Butler County Phns

“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/policies, personnel file review and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing contracted staff consistent with their expected roles at the time of orientation for 1 of 3 sampled contracted staff (Staff C, Occupational Therapist). Lack of emergency preparedness (EP) training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the undated agency policy titled Emergency Operations (EOP) Plan Home Care, emergency preparedness training will be conducted annually. Documentation of the training on the EOP and annual emergency preparedness training will be maintained by the administrator. During an interview on 8/12/26 at 10:06 AM, the Administrator reported that the EP training for staff C, OT was not able to be located. Review of Staff C’s personnel file lacked documentation of EP training for 2025. The agency failed to ensure all staff completed annual training in emergency preparedness. The above finding was reviewed with the Administrator.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to accurately encode Outcome and Assessment Information Set (OASIS) data items collected with each comprehensive assessment accurately to reflect the patient’s status at the time of assessment for 1 of 7 sampled patients (Patient #5). Failure to transmit accurate OASIS data for patients, at specific time points, did not provide accurate information to those payers in order to determine correct payment, patient outcomes, or the agency’s use of best practices. Findings include: Findings include: Patient #5 had a start of care date of 9/23/24. Clinical record review revealed: a. Plan of Care, dated 9/23/24 to 11/21/24, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing services. b. Comprehensive assessment completed at start of care, dated 9/23/24, completed by Staff G, Registered Nurse, included documentation physician ordered start of care date was not applicable. c. Referral intake form, dated 9/20/24, identified referral was received on 9/20/24 and patient would be admitted on 9/23/24 when labs are ordered to be drawn per verbal order from primary care physician. During interview on 8/12/26 at 10:54 AM, Staff A, Administrator, reported she reviewed the clinical record and confirmed to physician ordered start of care date was entered inaccurately and was not caught on review. The nurse failed to complete the comprehensive assessment accurately to reflect the physician ordered start of care date that was outside the 48 hour regulatory time frame. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. According to agency policy titled, Policies and Procedures for Using OASIS, dated August 2007, the encoded OASIS data will accurately reflect the client’s status at the time of assessment.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on staff interview, in- service education training documentation, and agency policy review, the agency failed to maintain documentation that 1 of 1 sampled home health aide (Staff C), employed for more than 1 year, completed a minimum of 12 hours of in- service educational training annually. The agency employed 3 home health aides (HHA) at the time of the survey. Failure to have HHA receive 12 hours of in-service training annually increased the potential that HHA lacked updated and current information related to the care provided by the hospice aides. Findings include: According to the agency policy titled Inservice Education/Staff Development, dated August 2006, the HHA must complete twelve hours per year either per lecture, video inservices, or in the client home while providing care. During a concurrent in- service education training documentation review and interview on 8/12/26 at 10:06 AM, the Administrator reported that it is unknown why Staff D, HHA, did not include the year with the date the training was completed and was not certain when the training was completed on the form. Staff D had a hire date of 9/30/19. Staff D’s personnel file contained a document titled Home Care Aide (HCA) In-Service Hours. 5 of the entries included that the training was completed in 2025 and 15 entries were dated with the month and date of the training. The agency failed to maintain documentation of when HHA in-service training was held including the year and ensure the HHA received 12 hours of in-service education. The above finding was reviewed with the Administrator.”

