Prospect Chartercare Home Health and Hospice, LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to accept patients for treatment on the reasonable expectation that the agency can meet the patient’s nursing needs in his or her place of residence and furnish services in accordance with accepted standards of practice for 1 of 1 client reviewed related to staffing not being available to complete required visits, Client ID #8. Findings are as follows: Record review for Client ID #8 revealed a Start of Care (SOC) of 11/12/2023. Review of the certification period 11/12/2023 through 1/10/2024, includes orders for skilled nursing 8 as needed visits with a start date of 1/11/2024 and twice weekly visits for 8 weeks beginning during the week of 1/14/2024. Review of the client’s visits for the week of 2/25/2024 through 3/2/2024 revealed 1 missed skilled nursing visit on 3/1/2024. Review of a skilled nursing visit note dated 3/1/2024 signed by Registered Nurse, Staff A, revealed in part, “[Registered Nurse] missed visit…No visit due to staffing issue.” During a surveyor interview on 3/6/2024 at approximately 3:40 PM with the Clinical Nurse Manager during record reviews, she acknowledged that the visit was not made due to lack of nursing staff to complete the visit.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to include all professional services as required, relative to Medical Social Work services as specified in §409.45 of this chapter. Findings are as follows: A review of the agency’s Admission Home Health Booklet, on page 4 under “Services” it lists, the services provided by the home care agency as follows: physical therapy, occupational therapy, speech-therapy, nutritional support, Medical social services (including psychosocial for patients and families), certified nursing assistants and Skilled Nursing. Record review of a staff listing provided by the agency revealed no Social Worker on staff or under contract if needed by the clients. During an interview with the Clinical Nurse Manager, Staff F, on 3/7/2024 she informed the surveyor that they do not have a Social Worker on staff, or under contract. She was unable to provide evidence that social services are available should the physician order these services.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to develop and maintain an emergency preparedness plan that must be reviewed and updated at least every 2 years. Findings are as follows: Record review on 3/6/2024 at approximately 2:00 PM of the Agency provided emergency preparedness plan document titled “Emergency Operations Plan” identified the plan was last revised on 5/1/2021. During a surveyor interview with the Assistant Clinical Nurse Manager on 3/6/2024 at approximately 2:30 PM she acknowledged that the last revision date documented on the plan was 5/1/2021. She failed to provide evidence that the plan was reviewed and updated at least every 2 years.”

“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 record review and staff interview it has been determined that the facility failed to ensure individualized emergency plans for each client, are included as part of the comprehensive assessment, and a copy of the individualized emergency plan is in the clients file for 13 of 13 records reviewed, Client ID #s 1,2,3,4,5,6,7,8,9,10,11,12 and 13 as well as a copy given to the client and/or their caregiver for 5 of 6 home visits observed, Client ID #s 2,3,4,6 and 8. Findings are as follows: Review of the clinical record for Client ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 in the presence of Staff F, or Staff E, failed to reveal evidence of individualized emergency plans related to natural or man-made disasters as part of the comprehensive assessments. Surveyor observations during home visits revealed the following: 1) Review of the home record for Client ID # 2, during a home visit on 3/4/2024, revealed the client was admitted with a start of care date of 2/18/2024. Review of the agency admission folder failed to reveal an individualized emergency plan for the client. 2) Review of the home record for Client ID # 3, during a home visit on 3/5/2024, revealed the client was admitted with a start of care date of 1/8/2024. Review of the agency admission folder failed to reveal an individualized emergency plan for the client. 3) Review of the home record for Client ID # 4, during a home visit on 3/5/2024, revealed the client was admitted with a start of care date of 7/22/2021. Review of the agency admission folder failed to reveal an individualized emergency plan for the client. 4) Review of the home record for Client ID # 6, during a home visit on 3/4/2024, revealed the client was admitted with a start of care date of 2/10/2024. Review of the agency admission folder failed to reveal an individualized emergency plan for the client. 5) Review of the home record for Client ID # 8, during a home visit on 3/6/2024, revealed the client was admitted with a start of care date of 11/12/2023. Review of the agency admission folder failed to reveal an individualized emergency plan for the client. During a surveyor interview on 3/6/2024 at approximately 2:30 PM with Staff E and Staff F, they were unable to provide evidence that an individual emergency plan was included as part of the comprehensive assessment for each patient. They further revealed that the clients are given a triage code which identifies during what time period the client must be contacted during an emergency; Level 1- within 24 hours, Level 2- within 24-48 hours, Level 3- within 48-72 hours. They were unable to provide evidence that an individualized emergency plan is part of the client’s comprehensive assessment.”

