Wayne County Public Health Nursing Service

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of the agency’s policies and procedures for their emergency preparedness plan and staff interview, the agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have a policy and procedure in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency’s emergency preparedness plan, updated most recently in March 2023, failed to include a policy/procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. During an interview on 1/31/24 at 10:30 AM, Staff A, RN, reported an inability to find a policy/procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The above information was shared with Staff A, RN and Staff B, RN. Agency staff provided no further information prior to the end of the survey.”

“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 review of the agency’s emergency preparedness plan and agency staff interview, the agency failed to ensure training in emergency preparedness to existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 4 of 4 sampled employees (Staff A regular employee and Staff D, F, G contracted staff). Lack of emergency training for staff puts patients at an increased risk should an emergency situation arise and staff be needed to assist patients. Findings include: According to the agency’s emergency preparedness Training and Testing plan, dated March 2023, the agency will provide initial training in emergency preparedness policies and procedures to all new and existing staff and volunteers consistent with their expected roles. Provide emergency preparedness training at least annually either internally or externally with response partners. Maintain documentation of all training provided each fiscal year. Demonstrate staff knowledge of emergency procedures. Review of the agency’s emergency preparedness training revealed the following: 1. Staff A, Registered Nurse (RN), direct hire staff. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff D, Home Care Aide, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. 3. Staff F, Occupational Therapist, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. 4. Staff G, Physical Therapist, contracted staff. The agency was unable to provide documentation of any emergency preparedness training. Interview with Staff A, Interim Administrator, on 1/30/24 at 3:30 PM, reported no documentation of staff trainings could be located for Staff A, D, F, and G. The above findings were shared with Staff A, RN, and Staff B, RN. No further information was provided prior to the end of survey.”

“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 the agency’s emergency preparedness plan and agency staff interview, the agency failed to conduct and/or document any exercises to test their emergency plan in 2022 and 2023. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency’s emergency preparedness Training and Testing plan, dated March 2023, the agency would conduct training and testing that complies with federal and state laws. Review of the agency’s emergency preparedness testing and training information did not include any exercises in 2022 and 2023. Interview with Staff A, Registered Nurse, on 1/30/24 at 3:30 PM, reported no knowledge of when an event/exercise during 2022 and 2023. The above findings were shared with Staff A, RN, and Staff B, RN. No further information was provided prior to the end of survey.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on agency policy review, personnel file review and staff interview, the agency failed to ensure 1 of 3 sampled home care aides (Staff D), completed a home health aide training program that addressed all areas identified in the Medicare Conditions of Participation. The agency provided Home Health Aide services to 11 patients at the time of the survey and employed 4 Home Health Aide under contract. Failure to ensure Home Health Aides successfully complete competencies in required basic skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to ensure all newly hired home health aides are competent in all of the basic home health aide skills by successfully demonstrating competency in the performance of all of the “hands on” basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of “hands on” basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation, positioning, nutrition and fluid intake and range of motion. Basic home health aide competencies may not be demonstrated using a mannequin, pseudo-patient or volunteer or by using verbalization or simulation. According to the agency policy titled “Home Care Aide Service”, dated 2/2022, each home care aide will have completed the necessary training as outlined by the Iowa Department of Public Health. Staff D, Home Health Aide, had a hire date of 7/27/22. Staff D’s personnel file lacked documentation of successful completion of training for the basic skills of hair shampooing in sink, tub, and bed and sponge, tub, and shower bath. On 1/31/24 at 10:30 AM, during an interview, Staff A, Registered Nurse (RN), reported no evidence to show Staff D, HHA, had completed training for the basic skills of hair shampooing in sink, tub, and bed and sponge, tub, and shower bath. Staff A, RN, and Staff B, RN, received the above findings. The agency provided no further information prior to the end of the survey.