Heartland Home Care

“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 agency policy review and staff interview, the agency failed to ensure the development of a procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed hospice 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 lacked a written policy and procedure for procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Interview on 4/17/24 at 11:00 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were reviewed with the Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of agency emergency preparedness policies and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place for to inform State and local officials of any patients they are unable to contact in the event of an interruption of services related to an emergency 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 lacked a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Interview on 4/17/24 at 11:00 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were presented to the Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on review of the emergency preparedness plan and related policies and staff interview, the agency failed to ensure the development of a policy and procedure for a medical documentation system that preserves patient documentation system that preserves patient information and confidentiality of patient information. Failure to have procedures in place for confidentiality of patient information placed patients at risk for not receiving needed assistance during or due to an emergency situation. Review of the emergency preparedness plan and related policies revealed the agency did not have a written policy and procedure for a system of medical documentation that preserves patient information and protects confidentiality of patient information. During an interview on 4/17/24 at 11: 30 AM, the Administrator reported she was unable to find a policy for the above concern. The above findings were reviewed with the Agency Administrator and the Office Manager, the hospice provided no further information prior to the end of the survey.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of the agency’s emergency preparedness plan and related policies, the agency failed to have a written policy and procedure for the use of volunteers in an emergency, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Failure to ensure the home health agency developed policies and procedures to address the use of volunteers or other emergency staffing strategies during an emergency, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include:a. Review of the agency’s emergency preparedness plan and related policies revealed a lack of a plan/procedure for the use of volunteers in an emergency or disaster situation. b. Review of the agency’s emergency preparedness plan lacked a written policy and procedure for the use of volunteers or other emergency staffing strategies during an emergency. Interview on 4/17/24 at 11:15 AM, Staff A, Administrator, confirmed there was not a written policy and procedure. The above findings were reviewed with the Administrator and the Office Manager, no additional information was presented prior to the end of survey.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on review of the agency’s emergency preparedness plan and staff interview, the agency failed to ensure agency staff developed and maintained an emergency communication plan that included a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. Failure to develop and maintain an emergency preparedness communication plan that included a method of sharing information and medical documentation for the agency patients to maintain the continuity of care during a time of disaster or emergency which could lead to poor client outcomes in the event of an emergency/disaster. Review of the agency’s Emergency Plan and related policies revealed the plan failed to include a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. On 4/17/24 at 11:00 AM, the Administrator acknowledged the agency’s communication plan failed to include a method of sharing information and medical documentation for the agency clients to maintain the continuity of care. The above findings were reviewed with the Administrator and the Office Manager, no additional information was presented prior to the end of 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 agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to all current staff annually. 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:During the review of the agency’s emergency preparedness plan, the plan lacked materials for training and documentation of training completion for staff . During an interview with the agency Administrator on on 4/17/24 at 11:30 AM, the Administrator indicated that no training for staff had been completed for the emergency preparedness plan. The above findings were reviewed with the Agency Administrator and the Office Manager, the agency provided no further information prior to the end of the 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 agency staff interview, agency policy review and review of testing documentation, the agency failed to conduct exercises to test the emergency plan by participating in a community based full scale exercise or an actual natural or man- made emergency that requires activation of the emergency plan, and an additional exercise that may include a second community based full-scale exercise, a mock disaster drill, or a tabletop exercise, that includes analyzing the facilities response to the event. 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: During an interview on 4/17/24, at 11:00 AM, with Staff A, Agency Administrator, stated no documentation of testing the plan existed. The agency failed to provide documentation of any exercises performed since the last survey included participation in an actual event or any type of table top exercise. The above findings were reviewed with the Agency Administrator and the Office Manager, the agency provided no further information prior to the end of the survey.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the update to the comprehensive assessment at discharge for 3 of 7 sampled patients requiring discharge from agency services (Patients #2, #6 and #7). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. According to the agency policy titled Client/Patient Record Management, dated 5/23, the drug regimen review will be a part of the plan of care under medications, section 10. The comprehensive assessments that are done every start of care, resumption of care, significant change i care, discharge and recertification period will have a page of the patient’s medications with the drug regimen review requirements as part of that document. In an interview on 4/16/24 at 8:59 AM, the Administrator/Clinical Manager reported that clinicians are expected to assess all medications at the time of discharge. 1. Patient #2 had a start of care date of 4/11/22. a. The plan of care (POC), dated 1/31/24 to 3/29/24 included orders for skilled nurse visit notes and orders for medications. b. The medication record identified the patient had orders for respiratory medications Atrovent and Albuterol sulfate. The orders also included duplicate bowel medications Miralax and Glycerin suppository. c. The drug regimen on the plan of care review failed to identify the patient had duplicate bowel and respiratory medications. 