Wel-Home Health of Sergeant Bluff

“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, review of agency emergency preparedness training and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 2 of 4 sampled employees (Staff C and D). Lack of emergency preparedness 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 agency’s policy titled Emergency Operations Plan, Training Program, dated August, 2023, the agency will provide emergency preparedness training at least every two years. Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies that occurred in the last two years and during review of the emergency operations plan every two years. During an interview on 3/6/24 at 9:30 AM the Vice President of Operations stated contracted staff had not been provided training on the agency’s Emergency Preparedness policy. Review of the agency’s emergency preparedness training revealed the following: 1. Staff C, Occupational Therapist, had a hire date of 7/31/18. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff D, Physical Therapy Assistant, had a hire date of 4/23/17. The agency was unable to provide documentation of any emergency preparedness training. The above stated findings shared with the Administrator. The agency provided no further information prior to the end of the survey.”

“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 agency policy review, clinical record review, staff and patient interview, and home observation visit, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment, and medications used by the patient for 2 out or 3 home observation visits. (Patient #2 and #3) Failure to maintain a complete and accurate Plan of Care, including necessary DME/Equipment, placed patients at risk of not receiving safe, effective and individualized care to meet each patients health care needs. 2. Patient #2 had a start of care date of 2/8/24. The POC, dated 2/8/24 to 4/7/24, included the following DME: brace/orthotics, elevated toilet seat, grab bars, Hoyer lift, oxygen, tub/shower bench, walker, wheelchair, oxygen/supplies, hand held shower and lift chair. During an observation home visit on 2/5/24 at 12:40 PM with Staff C, Occupational Therapist, the surveyor observed the patient to have a wheelchair ramp, wheelchair cushion and incontinent products. During an interview at the same observational home visit the patient’s family stated the patient utilized the DME prior to the start of home health services. The agency failed to include all DME on the POC the patient required which included the wheelchair ramp, incontinent products and wheelchair cushion. The above stated findings shared with the Administrator. The agency provided no further information prior to the end of the survey. According to agency policy, titled Plan of Care - CMS 485 and Physician/Practitioner orders, dated December 2020, the individualized plan of care must include all medications and treatments. All patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so that all Agency staff are working from a current plan. Orders are verified when there are questions or discrepancies with orders. Physician/practitioner services will be provided by a licensed Doctor of Medicine, include prescribing medications and therapeutic regimens. 1. Patient #3, had a start of care date 6/13/23. Review of the clinical record, staff interview and patient interview revealed the following: The Plan of Care (POC), dated 2/8/24 to 4/7/24, included physicians orders for all medications and supplements. a. On 3/5/24 at 10:30 AM , during a home visit observation, Staff B, RN (Registered Nurse) set up medications in a daily planner for Patient #3. The POC included orders for: green tea extract 500 milligrams (mg) to be taken once a day, cinnamon 500 mg capsule to be taken once a day, advantage digestive lactose supplement 1-2 tablets once a day, and Vitamin A 2,400 mg once a day. These supplements were not available for medication set up in the home. b. During the same observation visit, Staff B, RN set up the following supplements; apple cider vinegar 450 mg tablet once a day, garlic 100mg capsules once a day and cod liver oil 500 mg once a day. The POC lacked orders for these supplements. c. During the same home observation visit, Staff B, RN , set up the supplement fish oil 500 mg once a day , POC orders for this supplement to be taken 500 mg twice a day. d. In an interview with Staff B, RN during the same home observation visit, She stated the patient didn’t always pick up the supplements ordered at the store, and would frequently change his/her mind about what supplements he/she wanted to take. She also stated that she was working with the patient to decrease the number of supplements and had plans to discontinue supplements as he/she ran out. e. During an interview with Patient #3, also during the home observation visit, he/she stated was taking a whole tablet of the medication Trazadone, 100 mg (medication used to help with sleep and depression) at bedtime. The POC included the order for Trazadone 50 mg at bedtime. (equal to a half tablet) The Agency failed to obtain updated orders for supplements the RN was setting up in the home daily medication planner, and failed to obtain updated order for prescription medication patient self-administered. f. The POC, dated 2/8/24 - 4/7/24, included the following DME: cane, grab bars, walker, wheelchair, electric wheelchair and mediplanner. g. During an observation home visit on 2/5/24 at 10:30 AM, with Staff B, Registered Nurse, the surveyor observed the patient to have a shower/tub bench and no slip mats in the shower. During an interview at the same observational home visit the patient stated he/she received those items a while back through the insurance case manager so he could could still shower independently. The agency failed to include all DME on the POC the patient required which included the tub/shower bench and no slip bath mats in the shower.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on clinical record review, agency aide supervision guidelines and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 1 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #5). The agency reported 13 patients who received personal care assistance by a home health aide while also receiving skilled service provision. Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency’s Home Health Aide Supervision, dated February 2022, 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 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 must make an onsite visit to the patient’s home no less frequently than every 14 days. During an interview on 3/5/24 at 8:20 AM, the Administrator stated the home care aide supervision completed by the Registered nurse every 14 days if skilled services provided for the patient. On 4/22/19 at 1:34 PM, during an interview, Staff A, Administrator, reported the nurse documented supervision of the home health aide in the nursing assessment visit. Patient #5 had a start of care date of 12/8/23. The Plans of Care (POCs), dated 12/8/23 to 2/5/23 and 2/6/23 to 4/5/23, included physician orders for skilled nursing and home health aide services. Review of the clinical record included the following: a. The clinical record included home health aide services 2 times a week beginning 12/14/23. b. Documentation of home health aide supervision, dated 1/23/24. (5 weeks after the start of home health aide services). The agency failed to complete home health aide supervision every 14 days. The above information provided to the Administrator. 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 2 sampled patients with transfers/ discharges (Patient #7). 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: According to the agency policy titled, Discharge Summary, dated July 2021, the discharge summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. During an interview on 3/6/24 at 10:50 AM the Administrator the transfer summary and discharge summary were only sent to the primary care physician and not sent to the admitting facility. Patient #2 had a start of care date of 10/11/22 and discharged from the agency on 12/11/23. Clinical record review revealed: a. An interim physician’s order, dated 9/4/23, ordered to hold home health services on 9/3/23 until further notice due to the client in the hospital. b. A home health transfer summary completed by the Administrator, dated 9/4/23, included identification the patient transferred to the hospital and the summary sent to the primary care physician. c. An interim physician’s order, dated 12/11/23, ordered to hold home health services due to the client admitted to the hospital on 12/9/23. d. A home health discharge summary completed by the Administrator, dated 12/11/23, included identification the patient transferred to the hospital and the summary was sent to the primary care physician. The agency failed to send the transfer summary and discharge summary to the receiving hospital. The above findings shared with the Administrator. The agency did not provide further information prior to the end of the survey.”