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, patient interview, and agency staff interview, the agency failed to ensure accurate and through completion of pertinent components of the initial comprehensive assessment for 2 of 3 sampled patients with wounds at start of care. (Patient #3 and #4.) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. 2. Patient #4 had a start of care date of 3/21/23. a. The POC, dated 1/15/24 to 3/14/24, included orders for skilled nursing services. b. The update to the comprehensive assessment, dated 1?10/24, identified the patient had an abscess to the coccyx area. The assessment lacked documentation of an assessment of the abscess including measurements. c. The skilled nurse visit note, dated 1/25/24, included documentation the patient had a procedure on his/her abscess. The note lacked documentation of an assessment of the abscess area and provided no measurements.. The agency failed to complete an assessment including wound measurements for the patient’s wound area. The above findings reviewed with Staff A, RN and Staff B, RN. The agency provided no further information prior to the end of the survey. Findings Include: During an interview with Staff A, Registered Nurse (RN), January 30, 2024 at 2 PM, She reported the agency does not have a current wound care policy in place, reported they were looking at 2 different policies, but had yet to implement one. Staff A, reported that the expectation for wound care assessment would be wound assessments be performed every visit and include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least once weekly, the assessment will include wound measurements (length x width x depth in centimeters). 1. Patient #3 had a start of care date, 1/11/24. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 1/11/24, identified the patient had a wound with gangrene on the left foot and a diabetic ulcer on the right heel. The assessment lacked wound measurements for both wounds. b. Skilled nursing visit notes, dated 1/17/24, and 1/23/24, documented a general description of the wound on the left foot with gangrene, and the of the diabetic ulcer on the right heel, but lacked specific wound measurements of both wounds. c. During a home observation visit on 1-30-24, at 8:30 AM with staff B, surveyor observed wound care completed with no measurements obtained during the visit. During the home visit, a patient interview was completed with patient and spouse. The spouse reported the wound with gangrene is not improving, reported they were waiting on decision from physician on future treatment likely including partial amputation of the left foot. Agency failed to obtain baseline wound measurements on the initial comprehensive assessment and on subsequent skilled nurse visits.”

“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 clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 8 sampled patients (Patients #1, #2, #4). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #2 had a start of care date of 12/28/2023. Home visit observation, clinical record review, and accompanying patient interviews revealed the following: a. The Plan of Care (POC), dated 12/28/23 - 2/25/24 included orders for skilled nursing services and medications for the patient. b. The Medication Profile, dated 1/5/24, included medications for the patient. c. During a home observation visit on 1-29-24, at 12:00 PM, with staff E, Physical Therapy Assistant, surveyor identified patient had medications beside his chair that were not included in the plan of care. Patient reported that he takes ibuprofen on a regular basis because the hydrocodone and tylenol were not controlling his pain, and that he used different analgesic muscle rubs and sprays to help with pain control. Patient also reported that on occasion he used melatonin to help him sleep. Agency failed to identify and document all medications on the plan of care and medication profile including ibuprofen, melatonin and analgesic muscle rubs and sprays the patient is self administering. The above findings were shared with staff A, RN and staff B, RN. No further information provided prior to the end of survey. 2. Patient #4 had a start of care date of 3/21/23. Clinical review revealed the following: a. The POC, dated 1/15/24 to 3/14/24, included the following DME: oxygen, wheelchair and bedside commode. b. The skilled nurse note, dated 1/10/24, included documentation the patient incontinent and required incontinent products. The agency failed to include the DME incontinent products to the POC> Patient #1 had a start of care date of 1/17/24. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The Plan of Care (POC), dated 1/17/24 to 3/16/24, included the following durable medical equipment (DME) used by the patient: Adult diapers, walker, cane, shower chair, hand-held shower, long handled sponge, and grab bars/safety rails. b. During a home visit observation on 1/29/24 at 2:00 PM, with Staff A, Registered Nurse (RN), the surveyor identified the following additional DME in the home: Medication cassette, scale, pulse oximeter, urinal, and nebulizer. c. Interview with Staff A, RN, during the home visit observation revealed that agency provided the medication cassette at start of care for medication set up and the scale is utilized weekly to weigh the patient. d. Interview will Pt #1 revealed pulse oximeter, urinal, and nebulizer have been utilized for “a long time” due to his health issues. The POC failed to identify the DME medication cassette, scale, pulse oximeter, urinal, and nebulizer.