Evergreen Home Care

“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 the agency’s Emergency Preparedness (EP) documentation and staff interview, it was determined the agency failed to develop and maintain a comprehensive EP plan that was reviewed and updated at least every two years. This had the potential to negatively affect all 25 patients serviced by the agency and agency employees. Findings include: A review of the agency’s EP plan revealed there was no documentation the agency had reviewed and updated their EP plan since 2020. An interview was conducted on 8/13/25 at 2:00 PM with Employee Identifier # 1, Director, who confirmed the agency failed to review and update the EP plan at least every two years.”

“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 the agency’s Emergency Preparedness (EP) documentation and staff interview, it was determined the agency failed to develop and maintain an EP plan specific to the location of the agency, considering particular hazards most likely to occur in the surrounding area (Hazard Risk Assessment) at least every two years. This had the potential to negatively affect all 25 patients served by the agency and agency employees. Findings include: A review of the agency’s EP plan revealed there was no documentation the agency had completed a Hazard Risk Assessment, specific to the location of the agency, since 2022. An interview was conducted on 8/13/25 at 2:00 PM with Employee Identifier # 1, Director, who confirmed the agency failed to complete the Hazard Risk Assessment every two years.”

“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 observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure staff followed agency policy to prevent the spread of infection. This deficient practice did affect Home Visit (HV) # 2 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Home Care Bag Policy Number: Not Listed Revised: 6/2022 Policy: ...The home Care Bag will provide the basic equipment and supplies ... The Home Care Bag shall be used to prevent the potential spread of infection between and among staff and patients. Procedure: ... 4. Handwashing supplies shall be kept in the outermost pocket of the Home Care Bag for easy accessibility... 1. HV # 2 was admitted on 7/16/25 with diagnoses including Laceration Without Foreign Body, Right Lower Leg, Cellulitis of Right Lower Leg, and Chronic Kidney Disease. A HV was conducted on 8/12/25 at 9:50 AM to observe wound care provided by Employee Identifier (EI) # 2, Licensed Practical Nurse. The following is a summary of the visit: EI # 2 obtained Vital Signs, removed hand sanitizer from the uniform pocket, performed hand hygiene, then placed the sanitizer bottle back in the uniform pocket. EI # 2 then applied gloves, placed a plastic bag over the trash receptacle, removed gloves, removed sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, cleaned the re-useable vital sign equipment with disinfecting wipes, removed gloves, removed hand sanitizer from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, removed the soiled dressing from the right lower leg, removed gloves, removed sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, performed wound cleansing, removed gloves, removed hand sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, applied Xeroform gauze to wound bed, removed gloves, then performed hand hygiene with hand sanitizer from the uniform pocket. EI # 2 applied gloves, applied bordered dressing to the wound, removed gloves, then performed hand hygiene with the hand sanitizer from the uniform pocket. An interview was conducted on 8/13/25 at 8:15 AM with EI # 2 who confirmed he/she used the hand sanitizer from the uniform pocket each time hand hygiene was required. An interview was conducted on 8/13/25 at 1:30 PM with EI # 1, Director, who confirmed the agency failed to ensure staff followed the agency policy for hand hygiene and storing of hand sanitizer.”

“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 observations, agency policy and procedure, medical record (MR) review, and interviews, it was determined the agency failed to ensure medications in the home were reconciled with the current physician’s medication orders. This deficient practice affected one of three home visit (HV) patients, including HV # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Management Policy Number: Not Listed Revised: 9/2019 Purpose: It is the policy of Evergreen Home Care to ensure that every patient has an accurate and complete list of patient medications they are taking at home recorded in their medical record... A medication list is completed at the time of the patient’s start of care and updated as medications are added, changed, or discontinued. ...It is the policy of ... that the Skilled Nurse (SN) assess home medications on each visit... 1. HV # 3 was admitted on 8/1/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Foot, and Pressure Ulcer of Other Site, Stage 2. Review of the Home Health Certification and Plan of Care dated 8/1/25 revealed physician’s orders for SN one visit per week for one week, two visits per week for eight weeks, then one visit per week for one week. SN to perform medication review each skilled nursing visit and reconcile medications as indicated. A HV was conducted on 8/12/25 at 2:30 PM with Employee Identifier (EI) # 3, Physical Therapist Assistant (PTA). A review of the home medications was conducted with HV # 3 at the completion of the PTA visit. The following is a list of the medication discrepancies: 1. Aspirin 81 milligrams (mg) take one daily was listed on the Medication Profile (MP). HV # 3 stated he/she had not been taking the Aspirin for three to four years. 2. Metformin 500 mg take one half tablet twice daily was listed on the MP. HV # 3 stated he/she has not taken the Metformin for over a year. 3. Gabapentin 300 mg take two tablets three times a day was in the home but not on the MP. HV # 3 stated he/she had been taking the Gabapentin for leg pain for a few years. 4. Clopidogrel 75 mg take one daily, prescription bottle dated 8/4/25, was in the home and not on the MP. HV # 3 stated he/she had been taking the medication since the prescription was filled on 8/4/25. Review of the SN Visit Notes revealed SN visits on 8/7/25 and 8/11/25. 5. Allopurinol 300 mg take one daily, prescription bottle dated 7/31/25, was in the home but not on the MP. HV # 3 stated he/she had been taking the medication since the prescription was filled on 7/31/25. Review of the SN Visit Notes revealed SN visits on 8/4/25, 8/7/25, and 8/11/25. 6. Empagliflozin 25 mg take one half tablet every morning was in the home but not on the MP. HV # 3 stated he/she had been taking the medication for over a year. An interview was conducted on 8/13/25 at 1:40 PM with EI # 1, Director, who confirmed the medications were not reconciled during each SN visit per agency policy.”