“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 record review and staff interview it has been determined that the facility failed to establish and maintain a training program that includes initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and consistent with their expected roles. Findings are as follows: A review of the Emergency Preparedness documentation revealed no evidence the agency provided training to new and existing staff in emergency preparedness policies and procedures. During a surveyor interview with the Assistant Clinical Nurse Manager and Clinical Manager on 3/6/2024 at approximately 2:30 PM, they could not provide evidence of staff training on the emergency preparedness program.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the home health agency failed to conduct exercises to test the emergency plan annually, participate in a full-scale exercise that is community-based or conduct a facility-based functional exercise. Findings are as follows: Record review of the facility binder titled “…Home Health Emergency Management” revealed one exercise dated 2/12/2024 titled “Emergency Preparedness Plan for Winter Storm” The binder failed to reveal any exercises to test the emergency plan in 2023. During an interview on 3/6/2024 at approximately 2:00 PM, with the Assistant Clinical Nurse Manager and the Clinical Manager they could not provide evidence that the home health agency had completed all required exercises to test the emergency plan.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to ensure that services are written in an individual plan of care which is established, reviewed, and signed by a doctor for 2 of 13 clients reviewed, Client ID #s 1 and 3, Findings are as follows: 1) Record review for Client ID #1 revealed a start of care dated 2/27/2024 and an initial certification dated 2/27/2024 to 4/26/2024, that was not signed by the physician as required. During a surveyor interview with the Assistant Clinical Nurse Manager on 3/6/2024 at approximately 9:00AM she acknowledged that the above plan of care was not signed by the physician. She was unable to provide evidence that the physician had reviewed and signed the plan of care as required. 2) Record review for Client ID #3 revealed a start of care dated 1/8/2024 and an initial certification dated 1/8/2024 to 3/7/2024, that was not signed by the physician as required. During a surveyor interview with Assistant Clinical Nurse Manager on 3/6/2024 at approximately 8:20 AM, she acknowledged that the above plan of care was not signed by the physician. She was unable to provide evidence that the physician had reviewed and signed the plan of care as required.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and staff interview it was determined the agency failed to maintain a coordinated agency-wide program for the surveillance, investigation, identification, prevention, and control of infectious and communicable diseases as an integral part of the QAPI program. Findings are as follows: Review of the information provided to the surveyor for Quality Assurance Performance Improvement, revealed a policy titled “Quality Assurance Performance Improvement” last reviewed in November of 2022. The policy states in part: “B. Quality Assurance Performance Improvement Activities are ongoing and include: 1. conduct chart audits as identified in the plan 2. identify learning needs and plan education of staff...” During surveyor interview with the Clinical Nurse Manager on 3/7/2024 at approximately 11:15 AM, she stated that the agency did not have a performance improvement plan and was unable to produce evidence that that the policy was reviewed or revised since November of 2022. Additionally, she was unable to produce evidence that the agency had conducted chart audits, identified learning needs, and developed a plan for education to staff as identified in the policy.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and staff interview it has been determined the agency failed to ensure the patient’s clinical record identified all medications that the patient is taking (both prescription and non-prescription) as well as the time of medication administration and route for 5 of 6 clients who received a surveyor home visit, ID#’s 3, 4, 6, 7 and 8. Findings are as follows: Review of the agencies policy titled “Medication Management E 1” states in part; “...Assess and evaluate for medication changes with every patient at every visit... Document the assessment and the patient and/or caregiver education regarding the new medications(s)... Follow up with the physician regarding medication or treatment regimen changes as needed....” 