Essential Medical Services Inc.

“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 record review and interview the agency failed to develop an emergency preparedness plan. Findings Include: 1.On 12/11/24 at 11:59 a.m., an interview with the administrator/director of nursing revealed the agency did not have an emergency preparedness plan. She found a binder that stated emergency preparedness, but the binder was empty. She went on to state she had been with the agency since September 2024 and did not have time to develop an emergency preparedness plan for the agency.”

“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 interview and record review the agency failed to develop and implement policies and procedures based on the emergency plan and risk assessment. Findings Include: 1.On 12/11/24 at 11:59 a.m., an interview with the administrator/director of nursing revealed the agency did not have an emergency preparedness policies and procedures based on the risk assessment. She found a binder that stated emergency preparedness, but the binder was empty. She went on to state she had been with the agency since September 2024 and did not have time to develop an emergency preparedness policies and procedures for the agency.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the comprehensive assessment was updated and revised at the time of patient discharge for 1 of 1 patient records reviewed that had been discharged (Patient #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 12/11/24. The plan of care for the certification period dated 9/6/24 to 11/4/24, revealed a start of care date of 1/18/08; diagnoses included quadriplegia and neurogenic bladder. The plan of care included a skilled nurse (SN) visit once per week for medication management and once per month for suprapubic catheter change; and certified nursing assistant (CNA) visits three times a day for nine weeks for assistance with activities of daily living (ADL’s). a) The agency failed to document a comprehensive assessment upon Patient #7’s discharge. Clinical review of agency discharge list showed Patient #7 was discharged on 10/16/24. Further review of the record for Patient #7 failed to reveal any further information regarding the discharge on 10/16/24. There was no documentation or evidence that a comprehensive assessment had been completed for Patient #7. During an interview on 12/11/24 at 11:31 a.m., the director of nursing (DON) stated the agency had not completed a comprehensive assessment of Patient #7 at the time of discharge. The DON went on to state she was not aware she had to complete a comprehensive assessment when a patient discharged.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interviews and record review the agency failed to provide services in accordance with clinical practice guidelines and accepted professional standards of practice. Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to provide services in accordance with clinical practice guidelines; specifically the handling of a medication. Record review revealed the skilled nurses for Patient #6 have been crushing a medication and administering it via the g-tube. On 12/11/24 at 11:58 a.m., an interview with the administrator/director of nursing revealed she did not know the medication could not be crushed. She initially thought the mother was administering the medication until a review of the plan of care. She went on to say that she would notify the physician and ask for a liquid version of the medication that was meant for g- tube medication administration. She further acknowledged the agency had failed to provide services according to the clinical practice guidelines for this medication handling.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interviews and a review of records, the agency failed to maintain clinical documentation of patient assessment findings for 1 of 7 active patients. (Patient #6) Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to maintain documentation of patient assessments. A review of Patient #6’s record failed to show the assessments being performed by the skilled nurses. The charting was sparse and some boxes were left unchecked. On 12/11/24 at 11:54 a.m., an interview with the administrator/director of nursing revealed the electronic medical record (EMR) was new to the agency. She went on to say that she had a plan to get the staff trained on documentation in the EMR . She believed the assessments were performed but just not documented in the patient record to meet compliance. On 12/12/24 at 9:00 a.m., an interview with Patient #6’s mother showed that she was happy with the skilled nurse services from the agency and that she had no concerns with the skilled nurses.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interviews and a review of records, the agency failed to maintain clinical documentation of all interventions, including medication administration, treatments, services, and patient responses to those interventions for 1 of 7 active patients. (Patient #6) Findings Include: 1.The clinical record for Patient #6 was reviewed on 12/11/24. Plan of care orders for the certification period dated 10/19/24 to 12/17/24 revealed a start of care date of 10/19/24; diagnoses included head trauma, sleep apnea, dizziness and giddiness, and a disorder of the muscles. Plan of care orders included skilled nurse visits eight (8) times a week for nine (9) weeks, Monday through Friday, twice a day. Saturday and Sunday twice a day for medication set up and gastronomy tube (g-tube) administration. a. The agency failed to maintain clinical documentation of the medication administration and the patient’s response to the intervention. A review of Patient #6’s medication administration record failed to show documentation of the dates, times, and the patient’s responses to the medications administered by the skilled nurses providing care. On 12/11/24 at 11:50 a.m., an interview with the administrator/director of nursing revealed that she is new to the company and had not started doing record audits so she was unaware that the skilled nurses for Patient #6, were forgetting to chart medication administration. She also acknowledged that if the skilled nurse did not chart care, treatment, and services then they were not provided to the patient.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge for 1 of 1 patients records reviewed requiring a transfer or discharge summary (Patients #7). Findings include: 1. The clinical record for Patient #7 was reviewed on 12/11/24. The plan of care for the certification period dated 9/6/24 to 11/4/24, revealed a start of care date of 1/18/08; diagnoses included quadriplegia and neurogenic bladder. The plan of care included a skilled nurse (SN) visit once per week for medication management and once per month for suprapubic catheter change. Certified nurse aide (CNA) visits for four hours, three times a week and two hours, four days a week. CNA also visits one hour mid-day seven days a week and two hours every night, seven days a week. 2. Clinical review of agency discharge list showed that Patient #7 was discharged on 10/16/24. Further review of the record for Patient #7 failed to reveal any further information regarding the discharge on 10/16/24. The agency failed to send Patient #7’s discharge summary to the physician within five business days of the patient’s discharge. 3. During an interview on 12/11/24 at 11:31 a.m., the director of nursing (DON) stated the discharge summary was not sent to the MD and that was her mistake.”