2. Patient #6 had a start of care date of 7/6/21 and discharge date of 3/10/22. The POC, dated 3/3/22 to 5/1/22, identified the patient received skilled nursing services and included medication orders. Review of the discharge summary, dated 3/10/22, lacked documentation of a drug regimen review completed on discharge. The agency failed to complete a drug regimen review upon discharge. 3. Patient #7 had a start of care date of 9/21/21 and discharge date of 2/2/22. The POC, dated 1/19/22 to 3/19/22, identified the patient received skilled nursing services and included medication orders. Review of the discharge summary, dated 2/2/22, lacked documentation of a drug regimen review completed on discharge. The agency failed to complete a drug regimen review upon discharge. The above findings shared with the Administrator/Clinical Manager. No further information provided 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, 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 and equipment used by the patient in 6 of 7 sampled patients. (Pt #1, #2, #3, #4, #5, #6) Failure to maintain a complete and accurate plan of care, with current orders, placed the patients at risk to not receive services, medications and treatments, equipment and supplies, according to assessed needs and the physician orders. 4. Patient #2 had a start of care date of 4/11/22. Clinical record review revealed the following: a. The POC, dated 1/31/24 through 3/29/24, identified the following DME: feeding pump/supplies, gastrostomy-tube/supplies, tracheostomy/supplies, lift, ventilators, cough assistive/vests and oxygen/supplies. b. The comprehensive assessment, dated 1/29/24, included documentation the patient required use of a wheelchair, diapers, pull ups and ankle foot orthotics (AFOs). The agency failed to include the required DME wheelchair, diapers/pull ups and ankle foot orthotics on the patients POC. 5. Patient #3 had a start of care date of 10/6/17. Clinical record review revealed the following: a. The POC, dated 3/3/24 through 5/1/24, identified the following DME: wheel chair, ventilators, suction machine, suction catheters, retention catheters, Shiley trach and supplies, AMBU bag, lift, bed pan. b. The skilled nurse note, dated 3/30/24, included documentation the patient required use of a “warm up”. c. During an interview on 4/16/24 at 2:00 PM the Administrator stated a warm up is a bean filled pack warmed up in the microwave for heat. The agency failed to include the required DME warm pack. 6. Patient #6 had a start of care date of 7/6/21. a. The POC’s, dated 11/3/21 to 1/3/22, 1/2/22 to 3/2/22 and 3/3/22 to 5/1/22, lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient. The above findings shared with the Administrator/Clinical Manager. No further information provided prior to the end of the survey. Findings Include: According to agency policy, titled Client/Patient Record Management, dated May 2023, The plan of care (POC) developed in consultation with Agency staff is written and updated by RN staff and covers all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications, and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, therapies, and any other appropriate items. 1. Patient #1 had a start of care date 3/7/2024. Clinical record review, home observation visit and accompanying interviews revealed the following: a. The Plan of Care, (POC) dated 3/7/24 through 5/5/24, identified G-tube (Gastronomy tube, a tube that enters the stomach to provide all of the nutrition the patient needs ) a feeding pump, and tracheostomy tube and supplies. (a tube that allows the patient to keep an open airway for breathing). b. During a home observation visit on 4/15/24 at 12:30 PM, with Staff A, Registered Nurse (RN), the patient was using a continuous pulse oximeter machine, (a monitor that keeps continuous record of the patients oxygen level and alarms if the oxygen level drops to low) c. During the same home observation visit, a humidifier was noted to be in use for the patient in the bedroom. d. During the same home observation visit, a nebulizer machine (used to inhale medications if patient has trouble with breathing or congestion) was noted as well as an ambu bag. (used to assist with breathing if patient should stop breathing in the case of emergency) The POC lacked identification of the pulse oximeter machine, nebulizer and an ambu bag, as medical equipment and supplies used by the patient. 2. Patient #4 had a start of care date of 11/15/21. a. The POC dated 11/15/21 lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient. 3. Patient #5 had a start of care date of 10/11/21. a. The POC dated 10/11/21 lacked specific orders for the dose with the Synagis injection (given to premature babies at risk for severe respiratory illness) to be given monthly by the agency nurse as well as orders for when to obtain patient weights to calculate the Synagis dosage. The agency failed to obtain complete physicians orders before administering medication to the patient.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on clinical record review, agency staff interview, and home observation visit, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 1 sampled patients (Pt #1) with home observation visits. Failure to follow physician orders for administration of medications or treatments provided by agency staff, placed the patient at risk for inconsistent care or treatment and possible harm. Findings include: Patient #1 had a start of care date of 3/7/2024. a. The Plan of Care, (POC) dated 3/7/2024, included orders for the patient to be upright or have the head of the bed elevated 30 degrees when feeding is administered to prevent aspiration. (liquid breathed into the airway) b. During a home observation visit on 4/15/24 at 12:15 pm, Surveyor observed Staff A, Registered Nurse begin a feeding through the gastronomy tube in the patients stomach. Patient was lying flat in the crib asleep at the time feeding was started. c. In an interview with the Staff A, Registered Nurse, (RN) on 4/17/24 at 9:00 AM, she acknowledged the POC included physician orders to ensure the patient is in an upright position or with the head of the bed elevated at least 30 degrees before administering the feeding. The RN failed to ensure the patient was in an upright position before administering the nutritional feeding. The above findings were reviewed with the agency Administrator and the Office Manager, the agency presented no additional information prior to the end of survey.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review, and agency staff interview, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician, for 1 of 7 sampled patients. (Patient # 1) Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings Include: 1. Patient #1 had a start of care date of 3/7/24. a. The Plan of Care (POC) was dated 3/7/24 and included orders for 160 Milliliters of formula to be given through the G-tube. ( G-tube is a gastrostomy tube inserted through the abdomen that brings nutrition directly to the stomach) 6 times a day. Review of the nursing documentation completed on 3/17/24 at 8 AM, indicated that the parent of the patient only administered 75 milliliters of the formula for 2 separate feedings in the night and stated she did not want to disrupt the patients sleep. The documentation lacked any physician notification that patient did not receive all of the nutrition ordered. Failure to notify the physician, orders were not followed by the parent in the home for amount of nutrition the patient requires, placed the patient at further risk for weight loss and worsening of patient condition.”