1) Review of the medications during a home visit with Registered Nurse, Staff B, on 3/5/2024 at approximately 8:00 AM, revealed that Client ID #3 had a start of care date of 1/8/2024. Client ID #3 stated that s/he has been taking Melatonin 3 mg (milligrams) 3 tablets at bedtime to help him/her sleep for about a month and takes an albuterol inhaler 90 mcg (micrograms) 2 puffs 4 times per day for a long time. Review of the bottle of melatonin revealed that it was nearly empty, and review of the Albuterol inhaler revealed a filled by pharmacy date of 4/5/2023. Review of the facility provided current list of medications and the list in the client’s home failed to reveal a melatonin or Albuterol inhaler order. During a surveyor interview on 3/5/2024 at approximately 8:00 AM, Registered Nurse, Staff B acknowledged that the medications were not present on the client’s medication list. During a surveyor interview on 3/6/2024 at approximately 8:30 AM with Assistant Clinical Nurse Manager, Staff E, she could not provide evidence that the resident’s medications had been reconciled. 2) Review of the medications during a home visit with the nurse, Staff B, on 3/5/2024 at approximately 9:00 AM, revealed that Client ID # 4, with a start of care date of 7/22/2021 revealed the following list of medications that the client is currently taking, including but not limited to the following: Baclofen 10 mg oral tablets take 1 tablet 5 times a day dated 11/9/2023. Magnesium citrate 100 mg oral tablets take 2 tablets daily. Bisacodyl 10 mg rectal suppository; Administer 1 rectally once a day as needed. During a review of the medications in the home, the client’s caretaker stated they were discontinued. The caretaker further revealed that the Baclofen 10 mg is taken 5 times daily and also taking 20 mg at bedtime. During a surveyor interview with the Nurse, Staff B at the time of the visit she was unaware of the above discrepancies. 3) Review of the medications during a home visit with the nurse, Staff A, on 3/5/2024 at approximately 2:00 PM, revealed that Client ID # 6, with a start of care date of 2/10/2024 had the following list of medications that the client is currently taking, including but not limited to the following: cetirizine 10 mg capsule take one capsule once a day. naproxen 500 mg tablet, take one tablet twice a day as needed for pain. gabapentin 400 mg capsule take one 3 times a day. oxycodone 5 mg capsule take 1 capsule every 6 hours as needed for pain. During a surveyor interview with the client at the time of the home visit, s/he did not have the cetirizine, naproxen, oxycodone or gabapentin in the home, s/he stated that they had run out. The client also has benztropine 0.5 mg tablets which s/he is taking 1 to 2 times a day as needed for anxiety. This medication is not on the medication list or plan of care. During a surveyor interview with the nurse, Staff A at the time of the visit, he was unaware of the above medication discrepancies. 4) Review of the medications during a home visit with Registered Nurse, Staff B, on 3/6/2024 at approximately 9:30 AM, revealed that Client ID #7’s had a start of care date of 10/26/2022. The medication profile had the following list of medications that the client is currently taking, including but not limited to the following: Advair Diskus 100mcg- 50 mcg inhalation powder, 1 inhale 2 times a day. Spironolactone 50 mg 1 tablet once daily Surveyor observation of the medication with Staff B and Client ID #7 during the home visit on 3/6/2024 revealed the following: The Client stated that s/he had been off the Spironolactone for “a long time.” The Client also had a Ventolin 90mcg inhaler that was filled by the pharmacy on 1/4/2024 which the client stated s/he has been taking for many years as needed, this medication was not present on the client’s medication list. Additionally, the client’s Advair dosage was 250 mcg-50 mcg, and this was filled by the pharmacy on 12/27/2023. During a surveyor interview on 3/6/2024 at approximately 10:00 AM Staff A acknowledged the discrepancies between the client’s medication list and the medications the client was taking currently. 5) Review of the medications during a home visit with the nurse, Staff A, on 3/6/2024 at approximately 9:45 AM, revealed that Client ID # 8, with a start of care date of 1/7/2024 had the following list of medications that the client is currently taking, including but not limited to the following: Vitamin B-12 1000 mcg/ml injectable once a month without indication of when it is given or when it is due for administration. tramadol 50 mg tablet take 1 tablet once a day one hour prior to dressing change on left foot. Santyl 250 units topical ointment apply once a day to left foot wound. During surveyor interview with the client and spouse at the time of the home visit the Santyl has been discontinued since 2/12/2024, the tramadol 50mg is not taken prior to the dressing change but as needed, and the vitamin B-12 has no information regarding when it was last administered or when the next scheduled dose should be administered. Additionally, the client has a bottle of oxycodone that was filled on 1/23/2024 and states take one every 6 hours as needed for pain. This medication is not present on the client’s medication list. During surveyor interview with the nurse Staff A, during the home visit he was unaware of the above medication discrepancies.