Greenbelt Home Care

“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 staff interview, clinical record review and agency policy review, the agency failed to complete a hazard risk assessment (HVA), create an Emergency Preparedness Plan (EPP) from a HVA, and formulate strategies to use for events on a HVA. Failure to complete a HVA may lead to creating an EPP that does not include hazards identified as at risk for the agency. Failure to identify strategies for the agency to use for risk identified on a HVA may lead to the inability to care for patients in the event of an emergency. Findings include: According to the agency policy titled Emergency Preparedness Plan, dated 9/23/25, examples of events include: tornadoes, floods, snowstorms, chemical spills, industrial accidents, automobile accidents involving multiple injuries, earthquakes, biohazardous weapons, pandemic, and Avian influenza. The policy did not include directives about how the events were determined, or information about using a HVA to create the EPP. The policy did not include strategies to use for the emergency events listed in the EPP. Review of agency documents for emergency preparedness revealed a HVA was performed in 2023. Agency documents failed to reveal a HVA for 2025 or 2024. In an interview on 1/7/26 at 8:45 AM, Staff E, Registered Nurse (RN), reported that the list of emergency events identified on the EPP were from a HVA performed by Staff E for the county as Staff E is also the county Public Health Coordinator. Staff E and the Administrator reported that they were not aware that a HVA was required for the home health agency. Staff E reported that the agency did not have strategies to use for the emergencies listed in the EPP. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 staff interview, clinical record review and agency policy review, the agency failed to complete a specific home health aide care plan for foot care for 2 of 3 sampled patients with home health aide services (Patients #1 and #7). Failure to create a specific home health aide care plan to direct the home health aide in how to provide foot care for patients could lead to inaccurate care which could lead to adverse outcomes to patients. Findings include: 2. Patient # 7 had a start of care date of 8/6/25 and a discharge date of 9/25/25. Clinical record review revealed: a. The POC, dated 8/6/25 to 10/4/25, included orders for skilled nurse and home health aide services. b. The Aide care plan, dated 8/6/25, included instructions that directed the aide to provide foot care weekly. The nurse failed to specify what foot care the aide should provide to the patient. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Home Health Aide Care Plan, dated January 2020, the purpose of the home health aide care plan was to provide a means of assigning duties to the home health aide that are clear to the nurse, home health aide, and to the client/caregiver being served. 1. Patient # 1 had a start of care date of 11/16/24. Clinical record review revealed: a. The Plan of Care (POC), dated 11/11/25 to 1/9/26, included orders for skilled nurse and home health aide services. b. The Aide care plan, dated 11/11/25, included instructions that directed the aide to provide foot care at every visit. The nurse failed to specify what foot care the aide should provide to the patient.”

“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 home visit observations, patient interviews, staff interview, clinical record review and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication Profile/Drug Regimen Review (DRR), dated January 2020, the admission nurse will check all medications the client may be taking and will perform a DRR to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, drug interactions, duplicate drug therapy and contraindicated medication. The medication profile will be updated and a DRR will be completed during start of care, recertification, resumption of care, discharge or any time there is a change or discontinuation of a medication. During an interview on 1/6/26 at 1:42 PM, Staff B, Clinical Manager stated DRRs are completed at all assessment time points and whenever medication changes occur. 1.Patient #2 had a start of care date of 8/28/18. Clinical record review revealed: a. The Plan of Care (POC), dated 11/19/25 to 1/17/26, identified the patient had a diagnosis of Schizoaffective disorder, bipolar type and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 11/18/25, completed by Staff F, Registered Nurse (RN), included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/6/26 at 10:30 AM with Staff G, Licensed Practical Nurse (LPN), the surveyor identified the following medication discrepancy: The agency medication profile, dated 1/5/26, identified the patient takes Quetiapine Fumarate 25 milligrams (mg) with instructions to take 1 tablet by mouth 1 time daily as needed for anxiety; start date 9/1/25. The bottle in the home, last filled 9/25/25, identified the patient takes Quetiapine Fumarate 25 mg with instructions to take 1 tablet by mouth 2 times daily as needed for anxiety. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #3 had a start of care date of 3/4/25. Clinical record review revealed: a. The POC, dated 12/29/25 to 2/26/26, identified the patient had a diagnosis of Type II diabetes and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 12/24/25 completed by Staff F, RN, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/5/26 at 3:00 PM with Staff F, RN, the surveyor identified Famotidine (acid reducer) on the patient’s active medication profile; however, the RN did not set up the medication in the patient’s medication planner. d. During an interview, the patient identified he/she does not have Famotidine and he/she has not taken the medication for greater than 2 months. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator and Clinical Manager.”