“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 review and agency policy review, the agency failed to ensure the registered nurse (RN) developed home health aide (HHA) instructions for patient care that were specific and individualized to the patient’s needs for 1 of 4 sampled patient receiving HHA services (Patient #1). Failure to identify specific tasks for the HHA to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner. Findings include: Patient #1 had a start of care date of 12/13/24. Clinical record review revealed: a. Plans of Care, dated 6/6/26 to 8/4/26 and 8/5/26 to 10/3/26, included primary diagnosis of Parkinsonism and mild cognitive impairment and physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 6/6/25, included tasks: apply Benadryl cream to itchy areas per patient request after shower, do not apply hydrocortisone cream; and apply hydrocortisone cream to itchy area per patient request, do not apply Benadryl cream. Aide care plan failed to provide clear instructions to home health aides and directed aides to follow patients request which may not be appropriate due to patient’s cognitive impairment. During an interview on 8/12/26 at 8:20 AM, Staff A, Administrator, confirmed aide instructions were not clear. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. According to agency policy titled Home Care Aide Care Plan, dated July 2010, a complete and appropriate Care Plan, identifying duties to be performed by the home health aides (HHA) shall be developed by a Registered Nurse (RN). The purpose of the HHA Care Plan is to provide a means of assigning duties to the HHA that are clear to the nurse, HHA and to the client/caregiver being served, During an interview on 8/11/26 at 12:07 PM, the Clinical Manager reported that the admitting RN creates the HHA Care Plan and the HHA Care Plan is reviewed at every skilled nursing visit.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on agency policy review, and clinical record review, the agency failed to ensure accurate completion of all pertinent components of the start of care comprehensive assessment within the regulated time frame for 1 of 7 sampled patients. (Patient #5), Failure to accurately and thoroughly complete the start of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: Patient #5 had a start of care date of 9/23/24. Clinical record review revealed: a. Plan of Care, dated 9/23/24 to 11/21/24, included primary diagnosis of Type 2 Diabetes Mellitus and physician orders for skilled nursing services and blood work to be drawn. b. Comprehensive assessment completed at start of care, dated 9/23/24, completed by Staff G, Registered Nurse, included electronically signed and competed on 10/4/24, 14 days after the visit, 9 days late per regulations. The nurse failed to complete the comprehensive assessment in the required 5 day time frame. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on staff interview, clinical record reviews and agency policy review, the agency failed to provide a complete comprehensive assessment for patients with wounds for 3 of 3 sampled patients (Patients #2, #3 and #6). Failure to accurately and thoroughly complete wound assessments or provide a comprehensive assessment placed patients at an increased risk of unidentified condition changes. Findings include: 2. Patient #3 had a start of care date of 8/1/26. Clinical record review revealed: a. Plan of Care, dated 8/1/26 to 9/29/26, included primary diagnosis of right femur fracture and physician orders for skilled nursing services. b. Comprehensive assessment completed at start of care, dated 8/1/26, completed by Staff F, RN, included documentation of 2 right knee incisions, well approximated with scabbing to upper and lower end of main vertical incision and small horizontal incision below vertical incision has intact scab. The assessment failed to include documentation of wound measurements per agency policy. c. Skilled nurse visit note, dated 8/6/26, completed by Staff B, Clinical Manager, included documentation incision on right knee was assessed, pea size scab at top and bottom of incision and scattered small scabs throughout incision, rest of incision intact and closed. The assessment failed to include documentation of wound measurements per agency policy. During an interview on 8/12/26 at 8:25 AM with Staff A, Administrator, she reported the incision was approximated and scabbed, she did not think scabs needed measured. The nurses failed to document wound measurements, including length, width and depth, weekly per agency policy. 3. Patient #6 had a start of care date of 5/6/25 and a discharge date of 1/29/26. Clinical record review revealed: a. Plan of Care, dated 11/2/25 to 12/31/25, included primary diagnosis of Malignant neoplasm of endometrium (cancer of the lining of the uterus) and physician orders for skilled nursing services. b. Skilled nurse visit note, dated 12/8/25, completed by Staff A, Administrator, included documentation red areas on left upper thigh and left upper buttocks remain unchanged. The assessment failed to include documentation of wound measurements per agency policy. c. Skilled nurse visit note, dated 12/11/25, completed by Staff A, Administrator, included documentation red areas on left upper thigh and left upper buttock remain unchanged. The assessment failed to include documentation of wound measurements per agency policy. During an interview on 8/12/26 at 10:54 AM with Staff A, Administrator, she reported reviewed the clinical record and confirmed documentation wounds were unchanged but no measurements were documented. The nurse failed to document wound measurements, including length, width and depth, weekly per agency policy. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. According to the agency policy, titled Wound Assessment and Documentation, dated August 1999, wounds should be measured weekly and assess the wound length, width and depth. During Interview on 8/11/2 at 12:07 PM, the Clinical Manager reported that wounds should be measured weekly and include measurement of height, width and depth, periwound, drainage, odor and color. 1.Patient #2 had a start of care date of 7/6/17. Clinical record review revealed: a. The plan of care (POC), dated 5/20/26 to 7/18/26, included primary diagnosis of infection of end stage renal disease and orders for skilled nurse services. b. Skilled nurse assessment, dated 6/9/26, completed by Staff B, Clinical Manager, included documentation that the patient had an ulcer to the patient’s left great toe. The wound bed was assessed as 100% granulation. The wound measured 1 centimeter (cm) by 0.9 cm. The assessment failed to include documentation of measurements of wound depth. d. The skilled nurse assessment, dated 6/16/26, completed by Staff E, Licensed Practical Nurse (LPN), included documentation that the patient had an ulcer to the patient’s left great toe. The wound bed was assessed as 100% granulation. The wound measured 1 centimeter (cm) by 0.9 cm. The assessment failed to include documentation of measurements of wound depth. The skilled nurse assessments failed to include documentation of measurements of wound depth per agency policy.”