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to ensure that Drugs, services, and treatments are administered only as ordered by a physician for 5 of 6 clients who were observed during home visits, Client’s ID #’s 3, 4, 6, 7 and 8. Findings are as follows: 1. Review of the record for Client ID #3, revealed a start of care date of 1/8/2024. Review of the medications during a home visit with Registered Nurse, Staff B, on 3/5/2024 revealed the following: -Melatonin 3 mg (milligrams) 3 tablets at bedtime. The client stated s/he had been taking for approximately “1 month” for sleep. -Albuterol inhaler 90 mcg (micrograms) 2 puffs 4 times per day. The client stated s/he had been taking this for “a long time.” Review of the Albuterol inhaler revealed it had been last filled by the pharmacy on 4/5/2023. Review of the facility provided list of medications failed to reveal a physician’s order for the Melatonin or Albuterol inhaler which the client reports s/he is currently taking. Additionally, the list in the client’s home failed to identify these medications. During a surveyor interview on 3/5/2024 at approximately 8:00 AM, Registered Nurse, Staff B was unable to produce evidence of a physician’s order for the above medications. 2. Review of the record for Client ID #4, who has a start of care date of 7/22/2021. Review of the medications during a home visit with Registered Nurse, Staff B, on 3/5/2024 revealed the following: Baclofen 10 mg oral tablets take 1 tablet 5 times a day, started on 11/9/2023. Magnesium citrate 100 mg oral tablets take 2 tablets daily, started on 7/12/2023. Bisacodyl 10 mg rectal suppository; administer 1 rectally once a day as needed, started on 5/4/2022. During a review of the medications while in the home, the client’s caretaker stated that the Bisacodyl suppository and the Magnesium citrate had been discontinued. Additionally, the caretaker informed that the Baclofen 10 mg is taken 5 times a day, plus 20 mg at bedtime. During a surveyor interview with the Nurse, Staff B on 3/5/2024 at approximately 10:30 AM, she was unable to produce evidence that the physicians’ orders were being followed relative to the above medications. 3. Review of the record for Client ID #6, who has a start of care date of 2/10/2024, revealed the following medication orders: Cetirizine 10 mg capsule take one capsule once a day, started on 2/10/2024. Naproxen 500 mg tablet, take one tablet twice a day as needed for pain started on 2/10/2024. Gabapentin 400 mg capsule take one 3 times a day started on 2/20/2024. Oxycodone 5 mg capsule take 1 capsule every 6 hours as needed for pain started on 2/26/2024. During a surveyor interview with the client at the time of the home visit, s/he did not have the Cetirizine, Naproxen, Oxycodone or Gabapentin in the home. The client also has Benztropine 0.5 mg tablets, dated 1/29/2024 which s/he is taking 1 to 2 times a day as needed for anxiety. This medication was not present on the medication list or plan of care. During a surveyor interview with the Nurse, Staff A on 3/4/2024 at approximately 2:30 PM he was unable to produce evidence that the physician’s orders were being followed relative to the above medications. 4. Review of the record for Client ID #7, who has a start of care date of 10/26/2022. The client had the following current medication orders; Advair Diskus 100mcg-50 mcg inhalation powder, 1 inhale 2 times a day. Spironolactone 50 mg 1 tablet once daily started on 10/26/2022. During observation of the medication with Staff B the client stated that s/he had been off the Spironolactone for “a long time.” The client had a Ventolin 90mcg inhaler that was filled by the pharmacy on 1/4/2024 (which the client stated s/he has been taking for many years), this medication was not present on the client’s medication list. Additionally, the client’s dosage of Advair noted in the home was 250-50 mcg filled by the pharmacy on 12/27/2023. During a surveyor interview on 3/6/2024 at approximately 10:00 AM, Nurse Staff B was unable to produce evidence that the physician’s orders were being followed relative to the above medications. 