeks. During the week of 11/26/2023, there were two (2) PT visits (11/28/2023 and 11/30/2023). The PT Daily Note dated 11/28/2023 states, “patient will be treated one (1) to two (2) days per week for nine (9) weeks to improve the patient’s symptoms. There was no physician order present in the clinical record indicating that PT visits could be increased to 1 to 2 days per week. There was an OT missed visit the week of 11/26/2023. There was an OT missed visit note dated 11/27/2023 which stated, “patient has missed schedule visit due to SN has to complete a recert for patient before OT can continue.” Skilled nursing completed the recertification on 11/22/2023, two (2) days before the start of the new certification period, and five (5) days before the missed visit note stating that the recertification still needed to be completed. CR#5 SOC 07/31/2023, CP 07/31/2023 to 09/28/2023 contained a POC dated 07/31/2023 with orders for a home health aide (HHA) five (5) days per week for nine (9) weeks, PT two days per week for nine (9) weeks, and OT two (2) days per week for nine (9) weeks. For the week of 07/31/2023, there were three (3) missed HHA visits, one (1) missed PT visit, and two (2) missed OT visits. For the week of 08/06/2023, there was one (1) missed HHA visit and one (1) missed OT visit. For the week of 08/13/2023, there was one (1) missed HHA visit and two (2) missed OT visits. For the week of 09/03/2023, there was one (1) missed HHA visit and one (1) missed OT visit. For the week of 09/10/2023, there were three (3) missed HHA visits. For the week of 09/17/2023, there was one (1) missed HHA visit, and one (1) OT visit. There were no clinical or missed visit notes for any of the disciplines for the above referenced dates, nor was there any evidence that the physician was notified of the missed visits. CR#6 SOC 09/05/2023, CP 09/05/2023 to 11/03/2023 contained a POC dated 09/05/2023 with orders for a home health aide (HHA) three (3) days per week for nine (9) weeks. There were two (2) HHA missed visits during week 1. There were no HHA or missed visit notes present in the clinical record. CR#7 SOC 06/19/2023, CP 06/19/2023 to 08/17/2023 contained POC dated 06/19/2023 with orders for PT one (1) to three (3) days per week for nine (9) week and prn (as needed), and OT one day per week for nine (9) weeks. The POC orders were not timed. There is an additional, separate Physician Order also dated 06/19/2023 and timed 10:00 AM which contains orders for PT two (2) times per week for nine (9) weeks and prn, and OT two 2) days per week for nine (9) weeks and prn. The two sets of orders both dated 06/19/2023 are discrepant as it relates to the frequency of the physical therapy and occupational therapy visits. It is unclear as to which set of orders are the most current orders to be followed. There were no PT or OT visits during the weeks of 06/19/2023 and 06/25/2023. The initial PT evaluation was not completed until 07/03/2023, fourteen (14) days after the SOC. The initial OT evaluation was not completed until 07/06/2023, seventeen (17) days after the SOC. There were no clinical or missed visit notes from either discipline for the week of 06/19/2023 or 06/25/2023, nor any indication that the physician was notified of the missed visits. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 PM confirmed the above findings.”

“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 a review of the agency’s quality assessment and performance improvement (QAPI) program, and an interview with the administrator and director of nursing, the agency failed to demonstrate that at least one performance improvement project was either in development, on-going or completed each calendar year. Findings include: A review of QAPI documents conducted on December 12, 2023 at 3:00 PM and again on December 13, 2023 at 10:45 AM found no evidence that the agency identified and/or completed a performance improvement project annually. An interview with the administrator and director of nursing conducted on December 13, 2023 at 3:45 PM confirmed the above findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on a review of agency policy, personnel files (PF) and an interview with the administrator and director of nursing, the agency failed to provide Infection control education to staff at orientation and/or annually for four (4) of nine (9) PF: PF#1, PF#2, PF#4, and PF#7. Findings include: A review of the agency’s policy titled Infection Control Program (Reference #4001) conducted on December 12, 2023 at approximately 2:30 PM reads in part, “Infection control inservice education is provided to all Kindest Care Healthcare employees, including contracted personnel, during orientation and at least annual thereafter.” An interview was conducted with the administrator on December 13, 2023 at approximately 12:30 PM. The administrator stated that annual infection control education is provided by the director of nursing to personnel, but that specific documentation of annual infection control education is not maintained. A review of personnel files (PF) was conducted on December 12, 2023 starting at approximately 1:05 PM. The date of hire (DOH) is indicated below. PF#1 DOH 09/04/2020 did not contain evidence that infection control education was provided at the time of hire, nor annually. PF#2 DOH 02/21/2014 did not contain evidence that infection control