Bryan W. Whitfield Memorial Hospital Home Health

“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 review of Emergency Preparedness (EP) documentation, agency policy, and interview with staff, it was determined the agency failed to ensure their comprehensive EP plan/program was updated and reviewed biennially (every two years) to comply with the Federal EP requirements. This had the potential to negatively affect all staff and patients served by this agency. Findings include: Agency Policy: Emergency Preparedness Plan Policy Number: None Listed Date Updated: August 2019 Review of the EP documentation for the home health agency revealed the last update was August 2019. An interview was conducted on 1/9/25 at 9:15 AM with Employee Identifier (EI) # 1, Director, who confirmed there was no documentation the EP program/plan had been updated and reviewed every two years as required.”

“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 review of Emergency Preparedness documentation and staff interview it was determined the agency failed to complete a facility-based and community-based all hazards risk assessment every two years. This had the potential to negatively affect all patients, and staff served by this agency. Findings include: Review of EP documentation revealed no documentation of a facility-based and community-based all hazards risk assessment for the years 2020, 2021, 2022, 2023, or 2024. An interview was conducted on 1/9/25 at 9:15 AM with Employee Identifier (EI) # 1, Director, who confirmed the agency failed to complete a facility-based and community-based all hazards risk assessment for the years 2020, 2021, 2022, 2023, and 2024.”

“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 review of documents provided for the Emergency Preparedness (EP) program policies and procedures and staff interview, it was determined the agency failed to ensure policies and procedures were reviewed and updated every two years. This had the potential to negatively affect all patients and staff served by the agency. Findings include: Review of EP policies and procedures revealed the last update was August 2019. An interview was conducted on 1/9/25 at 9:15 AM with Employee Identifier # 1, Director, who confirmed policies and procedures had not been reviewed and updated every two years since August, 2019.”

“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 review of Emergency Preparedness (EP) documentation and staff interview, it was determined the agency failed to ensure annual testing of the EP program had been completed, documented and analyzed. This had the potential to negatively affect all patients and staff served by this agency. Findings include: Review of EP documentation revealed no documentation annual testing of the EP program had been completed, documented or analyzed. There was no documentation of any community or facility based exercises, actual events, and no documentation of any table top exercises for the years 2020, 2021, 2022, 2023, and 2024. An interview was conducted on 1/9/25 at 9:15 AM with Employee Identifier # 1, Director, who confirmed there was no documentation of any exercises of any kind documented for the years 2020, 2021, 2022, 2023, or 2024.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on review of agency policy and procedure, medical record (MR) reviews, and interviews, it was determined the agency failed to ensure each patient was provided the State toll free home health telephone hot line number. This affected three of three Home Visit (HV) patients including HV # 1, HV # 2, and HV # 3, four of four MR’s reviewed including MR # 1, MR # 2, MR # 3, and MR # 4, and had the potential to affect all patients served by this agency. Findings include: Agency Policy: The Patient Bill of Rights and Responsibilities Policy Number: Not Listed Revised: January 2023 ...Federal law requires that all individuals receiving home care services be informed of their rights as a patient... 18. Be advised of the telephone number and hours of operation of the state’s hotline, which receives questions and complaints..Telephone number 1-800-356-9596... 1. Seven of seven MRs reviewed revealed no documentation the patients had received the state’s hotline number. This included three home visits. There was no documentation of the state’s hotline number in the patient’s home folders, reviewed during the home visits. An interview was conducted on 1/8/25 at 3:10 PM with Employee Identifier # 1, Director, who confirmed the State hotline number had not been provided to patients. EI # 1 further stated that none of the current 70 patients had been provided with the State hotline number.”