5. Review of the record for Client ID #8, revealed a start of care date of 1/7/2024. The client has the following current medication orders; Vitamin B-12 1000 mcg/ml injectable once a month dated 11/12/2023. Tramadol 50 mg tablet take 1 tablet once a day one hour prior to dressing change on left foot started on 11/22/2023. Santyl 250 units topical ointment apply once a day to left foot wound dated 1/23/2024. During surveyor interview on 3/6/2024 at approximately 10:00 AM with the client and his/her spouse, the tramadol 50mg is not taken prior to the dressing change but is reported as being taken as needed by the client, the Santyl has been discontinued since 2/12/2024, and the vitamin B-12 is reported as administered at the physician’s office, however there is no documentation of when it was last administered, or the next scheduled due date. Additionally, the client has a bottle of Oxycodone that was filled on 1/23/2024, which states take one every 6 hours as needed for pain. This medication was not on the client’s current medication list. During a surveyor interview with Nurse, Staff A on 3/6/2024 at approximately 10:30 AM he was unable to produce evidence that the physician’s orders were being followed relative to the above medications.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to conform with the physician orders for home health aide services, occupational therapy, physical therapy, and skilled nursing services for 6 of 13 client records reviewed, Client ID #s 3, 6, 8, 9, 10 and 12. Findings are as follows: 1) Record review for Client ID #3 revealed a SOC (start of care date) of 1/8/202, includes orders for Physical Therapy (PT) 2 as needed: PT to assess, start date 1/8/2024. Then PT once weekly times 1 week and 2 times weekly times 3 weeks beginning the week of 1/9/2024. Review of the client’s visits for the week of 1/28/2024 through 2/3/2024 revealed one missed physical therapy visit on 1/31/2024 with no evidence of notifying the physician. 2) Record review for Client ID #6 revealed a SOC of 2/10/2024. Review of the certification period 2/10/2024 through 4/9/2024, includes orders for Physical therapy to assess and evaluate 2/9/2024 through 2/22/2024, skilled nursing once weekly for 9 weeks with 3 as needed visits starting on 2/11/2024 and OT once a week for 3 weeks, 1 additional visit as needed with a start date of 2/25/2024. Review of the client’s visits from 2/9/2024 through 2/22/2024 reveal that the physical therapy evaluation was not completed. There was no evidence of notifying the physician. Review of the client’s visits from 2/11/2024 through 2/17/2024 revealed that no skilled nursing visit was completed. There was no evidence of notifying the physician. Review of the client’s visits from 2/25/2024 through 3/2/2024 revealed that no skilled nursing visit was completed. There was no evidence of notifying the physician. Review of the client’s visits from 2/25/2024 through 3/2/2024 revealed that no Occupational therapy visit was completed. There was no evidence of notifying the physician. 3) Record review for Client ID #8 revealed a SOC of 11/12/2023. Review of the certification period 11/12/2023 through 1/10/2024, includes orders for skilled nursing 8 as needed visits with a start date of 1/11/2024 and twice weekly visits for 8 weeks beginning during the week of 1/14/2024. Review of the client’s visits for the week of 1/14/2024 through 1/20/2024 revealed 1 missed skilled nursing visit on 1/17/2024 with no evidence of notifying the physician. Review of the client’s visits for the week of 2/18/2024 through 2/24/2024 revealed 1 missed skilled nursing visit on 2/21/2024 with no evidence of notifying the physician. Review of the client’s visits for the week of 2/25/2024 through 3/2/2024 revealed 1 missed skilled nursing visit on 3/1/2024. 4) Record review for Client ID #9 revealed a SOC of 2/12/2024. Review of the certification period 2/12/2024 through 4/11/2024, includes orders for Skilled nursing 3 as needed visits and skilled nursing once weekly for 1 week, twice weekly for 1 week, and once weekly for 3 weeks beginning the week of 2/13/2024. Orders for Physical therapy include 1 as needed visit and Physical therapy once weekly for 1 week, and twice weekly for 3 weeks beginning the week of 2/18/2024. Review of the client’s visits for the week of 2/18/2024 through 2/24/2024 revealed 1 missed skilled nursing visit on 2/20/2024 with no evidence of notifying the physician. Review of the client’s visits for the week of 2/25/2024 through 3/2/2024 revealed 1 missed physical therapy visit on 2/27/2024 with no evidence of notifying the physician. 5) Record review for Client ID #10 revealed a SOC of 8/29/2021. Review of the certification period 2/15/2024 through 4/14/2024, includes orders for Skilled Nursing 4 as needed and Skilled nursing once weekly times 8 weeks with a start date of 2/18/2024. Review of the client’s visits for the week of 2/25/2024 through 3/2/2024 revealed 1 missed skilled nursing visit on 2/28/2024 with no evidence of notifying the physician. 