Precision Home Health Care

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview the agency failed to review and update the emergency preparedness plan at least every two years to evaluate its effectiveness for three (2022, 2023, and 2024) of three years reviewed. The failure placed the agency’s patients at risk of harm if the plan was not effective and the agency and its employees were not prepared to ensure patient safety if a disaster or emergency occurred in their service area. Findings include: In an interview on 02/03/2025 during the entrance conference with the Admin/DON at 10:25 a.m., the Admin/DON self-identified as the disaster coordinator. The Admin/DON identified (the Office Aide) as the alternate disaster coordinator. The surveyor provided an agency request list, which included a request for EP records. Review of the agency’s undated emergency preparedness and response plan binder did not reveal that the agency completed a review of the EP plan at least every two years to evaluate its effectiveness and to update the plan for 2022, 2023, and 2024. Continued review of agency’s undated EP binder revealed the following: An “Agency Emergency Preparedness Plan Evaluation.” Review of the plan evaluation revealed that the Admin/DON signed and dated the evaluation 12/15/2020. Further review of the EP binder did not reveal any EP plan reviews or evaluations after 12/15/2020. On 02/07/2025 during an interview with the Admin/DON at 3:25 p.m., the surveyor asked who at the agency was responsible for the agency’s emergency preparedness and response plan. The Admin stated that (the Admin) was responsible for the plan. The surveyor asked what the agency’s processes were for implementing the EP plan. The Admin stated that when there was “a situation or situation to be. We listen and when we become aware we call [the Office Aide/Alternate Disaster Coordinator]. We call the patients, call the staff to notify the patients. If needed, we call 911 for the patients. We do office drills (for the office staff).” The surveyor reviewed the findings and asked why the agency had not completed internal reviews of the EP plan at least annually to evaluate the plans effectiveness and to update the plan for 2022, 2023, and 2024. The Admin replied, “I don’t have an answer. An oversight.” The surveyor asked how the failure could adversely affect the agency’s clients. The Admin replied, “It would affect their health.” Review of agency policy titled; “Emergency Preparedness and Response Plan” dated 01/29/2020 read in part: “...Policy...Communication Plan: The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and Local laws and Must be reviewed and updated at least annually... The effectiveness of the Emergency Preparedness Plan and Response will be evaluated at least annually to evaluate its effectiveness, and after each actual emergency response. Results will be included in the Agency’s Annual program evaluation and updated as needed...””

“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 interview, the agency failed to maintain documentation of all emergency preparedness (EP) training, in that: No documentation was found of employees ongoing (at least every two years) emergency preparedness training in five (Admin/DON, Alt Admin/DON, LVN A, Office Aide, and HH aide A) of five personnel records reviewed (for review period 2022, 2023, and 2024). The failure placed the agency’s patients at risk of harm in the event of an actual emergency. The failure could limit the ability of the facility staff to respond with proper knowledge and actions prior to and in the event of actual emergency situations. Findings include: In an interview on 02/03/2025 during the entrance conference with the Admin/DON at 10:25 a.m., the Admin/DON self-identified as the disaster coordinator. The Admin/DON identified (the Office Aide) as the alternate disaster coordinator. The surveyor provided an agency request list, which included a request for EP records. Continued review of agency’s undated EP binder revealed the following: The last annual “Agency Emergency Preparedness Plan Evaluation” was signed and dated on 12/15/2020 by the Admin/DON. The last “Emergency Preparedness Drill/Report was dated 01/16/2024 and signed by the Admin/DON. Review of the drill report revealed that the staff who participated in the drill were office staff. Further review of the agency’s undated emergency preparedness and response plan binder did not reveal any documentation of employee training at least every two years (review period 2022, 2023, and 2023). Admin/DON: Hire date: 08.10.2004 was noted on staff list. Review of the Admin/DON’s personnel record revealed that it did not contain any record of training for the agency’s emergency preparedness and response plan for the years of 2022, 2023, and 2024. Alt Admin/DON: Hire date: 08.12.2004 was noted in personnel record. Review of the Alt Admin/DON’s personnel record revealed that it did not contain any record of training for the agency’s emergency preparedness and response plan for the years of 2022, 2023, and 2024. Office Aide: Hire date: 04/02/2018 was noted on staff list. Review of the Office Aide’s personnel record revealed that it did not contain any record of training for the agency’s emergency preparedness and response plan for the years of 2022, 2023, and 2024. LVN A: Hire date: 07/26/2018 was noted on staff list. Review of the LVN A’s personnel record revealed that it did not contain any record of training for the agency’s emergency preparedness and response plan for the years of 2022, 2023, and 2024. HH aide A: Date: 03/01/2011 was noted on staff list. Review of the HH aide A’s personnel record revealed that it did not contain any record of training for the agency’s emergency preparedness and response plan for the years of 2022, 2023, and 2024. On 02/07/2025 during an interview with the Admin/DON at 3:25 p.m., the surveyor reviewed the findings and asked who at the