Solid Care Home Health Agency Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to develop a written emergency preparedness and response plan (for 1 of 1 plan) based on an all-hazards risk assessment which identified disasters from natural and man-made causes likely to occur in the agency’s service area. This failure placed the agency’s Patients clients at risk for neglect and/or harm should a natural or man-made disaster occur. Findings include: During a record review on 2/5/2026 of the agency’s written emergency preparedness and response plan that the Administrator provided the agency’s emergency response plan with all Hazard Risk Assessment labeled “All Hazards Facility/ Community Based Risk Assessment For Potential Disasters,” dated 7/30/2024. Further review of the Hazard Risk Assessment listed the probability of tornados, extreme heat, and hail as “low risk”. Further record review of the Hazard Risk Assessment revealed wildfires were ranked “no risk”. During an interview on 2/5/2026 at 12:00 p.m. with the Administrator, the Administrator was informed of the above findings. The Administrator stated that it was his responsibility, but he completed it with consulting company. The Administrator agreed that the Patients service area is a moderate risk for tornados, extreme heat, and hail. The Administrator further stated that the Hazard Risk Assessment was important to determine the risk relevant to their patient service area. Record review of an agency policy titled, “ Emergency Preparedness and Response Plan,” revision date 1/29/2020, read in part, “…The Agency’s written plan will be based on a risk assessment by the agency that identifies disasters from natural and man-made causes…the agency will conduct a risk assessment using an all hazard approach…the agency will identify the full range of potential emergencies or disasters that could affect the agency that are specific to the location or circumstances of each providers and can be related to diverse issues…””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system, within 30 days of completing the assessment of the patient for 168 of 783 assessments processed for the time reviewed of 1/1/2025 to 12/31/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. The findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 1/1/2025 to 12/31/2025 was reviewed. Review of the HHA Error Summary Report for the time-period 1/1/2025 to 12/31/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with the error was 168 assessments and the percentage of assessments with this error was 21.46% of the total of 783 assessments completed by the Agency. A joint interview was conducted with the Administrator on 2/11/2025 at 10:00 a.m. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated the Agency both acknowledged the responsibility of the late submission. The Administrator also stated that the issue was he was not aware that the regulation pertained to all OASIS admissions conducted in 2025. During a record review of an Agency policy titled, “Timelines,” dated for revision 1/29/2020, read in part, “…All completed and encoded OASIS data will be transmitted within 30 days of the [admission] date…””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review and interview, the agency failed to enforce written policies addressing infection control including the prevention of the spread of infectious and communicable disease with 2 of 3 home visit Patients (Patient #1 and Patient #2), in that: 1) LVN A failed to maintain cleanliness of a drainage tubing of the wound vac (suction device that is attached to an open wound with a tube and a sponge in the wound to facilitate healing) tubing during a wound vac dressing change for Patient #1 2) LVN B failed to clean a reusable tourniquet after drawing blood on Patient #2 This failure placed the agency’s Patients at risk of an infection. Findings include: During a home observation for Patient #1, on 2/9/2026 at 10:30 a.m., LVN A was observed, prior to wound vac change, disconnecting the wound vac tubing that was connected to Patient #1’s bottom pressure wound. Further observation revealed LVN A placed the disconnected tubing on the floor. Further observation revealed that after LVN A changed Patient #1’s buttock pressure wound, LVN A reconnected the tubing from the floor to the new wound on Patient #1’s buttock. During a record review of Patient #1’s plan of care revealed that that Patient #1’s start of care date was 7/9/2025, with a certification period of 1/5/2026-3/5/2026, with a diagnosis of pressure wound on the bottom. Further record review revealed that Patient #1 was receiving skilled nursing care two to three times per week for a wound vac dressing change. During an interview with LVN A on 2/9/2026 at 11:00 a.m., LVN A was informed of the above findings. LVN A stated that he understood that the above findings placed Patient #1 for a high risk of infection. LVN A further stated he was instructed on infection control by the agency. During home observation for Patient #2, on 2/9/2026 at 1:00 p.m., LVN B was observed using a reusable tourniquet (a device used to stop blood flow to an affected area in order to obtain blood for laboratory readings) on Patient #2 during a blood draw from Patient #2’s left arm. Further observation revealed that LVN B did not sanitize the reusable tourniquet after blood was drawn from Patient #2’s left arm. During a record review of Patient #2’s plan of care revealed that Patient #2’s start of care date was 4/9/2025 with a diagnosis of congestive heart failure weakness of the heart muscle. Further record review revealed that Patient #1 was receiving skilled nursing care once per week. During an interview with LVN B on 2/9/2026 at 1:30 p.m., LVN B was informed of the above findings. LVN B stated that she understood that the above findings placed Patient #2 with a high risk of infection. LVN B further stated she was instructed on infection control by the agency. During a record review of LVN B’s infection control training record revealed that LVN B completed Bloodborne pathogen training in February 2026. During an interview with the Administrator on 2/11/2026 at 10:00 a.m., the Administrator was informed of the above findings. The Administrator stated that the agency staff was instructed on infection control and understood that the deficient practice can lead to a high risk of infection for the agency Patients. Record review of an agency policy titled, “ Infection Control Program,” revision date 1/29/2020, read in part, “The HHA must follow accepted standards of practice, including the use of standard precautions (precautions when in contact with body fluids), to prevent the transmission of infection and communicable diseases…” Record review of the agency policy titled, “Bag Technique, revision date 1/29/2020, read in part, “…When the visit is completed, reusable equipment is cleaned using alcohol, and soap and water as appropriate...for your reusable tourniquet, use and water and/or alcohol…””