education was provided annually. PF#4 DOH 11/05/2010 did not contain evidence that infection control education was provided annually. PF#7 DOH 08/09/2007 did not contain evidence that infection control education was provided annually. An interview conducted with the administrator and director of nursing starting at 3:45 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 home health agency documents, clinical records (CR) and an interview with the administrator, the agency failed to demonstrate that patients were 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 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: A review of the Patient Information Packet, which is provided by the home health agency to patients at the time of admission, was conducted on December 11, 2023 at approximately 11:00 AM. The Patient Information Packet did not contain 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. A review of clinical records was conducted on December 11, 2023 starting at approximately 11:00 AM. The start of care (SOC) and Certification Period (CP) are indicated below. CR#1 SOC 10/16/2023, CP 10/16/2023 to 12/14/2023 found no evidence that the patient received 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. CF#2 SOC 10/25/2023, CP 10/25/2023 to 12/23/2023 found no evidence that the patient received 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. CR#3 SOC 09/25/2023, CP 11/24/2023 to 01/22/2024 found no evidence that the patient received 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. CR#4 SOC 04/18/2023, CP 08/16/2023 to 10/14/2023 found no evidence that the patient received 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. CR#5 SOC 07/31/2023, CP 07/31/2023 to 09/28/2023 found no evidence that the patient received 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. CR#6 SOC 09/05/2023, CP 09/05/2023 to 11/03/2023 found no evidence that the patient received 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. CR#7 SOC 06/19/2023, CP 06/19/2023 to 08/17/2023 found no evidence that the patient received 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. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 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 agency policy, clinical records (CR) and an interview with the administrator and director of nursing, the agency failed to ensure that the initial assessment visit was held within 48 hours of the referral for one (1) of seven (7) CR’s reviewed: CR#7. Findings include: A review of the home health agency’s policy titled Assessment (Reference #2008) conducted on December 11, 2023 at 3:00 PM, states in part, “Admission assessments should be performed by a Registered Nurse within 48 hours of the time of the referral, or the patient’s return home, or the physician-ordered start of care date.” A review of clinical records was conducted on December 11, 2023 starting at approximately 11:00 AM. The start of care (SOC) and Certification Period (CP) are indicated below. CR#7 SOC 06/19/2023, CP 06/19/2023 to 08/17/2023 OASIS (Outcome and Assessment Information Set) Form contained a referral date of 06/16/2023. There was otherwise no physician-ordered start of care date. The initial assessment was completed on 06/19/2023, which is greater than forty-eight (48) hours after the referral date. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 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), the Medicare Benefit Policy Manual, and an interview with the administrator and director of nursing, the agency failed to ensure that the individualized plan of care (POC) included the frequency and duration of PRN (as needed) visits to be made for three (3) of seven (7) CR: CR#4, CR#6, and CR#7. Findings include: A review of the Medicare Benefit Policy Manual conducted on December 8, 2023 at approximately 2:00 PM reads in part, “The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services. Orders for services to be furnished “as needed” or “PRN” must be accompanied by a description of the patient’s medical signs and symptoms that would occasion a visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained.” A review of clinical records was conducted on December 11, 2023 starting at 11:00 AM. The start of care (SOC) and certification period (CP) are indicated below. CR#4 SOC 04/18/2023, CP 08/16/2023 to 10/14/2023 contained orders on the POC for Skilled Nursing (SN) two (2) days per week for nine (9) weeks, and PRN (as needed). There was no indication for a PRN visit, nor was there a specific limit on the number of visits to be made under the POC order. CR#6 SOC 09/05/2023, CP 09/05/2023 to 11/03/2023 contained orders on the POC for Physical Therapy (PT) two (2) days per week for nine (9) weeks, and PRN (as needed). There was no indication for a PRN visit, nor was there a specific limit on the number of visits to be made under the POC order. CR#7 SOC 06/19/2023, CP 06/19/2023 to 08/17/2023 contained orders on the POC for SN one (1) day per week for nine (9) weeks and PRN; PT one (1) to three (3) days per week for nine (9) weeks and PRN, and OT one (1) day per week for nine (9) weeks and PRN. There was an additional, separate Physician Order which contained orders for SN one (1) day per week for nine (9) weeks and PRN; PT two (2) times per week for nine (9) weeks and prn, and OT two (2) days per week for nine (9) weeks and prn. There