“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 review of medical records (MRs), observations, agency policy and interviews with staff, it was determined the agency failed to ensure medications were reconciled in two of three Home Visits (HV) conducted. This affected HV # 3, HV # 1 and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Medication Management and Reconciliation Policy Number: None Listed Date Revised: 01/2023 A medication profile is completed at the time of the patient’s admission. ...2. When a new medication is ordered, the medication is added to the medication profile along with the appropriate information. ...5. All skilled nurses are to review the patient medication profile list at each skilled nurse visit and document any new or changed medications. ...10. Medications are monitored and reconciled by the RN’s, but other disciplines may review medications/medication list with the patient/caregiver and notify the skilled nurse if any discrepancies are noted. 2. HV # 1 was admitted to the agency on 6/28/24 and recertified for continued care from 12/25/24 to 2/22/25 with the diagnosis of Foot Drop. A HV was conducted on 1/7/25 at 1:45 PM with EI # 5, Licensed Physical Therapy Assistant (LPTA). A comparison was made between the MP at the Assisted Living Facility (ALF) and the MP dated 1/7/25 provided from the agency prior to the HV. The following medications were listed on the MP for the ALF as current, but not listed on the MP for the agency: a. Coricidin Hbp (brand name) 200 mg / 10 mg Softgel, take one capsule by mouth once a day as needed for congestion, start date of 10/18/24. b. Meclizine 12.5 mg tablet, take one tablet by mouth three times a day as needed for dizziness, start date 10/28/24. The Following medications were listed on the agency MP dated 1/7/25, and not on the ALF MP as current: a. Colchicine 0.6 mg, take one tablet daily, start 6/28/24. b. Loratadine 10 mg, take one tablet daily as needed, start 6/28/24. An interview was conducted on 1/8/25 at 3:51 PM with EI # 1, who confirmed the agency staff failed to ensure medications were reconciled and all current medications were included on the MP. 1. HV # 3 was admitted to the agency on 2/1/24 and recertified for continued care from 11/27/24 to 1/25/25 with the diagnosis of Epilepsy, Unspecified, not Intractable. Review of the Home Health Certification (HHC) and Plan of Care (POC) for the dates of 11/27/24 to 1/25/25 revealed physician’s orders for the Skilled Nurse (SN) to visit one time a week for nine weeks. A home visit was conducted on 1/7/25 at 1:19 PM with Employee Identifier (EI) # 4, Home Health Aide (HHA). A comparison was made between medications observed in the home and the Medication Profile (MP) dated 1/7/25 provided from the agency prior to the HV. The following medications were in the home, but were not listed on the MP: a. Hydrochlorothiazide 12.5 mg (milligram) take one daily. Filled on 12/8/24. b. Levetiracetam 500 mg take at bedtime. Filled on 12/11/24. c. Protonix 40 mg take one daily. Filled on 12/21/24. An interview conducted on 1/8/25 at 3:39 PM with EI # 1, Director, confirmed the agency staff failed to ensure medications were reconciled and all current medications were included on the MP.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and interviews it was determined the Home Health Agency failed to ensure the staff notified the physician of changes in the patient’s condition per agency policy, which included an increase in wound size. This did affect one of 3 Home Visits conducted including (HV) # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Physician Communication Date: October 2013 Policy: It is the policy of this Agency to establish and maintain ongoing communication with the physician or outside entities to ensure safe and appropriate care for the patient. Purpose: To promote ongoing communication between the agency staff, physician, or other designated providers... Procedure: The agency will contact the patient’s physician:... b. When there are changes in the patient’s condition... 2. All conferences or attempts to communicate with the physician will be documented on the proper form and included in the patient’s agency clinical record... HV # 2 was admitted to the agency on 11/30/2023 and recertified for care 11/24/24 to 1/22/24 with a primary diagnosis of Peripheral Vascular Disease. Review of the Home Health Certification and Plan of Care dated 11/24/24 to 1/22/24, revealed: Skilled Nurse (SN) visits one every week for nine weeks. Wound Care Right Heel- Per Visit... assess wound, change daily. Caregiver (CG) to change on days no SN visit. Review of the MR revealed a SN visit dated 11/27/24. The SN documented the wound size of the right (R) heel pressure ulcer (PU) as 2 inches (in) x (by) 2 in. Review of the SN visit note dated 12/4/24 revealed the SN documented the wound size of the R heel PU as 2 in x 2.5 in. There was no documentation the SN notified the physician of the increase in the patient’s wound size. Review of the SN visit note dated 12/11/24 revealed the SN documented the wound size of the R heel PU as 2.5 in x 2.5 in. There was no documentation the SN notified the physician of the increase in the patient’s wound size. Review of the SN visit note dated 12/17/24 revealed the SN documented the wound size as 2.5 in x 3 in. There was no documentation the SN notified the physician of the increase in the patient’s wound size. An interview was conducted on 1/8/24 at 3:24 PM with Employee Identifier # 1, Director, who confirmed there was no documentation the physician was notified of the changes in the patient’s condition per agency policy.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on review of personnel records, job descriptions, agency policy, and interviews, it was determined the agency failed to to ensure annual competencies were performed. This deficient practice did affect Employee Identifier (EI) # 4, Certified Nursing Assistant (CNA), one of two CNA’s employed by the agency and had the potential to affect all patients served by the agency. Findings Include: Agency Policy and Procedure: Home Care Competency Updated: January 2018 Policy: The competency of Home Care employees shall be validated on initial employment and annually thereafter. It shall be appropriate to the scope of care provided by the organization based on patient needs, level of care required and applicable laws, regulations and/or certifications. Purpose: To provide documented evidence that home care staff members are competent to perform the skills required and understand the concepts necessary for community health nursing... Review of the employee file of EI # 4, Certified Nursing Assistant it was revealed the last competency skills were performed in 2022. An interview was conducted on 1/8/25 at 3:00 PM with EI # 1, Director, who confirmed the agency failed to assess annual competencies for the CNA in 2023 and 2024.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on review of Medical Records (MR), agency policy, and interviews with the staff, it was determined the agency failed to complete a supervisory assessment of the Home Health Aide (HHA) services being provided no less frequently than every 14 days. This affected one of two patients receiving HHA services, including Home Visit (HV) # 3, and had the potential to negatively affect all patients receiving HHA services. Findings include: Agency Policy: Home Health Aide Supervision Policy Number: None Listed Revised Date: 01/2023 Purpose: To assure the appropriateness of home health aide services and to maintain quality of care. Policy: ...The registered nurse (RN) will schedule home health aide supervisory visits at least every fourteen (14) days....The RN makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. HV # 3 was admitted to the agency on 2/1/24 and recertified for continued care from 11/27/24 to 1/25/25 with the diagnosis of Epilepsy, Unspecified, not Intractable. Review of the Home Health Certification (HHC) and Plan of Care (POC) for the dates of 11/27/24 to 1/25/25 revealed physician’s orders for the Skilled Nurse (SN) to visit one time a week for nine weeks. HHA to visit one time a week for one week, then two times a week for eight weeks. Review of the MR revealed HHA visits for 12/17/24, 12/23/24, 12/27/24, 12/31/24 and 1/3/25 were completed by the HHA. Further review of the MR revealed one SN Supervisory visit was completed on 12/19/24, for the recertification period from 11/27/24 to 1/25/25. There was no documentation of onsite HHA supervisory assessment visits for the recertification period. An interview was conducted on 1/8/25 at 3:39 PM with Employee Identifier # 1, Director, who confirmed the agency failed to complete HHA supervisory assessments every 14 days.”