agency was responsible for the agency’s emergency preparedness and response plan. The Admin stated that (the Admin) was responsible for the plan. The surveyor asked what the agency’s processes were for implementing the EP employee training. The Admin stated that the agency does training with a few who came to the office. The surveyor asked why there was no documentation of the training. After reviewing the agency’s records, the Admin replied, “There is no documentation.” The surveyor asked how the failure could adversely affect the agency’s clients. The Admin replied, “It would affect their health.” Review of agency policy titled; “Emergency Preparedness and Response Plan” dated 01/29/2020 read in part: “...Policy...Communication Plan: The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and Local laws and Must be reviewed and updated at least annually…7 The Agency staff, including contractors, will be educated regarding their responsibilities in the agency’s Emergency Preparedness and Response Plan upon hire and annually thereafter…” Review of agency policy titled, “Personnel Records” dated 01/29/2020 read in part, “The Agency will adhere to federal and state laws and regulations when establishing and maintain personnel records to ensure accuracy, completeness...1. Personnel contents...Education attendance...””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure that all entries in the patients’ clinical records were completed and appropriately authenticated, dated, timed with a primary author’s signature and title, who had reviewed and approved the entry, in four (Patients # 1, 2, 4, and 5) of five active patient records reviewed for authentication whose certification period ended in 2025. The failure could place the patient at risk of harm if care and treatment were not reviewed, approved, and authenticated by an agency registered nurse. Findings included: Clinical Record # 1: Review of Patient # 1’s records revealed a POC for the certification period of 01/06/2025 to 03/06/2025 with a SOC date of 05/11/2024. The POC included a primary diagnosis of hypertension (high blood pressure) with ulcer of lower extremity (wound of lower leg). The POC included an order for SN visits five to seven hours Monday through Sunday. The POC was not signed, dated, timed, or titled by the primary author. The record also included a medication profile for the certification period of 01/06/2025 to 03/06/2025. The Medication profile was in draft form (not completed) and was not signed, dated, timed, or titled by the primary author. Review of SN visit notes revealed that the following notes were in draft form and not completed: 01/09/2025 and 01/10/2025 (signed by the Admin/DON) and 02/04/2025 signed by LVN A. Clinical Record # 2: Review of Patient # 2’s records revealed a POC for the certification period of 11/14/2024 to 01/12/2025 with a SOC date of 05/24/2023. The POC included a primary diagnosis of age-related osteoporosis (brittle bones and prone to fractures). The POC included an order for SN visits one-time weekly every other week. Home Health Aide visits one time weekly for one week and three times weekly for eight weeks. The record also included a medication profile for the certification period of 11/14/2024 to 01/12/2025. The Medication profile was in draft form (not completed) and was not signed, dated, timed, or titled by the primary author. Review of SN visit notes revealed that the following notes were in draft form and not completed: 11/14/2024 (not signed or dated by an agency nurse) and SN visit notes that were listed as scheduled visits assigned to the Admin/DON could not be opened to review 11/28/24, 12/12/2024, and12/26/2024. Clinical Record # 4: Review of Patient # 4’s records revealed a POC for the certification period of 12/30/2024 to 02/27/2025 with a SOC date of 03/16/2022. The POC included a primary diagnosis of dementia. The POC included an order for SN visits one time per week for nine weeks. The record also included a medication profile for the certification period of 12/30/2024 to 02/27/2025. The Medication profile was in draft form (not completed) and was not signed, dated, timed, or titled by the primary author. Review of SN visit notes revealed that the following notes were in draft form and not completed: 11, 05/2024, 11/15/2024, 11/22/2024, 12/06/2024, 12/13/2024, 01/03/2025, 01/24/2025, and 01/31/2025 (signed by the Admin/DON). Clinical Record # 5: Review of Patient # 5’s records revealed a POC for the certification period of 11/29/2024 to 01/27/2025 with a SOC date of 09/30/2024. The POC included a primary diagnosis of hypertension (high blood pressure). The POC included an order for SN visits one time per week for nine weeks. The record also included a medication profile for the certification period of 11/29/2024 to 01/27/2025. The Medication profile was in draft form (not completed) and was not signed, dated, timed, or titled by the primary author. Review of SN visit notes revealed that the following notes were in draft form and not completed: 01/02/2025, 01/07/2025, 01/14/2025, and 01/21/2025 (signed by the Admin/DON) and 02/04/2025 signed by LVN A. During an interview on with the Admin/DON on 02/07/2025 at 3:59 p.m., the surveyor reviewed the findings and asked who was responsible for ensuring authentication of the patients records. The Admin/DON stated that she was responsible. He surveyor asked what the agency processes were for ensuring records were authenticated. The Admin/DON stated that the records had to be completed and filed weekly (every Monday). The surveyor asked why the agency had not followed its process and policy. The Admin/DON stated that it was a time factor for her. “I am very short of help.” The survey asked how the failure could adversely affect the agency’s patients. The Admin/DON stated that, “It will affect their health negatively.” Review of agency policy titled “Authorization and Authentication of Client Record Entries” revised 01/29/2020 read in part: “…All client record entries will be made by appropriate staff and authenticated by the author of the entry…. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and title…of a primary author who had reviewed and approved the entry…””

