Atlas Healthcare 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 interview, the agency staff failed to document an all-hazards risk assessment as part of the Emergency Preparedness plan in 1 of 1 plan reviewed. Findings include: Review of policy “Emergency Preparedness Policy” dated 2023 states in part, “An emergency will be described as an unforeseen happening which causes much damage; examples of emergencies include but not limited to: Tornados, Floods, Snowstorms, Chemical Spills, Industrial Accidents, Earthquakes, Biohazardous Weapons.” There was a form located in the “Emergency Preparedness Binder” labeled Risk Assessment, that was not completed, addressing all hazards that had the potential to impact the patients, staff, and agency. An interview was conducted 01/18/2024 at 2:45 PM with Administrator A. When asked if an all-hazards risk assessment had been conducted as part of the Emergency Plan, Administrator A stated “No”.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program utilized program quality indicator data in identifying improvement opportunities, monitoring effectiveness, and outlining detail interventions and frequency of data collection in 1 of 1 QAPI programs reviewed. Findings include: Record review of policy and procedure titled “Quality Assessment and Performance Improvement” (QAPI) not dated, revealed in part: “Purpose: The agency’s performance improvement program consists of, but is not limited to the following: Outcome based OBQI (Outcome Based Quality Improvement) and OBQM (Outcome Based Quality Monitoring) data from OASIS (Outcome and Assessment Information Set) submission documents. OASIS review and evaluation. Risk management program to evaluate areas of concern and implement plans to improve patient’s quality of care…. To implement and maintain a QAPI Program within our Home Care Program designed to have a method of objectivity identifying areas of improvement, systematically monitoring the outcomes and appropriateness of patient care and continuously improve the quality of services rendered.” Record review of the QAPI binder contents revealed: no documentation the agency utilized quality indicator data nor indicated at what detail and frequency to gather data to identify opportunities of improvement as part of the QAPI program as listed per policy. Per interview on 01/18/2024 at 3:30 PM with Administrator A, when asked about the agency’s wide specific QAPI program and how data is collected identifying areas of concern to improve on, Administrator A replied “We have not done an OASIS for years, we have not had any skilled cases. We wouldn’t have anything specific for our agency. Our area of concern was/is loss of reimbursement when the required EVV (Electronic Visit Verification) was implemented.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, agency staff failed to individualize patient goals based on each patient’s need in 7 of 7 patient record reviews completed (Patients #1, #2, #3, #4, #5, #6 and #7). Findings include: Review of policy titled “Case Conference/Progress Summary” not dated revealed in part, “Case conferences will be held at the start of care and at least every 60 days to review the frequency and type of service, changes in the patient’s overall status, problems, and progress towards goals.” Review of Patient #1’s “Home Health Certificate and Plan of Care,” SOC (start of care) date 02/13/2020 revealed, Patient #1 was being seen 2 hours a day, 7 days a week by a PCW (personal care worker) for assistance with daily tasks of living. The listed goal “personal care services through the end of certification period; no plans for discharge,” fails to support the reason and need for the assistance with daily tasks of living. Review of Patient #2’s “Home Health Certificate and Plan of Care,” SOC date 03/03/2016 revealed Patient #2 was being seen 6 hours a day, 7 days a week by a PCW for assistance with daily tasks of living. The listed goal “Personal care services to be met through the end of certification period, no plans for discharge,” fails to address the need for assistance with daily tasks of living. Review of Patient #3’s “Home Health Certificate and Plan of Care,” SOC date 03/24/2023 revealed Patient #3 was being seen 2 hours a day, 5 days a week by a PCW for assistance with daily tasks of living. The listed goal “Demonstrate compliance with medical regimen, no plans for discharge,” fails to support the reason and need for the assistance with daily tasks of living. Review of Patient #4’s “Home Health Certificate and Plan of Care,” SOC date 06/15/2021 revealed Patient #4 was being seen 4.5 hours a day, 7 days a week by a PCW for assistance with daily tasks of living. The listed goal “Demonstrate compliance with medical regimen, no plans for discharge,” fails to support the reason and the need for assistance with daily tasks of living. Review of Patient #5’s “Home Health Certificate and Plan of Care,” SOC date 05/05/2023 revealed Patient #5 was being seen 2 hours a day, 7 days a week by a PCW for assistance with daily tasks of living. The listed goal “Demonstrate competence with medical regimen, no plans for discharge,” fails to support the reason and the need for assistance with daily tasks of living. Review of Patient #6’s “Home Health Certificate and Plan of Care,” SOC date 02/20/2017 revealed Patient #6 was being seen 3 hours a day, 5 days a week by a PCW for assistance with daily tasks of living. The listed goal “Personal care services to be met through the end of certification period, no plans for discharge,” fails to address the need for assistance with daily tasks of living. Review of Patient #7’s “Home Health Certificate and Plan of Care,” SOC date 12/19/2022 revealed Patient #7 was being seen 5 hours a day, 3 days a week by a PCW for assistance with daily tasks of living. The listed goal “Demonstrate competence with medical regimen, no plans for discharge,” fails to support the reason and the need for assistance with daily tasks of living. An interview was conducted on 01/19/2024 at 2:30 PM with Administrator A to review the above findings. Administrator A confirmed the above findings, “we have unskilled cases with plans to provide assistance with daily tasks of living with no discharge plans.””