Bent County Public Health

“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 interview and record review, the agency failed to fully develop the emergency preparedness plan. Specifically, the agency failed to educate employees on an annual basis regarding the emergency preparedness plan, implement strategies for identified risks and emergency situations, and have a strategy to protect and transfer consumer records, as well as reviewing the preparedness plan at least annually. Findings include: 1. A review of the policies and procedures for the emergency preparedness plan revealed that no plan had been created. The agency had policies regarding emergency preparedness but had not completed the actual emergency preparedness plan. 2. During an interview on 1/27/26 at 12:25 p.m., the executive director #7 admitted the agency’s current emergency preparedness plan did not meet the standards of the regulations. The executive director #7 stated the agency did not have strategies for emergency situations, did not have a strategy for protecting and transferring consumer records, and did not provide an initial or annual training of emergency preparedness to the employees of the agency.”

“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 ensure staff followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases during a home visit (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 1/26/26. The plan of care for the certification period dated 1/5/26 to 3/5/26 revealed a start of care date of 1/5/26; diagnoses included chronic pain, stage 2 pressure ulcers, and wound on left second toe. Plan of care orders included skilled nurse (SN) visits every day for nine weeks and home health aide (HHA) three times a week for 9 weeks. Wound care orders on the plan of care, dated 1/5/26, were to cleanse with normal saline, pat dry, apply skin prep to all peri wounds, apply medihoney to buttocks wound, cover with non stick dressing secure, apply alginate to left 2nd wound and secure. a) Observations showed the agency failed to be in accordance with professional standards of practice during the provision of wound care for Consumer #1. A home visit was conducted on 1/28/26 at 9:00 a.m. for Patient #1. The surveyor observed licensed practical nurse (LPN) #4 providing wound care to Patient #1’s left lower extremity wound and two wounds on the buttocks. The consumer was laid on the bed and there was no sterile barrier laid underneath the consumer and the bed while changing and cleansing the wound. The bed had cat hair on it during the dressing change. During an interview on 1/27/26 at 12:58 p.m., LPN #8 and #4 stated that the agency only puts down sterile barriers if there would be a mess while changing the wound dressing, however they always put their supplies on a sterile paper barrier. During an interview on 1/27/26 at 1:16 p.m., the administrator, Employee #1, stated that their policy for wound care was to have a paper barrier under the wound to make sure there is a clean and sterile environment. The administrator stated that they would be observing all employees that do wound care to make sure infectious disease protocols are being followed.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the written patient care instructions for a home health aide were prepared by a registered nurse for 1 of 4 sample patients receiving home health aide services (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 1/26/26. Plan of care orders for the certification period dated 1/13/26 to 3/13/26 revealed a start of care date of 1/13/26; diagnoses included acquired absence of left leg below knee and type two diabetes. Plan of care orders included skilled nursing services once a day for wound care, medication administration, and diabetic management and education; physical therapy twice per week for transfer training and assessment of appropriate body mechanics and equipment use; and home health aide services three times per week for assistance with showering and activities of daily living. a) The agency failed to ensure the aide care plan was prepared by a registered nurse. Review of the clinical record revealed the aide care plan had been created by a licensed practical nurse (LPN #4) on 1/15/26. During an interview with LPN #4 on 1/27/26 at 1:31 p.m., LPN #4 acknowledged she had created the aide care plan and stated she did not know the aide care plan should be prepared by a registered nurse. During an interview with the agency administrator on 1/28/26 at 10:30 a.m., the administrator stated the agency’s policy was for registered nurses to prepare the aide care plans for the home health aide in order to have written instructions when aide services are ordered.