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 4 of 4 sampled patients with new verbal/interim orders. (Patients #1, #4, #6 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: 4. Patient #7 had a start of care date of 12/5/22 Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 12/5/22 to 2/2/23, included orders for skilled nursing services and medications for the patient. b. Physician’s interim order dated,12/21/22, included a change in the dosage of the medication Valsartan (to lower blood pressure) Order changed the dosage from 40 mg once a day in the morning to 20 mg once a day in the morning. c. Physicians Interim order dated, 1/12/23, included a change in the time of day the medication Valsartan 20 mg, was to be taken from morning to evening. d. Physicians interim order, dated 1/12/23, included a change in the frequency of the medication, Glipizide Extended release,(diabetes medication to lower blood sugar) 2 mg from one tablet every day to one tablet every other day. e. Physicians interim order, dated 1/2/24, included frequency for Physical Therapy Visits, for two times a week for two weeks. The agency failed to ensure the POC was updated to include all interim patient care orders for medications and visit frequencies. The above findings were reviewed with Staff A, RN and Staff B, RN , the agency presented no additional information prior to the end of the survey. 3. Patient #1 had a start of care date of 1/17/24. Review of the clinical record revealed the following: a. The POC, dated 1/17/24 to 3/16/24, included orders for skilled nursing services, aide services, and medications for the patient. b. The physician’s order, dated 1/26/24 at 11:42 AM, included Aspirin 81 mg oral tablet 1 time a day, Vitamin D3 25 micrograms (mcg) capsule 1 time a day, and discontinue Prednisone (steroid) 20 mg oral tablet once a day. c. The physician’s order, dated 1/26/24 at 11:45 AM, included Thermotabs 287mg-180mg 1 tablet orally 3 times a day for 7 days (Start 1/26/24 End 2/1/24). d. The physician’s order, dated 1/26/24 at 11:49 AM included discontinue effective 1/26/24: Xalatan 0.005% ophthalmic solution apply 1 drop in each eye once a day. e. The physician’s order, dated 1/26/24 at 3:58 PM included discontinue effective 1/26/24 rosuvastatin (high cholesterol) 10mg capsule orally once a day and start rosuvastatin 20mg oral tablet once a day. The agency failed to ensure the POC was updated to include all patient care orders to reflect new medications (Aspirin, Vitamin D3, Thermotabs), changed doses (rosuvastatin), and discontinued medications (Prednisone, Xalatan). During an interview on 1/30/24 at 8:40 AM Staff A, Registered Nurse (RN) stated the agency did not complete updates to the Plan of Care to include new physician orders. 1. Patient #4 had a start of care date of 3/21/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/15/23 to 3/14/24, included orders for skilled nursing services and medications for the patient. b. The physician’s order, dated 11/30/23 included Doxycycline (antibiotic) 120 milligrams (mg) 2 times a day for 15 days. The agency filed to ensure the POC was updated to include all patient care orders to include Doxycycline. 2. Patient #6 had a start of care date of 6/1/23 and discharge date of 6/20/23. Review of the clinical record revealed the following: a. The POC, dated 6/1/23 to 7/30/23, included orders for skilled nursing services. b. The physician’s order, dated 6/20/23 included orders to decrease skilled nursing services to weekly and as needed. The agency filed to ensure the POC was updated to include all patient care orders to include a decrease in skilled nursing services.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and policy review the agency failed to authorize in writing by the administrator and the governing body a qualified pre-designated person who assumes the same responsibilities and obligations as the administrator. Failure to authorize a pre-designated person to assume the same responsibilities and obligations puts agency patients at risk for receiving inconsistent services. Findings include: During an interview on 1/29/23 at 1:40 PM Staff A, Registered Nurse (RN) stated the Administrator on vacation and considered the Clinical Manager as well. Staff A identified she would be the back-up for the Administrator if she is not in the office but had no title and not identified in writing. Review of the Governing Body Minutes, dated 3/13/19, included the Board of Health approval of the Administrator. The note failed to included a pre-designated person to assume the same responsibilities and obligations as the administrator. Staff A, RN, and Staff B, RN, received the above findings. The agency provided no further information prior to the end of the survey.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient’s transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 3 sampled patients with transfers/ discharges (Patients #8). Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: Patient #8 had a start of care date of 2/16/14. Clinical record review revealed: a. The Plan of Care, dated 11/25/23 to 1/26/24, included orders for skilled nursing services. b. The transfer assessment, dated 12/29/23, documented the patient was transferred to the hospital. c. Review of the medical record lacked documentation of a transfer summary. The agency failed to complete a transfer summary. The above information provided to Staff A, Registered Nurse (RN) and Staff B, RN. No further information provided prior to the end of the survey.”