6) Record review for Client ID #12 revealed a SOC of 11/16/2023. Review of the certification period 11/16/2023 through 1/14/2024, includes orders for skilled nursing once weekly for 1 week, once weekly for 1 week, twice weekly for 6 weeks beginning during the week of 11/17/2023. Review of the client’s visits for the week of 12/3/2023 through 12/9/2023 revealed 1 missed skilled nursing visit on 12/3/2023 with no evidence of notifying the physician. Review of the client’s visits for the week of 12/10/2023 through 12/16/2023 revealed 1 missed skilled nursing visit on 12/10/2023 with no evidence of notifying the physician. Review of the client’s visits for the week of 12/17/2023 through 12/23/2023 revealed 1 missed skilled nursing visit on 12/17/2023 with no evidence of notifying the physician. Review of the client’s visits for the week of 12/24/2023 through 12/30/2023 revealed 1 missed skilled nursing visit on 12/24/2023 with no evidence of notifying the physician. Review of the client’s visits for the week of 12/31/2023 through 1/6/2024 revealed 1 missed skilled nursing visit on 12/31/2023 with no evidence of notifying the physician. During a surveyor interview on 3/6/2024 at approximately 1:00 PM with the Assistant Clinical Nurse Manager, Staff E she acknowledged that the physician was not notified of the missed visits. She further revealed that the physician is not notified of missed visits until the end of the certification period in which the visits are missed. During a surveyor interview on 3/6/2024 at 1:53 PM with the Utilization Review Coordinator, Staff G revealed that the physician is not notified of missed visits until the end of the certification period.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on record review and staff interview it has been determined that the agency failed to assure client needs are continually assessed for 1 of 6 clients who received surveyor home visits, Client ID # 4. Findings are as follows: Review of the record for Client ID # 4, reveals a start of care date of 7/22/2021, with a primary diagnosis of Multiple Sclerosis. The client has additional diagnoses including neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, osteoarthritis, disorder of the skin and subcutaneous tissue and a history of urinary tract infections. Review of the current Certification and Plan of Care for the period of 1/8/2024 through 3/7/2024, includes orders for skilled nursing services once a month for 3 months, and 4 as needed visits for foley catheter care. During surveyor interview with the client and spouse during a home visit on 3/5/2024 with Staff Nurse B, they offered multiple concerns relative to the patient’s care and needs. The surveyor observed the client transferring from the scooter to the bed with the use of a small slide board, with a great deal of difficulty. The client stated that his left side was “the affected one” but now his right leg is also not good”. The client stated s/he had to pull his legs with his arms to move onto the bed from the scooter. The client’s spouse stated that they had therapy in the past, but they have not seen the client in a long time. The spouse further stated s/he cannot lift his legs or reposition himself in the scooter. Record review reveals no evidence of a referral or re-evaluation for Physical Therapy service to address the decline in mobility and transfers. During surveyor interview at the time of the home visit with Staff Nurse B, she was unaware that the client can no longer use his legs and has difficulty in transferring from bed to scooter. During surveyor interview with the Clinical Nurse Manager on 3/7/2024 at approximately 11:15 AM, during a review of the home visit, she was unable to produce evidence that the client’s needs were continually assessed related to a possible decline in mobility.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and staff interview it was determined that the Home Health Agency failed to ensure that the clinical record was complete and accurate for 1 of 1 sample clients who have pressure wounds requiring treatments, Client ID #2. Findings are as follows: Review of the facility policy titled “Wound Care” revealed in part, “Wound measurements will be performed at the patient’s first visit of each week. Additional measurements may be performed as appropriate. Documentation of the wound measurements will include: Length Width Depth Undermining if present Tunneling if present…” Record review for Client ID # 2 revealed s/he has a start of care date of 2/18/2024 and has diagnoses including but not limited to, a stage 3 pressure ulcer (wound that has broken through the top two layers of the skin and into the fatty tissue) of the sacral region. A physician’s order for the certification period 2/18/2024 through 4/17/2024 revealed an order for the skilled nurse to perform wound care every 3 days. Additionally, the nurse is to assess pressure ulcer status including signs and symptoms of healing and complications. Review of the wound documentation in the patients record revealed missing documentation of weekly wound measurements during the week of 2/25/204 to 3/2/2024. During an interview with the Assistant Clinical Nurse Manager, Staff E, on 3/5/2024 at approximately 11:00 AM, she was unable to provide evidence that these weekly measurements were obtained per policy.”