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide services in conformance with physician orders. Specifically, for 2 of 7 sample patients, the agency failed to provide home health aide visits as ordered (Patient #1 and #2). Additionally, the agency failed to provide wound care as ordered for 3 of 4 sample patients receiving wound care (Patient #1, #4, and #6). Findings include: I. Missed home health aide visits: 1. The agency failed to ensure home health aide visits were completed as ordered. a) The clinical record for Patient #1 was reviewed on 1/26/26. The plan of care for the certification period dated 1/5/26 to 3/5/26 revealed a start of care date of 1/5/26; diagnoses included chronic pain, stage 2 pressure ulcers, and wound on left second toe. Plan of care orders included skilled nurse (SN) visits every day for nine weeks for wound care and home health aide (HHA) visits three times a week for nine weeks for assistance with showering and activities of daily living. b) The clinical record for Patient #2 was reviewed on 1/26/26. The plan of care for the certification period dated 1/16/26 to 3/16/26 revealed a start of care date of 4/12/21; diagnoses included type 2 diabetes, essential (primary) hypertension, and hyperlipidemia. Plan of care orders included SN twice per day for nine weeks for medication administration and HHA visits three times per week for eight weeks for bathing assistance. c) Review of the clinical records revealed a missed HHA visit for Patient #1 on 1/26/26 and also revealed a missed HHA visit for Patient #2 on 1/26/26. The missed visit notes placed in the medical records both stated “cancelled due to weather.” The missed visit notes did not include information regarding rescheduling the visits or how the HHA care would be provided to the patients. d) During an interview with the agency administrator on 1/27/26 at 1:40 p.m., the administrator stated she did not know why the missed visit notes did not include more documentation. Additionally, she acknowledged the agency should have reached out to the patients to reschedule the visits for a different time so the patients could receive the ordered HHA visits. II. Wound care not provided as ordered: 1. The agency failed to provide wound care as ordered. a) The clinical record for Patient #1 was reviewed on 1/26/26. The plan of care for the certification period dated 1/5/26 to 3/5/26 revealed a start of care date of 1/5/26; diagnoses included chronic pain, stage 2 pressure ulcers, and wound on left second toe. Plan of care orders included SN visits every day for nine weeks for wound care and HHA three times a week for nine weeks for assistance with showering and activities of daily living. Wound care orders on the plan of care, dated 1/5/26, were to cleanse with normal saline, pat dry, apply skin prep to all peri wounds, apply medihoney to buttocks wound, cover with non stick dressing secure, apply alginate to left 2nd wound and secure. These orders were to be followed for the wound on Patient #1’s left second toe and the two pressure ulcers on the buttocks. Record review of the nursing notes dated 1/26/26 by a licensed practical nurse (LPN #8) stated they cleansed with normal saline, patted dry, applied skin prep to all peri wounds, applied medihoney to buttocks wound, covered with non stick dressing, secured with tape to the skin, applied alginate to left second toe wound and secured with a tape. From 1/5/26 to 1/27/26 LPN #4, LPN #8, and registered nurse (RN, #2) noted that they secured the nonstick dressing to the skin with tape. The LPNs and RN were applying tape directly to the skin without doctors’ orders. A home visit was conducted on 1/27/26 at 9:00 a.m. for Patient #1. The surveyor observed LPN #4 providing wound care to Patient #1’s left lower extremity wound and buttocks. LPN #4 removed the old bandage, cleansed with normal saline, patted dry, applied medihoney to buttocks wound, covered with non stick dressing, secured with tape to the skin, applied alginate to left second toe wound and secured with a tape. The LPN stated they forgot to apply the skin prep to the periwounds on the buttocks. During an interview on 1/27/26 at 12:58 p.m., LPN #4 stated she had read the plan of care and thought securing with tape specifically was in the order. She stated not applying the skin prep to the periwounds on the buttocks was a mistake and she was nervous. During interview on 1/27/26 at 1:15 p.m., the agency administrator stated the nurses were supposed to follow all physician orders including wound care orders. b) Similar findings of not following wound care orders was found for Patients #4 and #6.”

“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 record review and interview, the agency failed to ensure supervisory assessments of aide services were provided no less frequently than every 14 days for 4 of 4 sample patients receiving home health aide services (Patient #1, #2, #5, and #7). Findings include: 1. The clinical records for Patients #1, #2, #5, and #7 were reviewed on 1/26/26. All four patients had home health aide services in their plan of care orders. a) The agency failed to ensure supervisory assessments were completed and documented. For Patients #1, #2, #5, and #7, review of clinical records revealed supervisory visits were scheduled and the visits were made at 14-day intervals; however, the supervisory portions of the visit notes were not completed. During an interview with the agency administrator on 1/27/26 at 1:40 p.m., the administrator stated she was not sure why the documentation was not showing in the medical record. She stated the supervisory visits were being completed, and going forward the agency would ensure they were being entered into the electronic medical record properly.”