was no indication on either set of orders for a PRN visit, nor was there a specific limit on the number of visits to be made under the POC order. An interview conducted with the administration and director of nursing on December 13, 2023 starting at 3:45 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), agency policies, the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, 29 CFR 1910,1030, the CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, and an interview with the administrator and director of nursing, the agency failed to demonstrate the presence of the following: screening for mycobacterium tuberculosis (TB) for one (1) of nine (9) PF: PF#1, completion of a TB symptom screen and risk assessment for two (2) of nine (9) PF: PF#8 and PF#9, and Hepatitis B Vaccination acceptance or declination for two (2) of nine (9) PF: PF#5, and PF#8. Findings include: 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 December 8, 2023 at approximately 2:00 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 Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Fact Sheet was conducted on December 8, 2023 at approximately 2:30 PM. The fact sheet reads in part, “Hepatitis B virus (HBV) is a pathogenic microorganism that can cause potentially life-threatening disease in humans. HBV infection is transmitted through exposure to blood and other potentially infectious materials (OPIM) as defined in the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030. Any workers who have reasonably anticipated contact with blood or OPIM during performance of their jobs are considered to have occupational exposure and to be at risk of being infected. An employer must develop an exposure control plan.... employers must make hepatitis B vaccination available to these workers.... employers must offer the vaccination series to all workers who have occupational exposure. Examples of workers who may have occupational exposure include, but are not limited to, healthcare workers...the vaccine must be offered at no cost to the worker and at a reasonable time and place.” A review of OSHA Bloodborne Pathogens Standard, 29 CFR 1910,1030 was conducted on December 8, 2023 at approximately 2:30 PM. Standard 1910.1030b defines Occupational Exposure as “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. Standard 19.10.1030(c)(1)(i) states “each employer having an employee(s) with occupational exposure shall establish a written Exposure Control Plan designed to eliminate or minimize employee exposure.” Section 1910.1030(f)(1)(i) states, “the employer shall make available the hepatitis B Vaccine and vaccination series to all employee who have occupational exposure.” Section 1910.1030(f)(1)(ii)(A) states, “made available at no cost to the employee.” Section 1910.1030(F)(1)(ii)(B) states, “made available to the employee at a reasonable time and place.” A review of the agency’s policy titled Tuberculosis Screening Program (Reference #4005) conducted on December 13, 2023 at approximately 10:00 AM reads in part, “It is the policy of Kindest Care Healthcare to screen all employees for the presence of inactive or active tuberculosis at the time of employment and at least annually thereafter.” A review of the agency’s policy titled Exposure Control Plan (Reference #4013) conducted on December 13, 2023 at approximately 10:15 AM reads in part, “Kindest Care has implemented a Hepatitis B Vaccination Program which is available at no cost to all personnel who have occupational exposure to the blood borne pathogens….Personnel who decline the vaccine are asked to sign a declination statement.” A review of the agency’s policy titled Contracted Services (Reference #6016) conducted on December 13, 2023 at approximately 10:30 AM reads in part, “Kindest Care Healthcare retains overall responsibility, accountability and authority for the care, treatment and/or services provided by contracted personnel/entities. All services provided by contracted arrangement, consultation or other agreements are delineated in writing and adhere to the applicable JCAHO (Joint Commission) standards and any applicable laws and regulations.” A review of personnel files (PF) was conducted on December 12, 2023 starting at approximately 1:05 PM. The date of hire (DOH) or orientation date for contracted personnel (ODCP) are indicated below. PF#1 DOH 09/04/2020 contained a tuberculin skin test (TST) that was administered on 02/13/2018. A second TST contained in the file was dated 11/15/2023. There was no evidence that a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), was completed upon hire. PF#5 DOH 0613/2022 contained no evidence of a Hepatitis B Vaccination acceptance or declination. PF#8 ODCP 03/28/2022 contained a tuberculosis symptom screening questionnaire and risk assessment form dated 03/02/2023, one year after the date of hire. In addition, the TB risk assessment section of the questionnaire was not completed. There was no Hepatitis B Vaccination acceptance or declination contained in the file. PF#9 ODCP 08/23/2023 contained a tuberculosis symptom screening questionnaire and risk assessment form dated 08/23/2023. The symptom screen portion of the form was only partially completed, and the risk assessment was not completed. An interview conducted with the administrator and director of nursing on December 13, 2023 starting at 3:45 PM confirmed the above findings.”