“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 staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review (DRR) with comprehensive discharge assessments for 2 of 2 sampled patients (Patients #6 and #7). Failure to ensure medications reviewed at the time of each DRR are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 2. Patient #6 had a start of care date of 5/6/25 and a discharge date of 1/29/26. Clinical record review revealed: a. Plan of Care dated 1/1/26 to 3/1/26, identified primary diagnosis of Malignant neoplasm of endometrium (cancer of the lining of the uterus) and physician orders for skilled nursing and home health aide services. b. Comprehensive assessment completed at discharge, dated 1/29/26, completed by Staff A, Administrator, lacked documentation of a Drug Regimen Review. During an interview on 8/12/26 at 10:54 AM, Staff A, Administrator, reported she had reviewed the clinical record and confirmed no Drug Regimen Review had been completed for the discharge comprehensive assessment. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. According to the agency policy titled Policies and Procedures for Using Outcome and Assessment Information Set (OASIS), dated August 2007, the comprehensive assessment will be updated and revised when a patient is discharged from the agency. The comprehensive assessment will include a review of all medication in the home including the ones the client is currently using. The review is done to identify all potential interactions or adverse effects not just significant, severe or actual ones, including ineffective drug therapy and non-compliance with drug therapy. During an interview on 8/11/26 at 12:07 PM, the Clinical Manager reported that a DRR is completed with the discharge and is performed by the nurse assigned to that visit. 1.Patient #7 had a start of care date of 6/24/26 and a discharge date of 7/1/26. Clinical record review revealed the following: a. The plan of care (POC), dated 6/24/26 to 8/22/26, identified primary diagnosis of encounter for adjustment and management of vascular access device (VAD) and physician orders for skilled nursing services. b.Comprehensive assessment at discharge, dated 7/1/26, completed by Staff F, Registered Nurse (RN), lacked documentation of a DRR. The skilled nurse failed to complete a DRR at discharge.”

“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 a home observation visit, staff interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medications used by the patient for 1 of 3 sampled patients with home observation visits (Patient #1). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders Findings include: Patient #1 had a start of care date of 12/13/24. Clinical record review revealed Plans of Care, dated 4/7/26 to 6/5/26, 6/6/26 to 8/4/26 and 8/5/26 to 10/3/26, included primary diagnosis of Parkinsonism and physician orders for skilled nurse services and medications, including Ibuprofen 200 milligrams (mg) oral tablet; take 1 tab once a day (in the morning). During a home observation visit, 8/11/26 at 11:40 AM, with Staff G, Registered Nurse (RN), surveyor observed Staff G, RN, set up medications. Staff G, RN, set up Ibuprofen 200 mg tablet in the morning box and the 200 mg in the evening box. Staff G, RN, reported during home observation visit, Patient #1 has requested to have meds set up this way. Staff G, RN, took over as case manager for Patient #1 approximately one month ago, unsure how long Ibuprofen has been set up this way. Patient medication list in the home, typed by patient’s brother/caregiver, dated 4/7/26, identified Ibuprofen to be placed in morning and evening medication boxes. Nurse failed to obtain physician order for change in Ibuprofen administration and update Plan of Care to include new order and accurate medication administration. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. According to agency policy titled, Plan of Care (POC), dated July 2010), the POC shall be completed in full to include medications. Verbal orders shall be obtained from the client’s physician for changes in the POC.”

“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 agency staff interview and clinical record review, the agency failed to ensure a registered nurse (RN) or other appropriate health care professional completed home health aide (HHA) supervision at least every 14 days for 1 of 3 sampled patients with HHA services longer than 14 days (Patient #6). Failure to supervise HHA services at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from the HHAs. Findings include: Patient #6 had a start of care date of 5/6/25 and a discharge date of 1/29/26. Clinical record review revealed: a. Plans of Care, dated 11/2/25 to 12/31/25 and 1/1/26 to 3/1/26, included primary diagnosis of Malignant neoplasm of endometrium (cancer of the lining of the uterus) and physician orders for skilled nursing and home health aide services. b. Comprehensive assessment completed at recertification, dated 12/30/25, completed by Staff A, Administrator, included documentation of home health aide supervision. c. Skilled nurse visit note, dated 1/15/26, completed by Staff A, Administrator, included documentation of home health aide supervision, 16 days after the last supervision visit, 2 days late per regulations. During an interview on 8/12/26 at 10:54 AM Staff A, Administrator, confirmed aide supervision was not documented on the visits between 12/30/25 and 1/15/26. The above stated findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”