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview the agency failed to assure communication with all physicians involved in the plan of care, in that: for one (Patient # 3) of one patient who had not received any visits since admission on 01/15/2025 the agency failed to communicate with the primary care physician that services were not initiated as ordered in the plan of care. The failure could cause patient harm due to lack of service provision and could lead to a decline in the patients’ health status. Findings include: Clinical Record # 3: Record review of Patient # 3’s clinical records revealed a POC with a SOC date of 01/15/2025 and a certification period of 01/15/2025 to 03/15/2025. Review of the POC revealed that it was dated 01/15/2025 and signed by the Admin/DON. The POC included a primary diagnosis of nutritional deficiency. The POC included an order for SN visits one time per week for nine weeks. Further review of the record did not reveal that any visits had been completed, since the admission visit on 01/15/2025. The next visits were due the weeks of 01/19/2025 and 01/26/2025. Further review of the record did not reveal any records that indicated the agency had communicated the delay in service provision to the client’s primary physician. During an interview with the Admin/DON on 02/07/2025 at 4:08 p.m., the surveyor asked who was responsible for communicating missed visits and delayed service provision to the patient’s physician. The Admin/DON stated that she was responsible. The Admin/DON stated that the agency did not have authorization form the insurance. The surveyor asked why the agency had not communicated with the patient’s physician. She stated that she did not document communication with the physician. Review of agency policy titled, “…Coordination of Care” dated 01/29/2020 read in part: “The HHA must: Assure communication with all physicians involved in the plan of care…” Review of agency policy titled, “Implementing Care and Treatment” dated 01/29/2020 read in part: “…When provision of care/treatment cannot be implemented as established on the care planning document(s), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by discipline/Patient Care Manager…””

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all skilled professional staff participated in the agency’s QAPI program, in that: the contracted skilled professional therapists did not participate in the QAPI program for 2022, 2023, and 2024. The failure placed the agency clients’ health and safety at risk if the agency did not identify problems in the delivery of therapy services, and therefore not implement needed changes to address any specific service delivery problems. FINDINGS INCLUDED: During the entrance conference at 10:25 a.m. on 02/04/2025, the surveyor requested the agency’s QAPI records. During an interview with the Admin/DON on 02/04/2025 at approximately 4:15 p.m. the surveyor requested the agency’s QAPI records. At 4:58 p.m., the Admin/DON provided the surveyor with an undated binder that included agency QAPI reports, document, and records and stated, “This is what I have.” Review of the binder revealed the following: An Active and Inactive patient listing dated 02/24/2022. 1st and 2nd biannual 2021 QAPI reports. Second biannual 2020 QAPI report with performance improvement project for 2021. The Admin/DON and Alt Admin/DON signed the reports. Continued review of the binder did not reveal any QAPI records for 2022, 2023, and 2024. During an interview with the Admin/DON on 02/07/2025 at approximately 3:45 p.m., the surveyor asked who at the agency was responsible for the agency’s QAPI program. The Admin/DON replied, “It’s me.” The surveyor asked what the agency processes were for the QAPI program. The Admin/DON stated that the agency was supposed implement the program twice a year; review all the notes, if there are any infection to include, incidents, complaints, and patient diagnoses. The surveyor reviewed the findings and asked why the agency was not following its processes, policy, and regulations in implementing its QAPI program for 2022, 2023, and 2024. The Admin/DON stated, “I was looking for it. I couldn’t find it.” The Admin/DON provided more QAPI records as follows: First Biannual QAPI Meeting Minutes 2022 and Data analysis, signed and attended by the Admin/DON. Second biannual 2022 QAPI report and Data analysis, signed by the Admin/Don. First Biannual 2023 QAPI Report and Data analysis, signed by the Admin/DON. Second Biannual 2023 Data analysis 2023, signed by the Admin/DON. Review of the QAPI records revealed that the agency’s contracted physical therapist provided services to the agency’s patients but did not participate in the agency’s QAPI program. During an interview with the Admin/DON at 3:55 p.m. on 02/07/2025, the surveyor who was on the agency’s QAPI team. The Admin/DON replied, “It’s me.” The surveyor asked why the QAPI team did not include representation form therapy services. The Admin/DON replied, “That’s a good question.” The surveyor asked if that was her answer. The Admin/DON replied, “Yes, Ma’am.” The surveyor how the failure could adversely affect agency patients. The Admin/DON stated that, “It’s going to affect their health, and their care, and delay their need to get better.” Agency policy titled “Quality Assessment Performance Improvement Plan” read in part: “…Executive Responsibilities: The Agency’s governing body is responsible for ensuring... 7. The governing board will assemble a QAPI working team that consists of the Administrator, supervising nurse or therapist, clinical coordinator, and individuals representing the scope of services provided by the agency…””