Pike County Health Department

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on document review and interview, it was determined the facility failed to review and update the Emergency Plan for the Agency at least every two years. The Emergency Plan manual was reviewed on 2/21/24 at approximately 2:00 PM. The manual noted the last time the Emergency Plan was reviewed and updated was 3/2021. The plan lacked review of at least every 2 years. 2. During an interview on 2/22/24 with E# 1 (Director of Nursing) at approximately 11:00 AM. E#1 verbally confirmed that 3/2021 was the last signed review of the Emergency Plan.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on document review and interview, it was determined for 1 of 2 (Pt. #3) patients with Aide services, the Agency failed to ensure visits were conducted in accordance with the physician’s ordered plan of care. Findings include: 1. The policy titled “Visit Frequency” was reviewed on 2/21/24 at approximately 11:00 AM. The policy noted “....4. If any visits are...omitted outside the POC (plan of care)/ 485 ordered visit frequency...the order must then be sent to the health care professional responsible for the home health care plan of care for signature...” 2. Pt #3 Start of Care: 01/27/24 Diagnosis: Idiopathic Aseptic Necrosis of Left Femur. The clinical record was reviewed on 2/21/24 at approximately 2:00 PM. The POC dated 1/27/24 noted an order for the Aide to visit the pt. 2 times a week beginning 1/29/24. The record noted a missed visit by the Aide on 2/9 and 2/26/24. The missed visit note lacked documentation the physician was notified. 3. During an interview with the Director of Nursing (E#1) on 2/21/24 at approximately 12:40 PM. E#2 verbally agreed that the doctor wasn’t notified of the missed visits.”

“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 document review and interview, it was determined for 1 of 2 (Pt #3) patients receiving home health aide services, the Agency failed to ensure the the Aide completed care and services as ordered on the plan of care Findings include: 1. Pt #3 Start of Care: 01/27/24 Diagnosis: Idiopathic Aseptic Necrosis of Left Femur. The clinical record was reviewed on 2/21/24 at approximately 2:00 PM. The Aide Care Plan dated 1/27/24 completed by the Registered Nurse, noted, weigh patient every visit. Between 1/31/24 and 2/12/24, 4 out of 5 Aide visit notes lacked weights. 2. During an interview with the Director of Nursing (E#1) on 2/21/24 at approximately 12:40 PM. E#2 verbally agreed that the Aide didn’t weigh the patient as per care plan.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on document review and interview, it was determined in 3 of 7 (Pt #1, Pt #3 and Pt #6), patient records reviewed, the Agency failed to ensure documentation was appropriately authenticated within the required timeframe. Findings include: 1. The Policy titled “Clinical Documentation and Filing Timelines” (revised 11-4-21) was reviewed on 2/20/2024 at approximately 11:00AM. The policy noted on page 1, “If using computer system, visits must be locked and closed within 24 hours.” 2. The clinical record of Pt #1 was reviewed on 2/20/2024 at approximately 1:00PM. Pt #1 was SOC (Start of Care) was on 1/18/2024 with the diagnosis of Critical illness myopathy. Pt #1’s clinical record was reviewed, and it was noted 3 of 18 clinical visits reviewed were not locked and closed within 24 hours. Skilled nursing visit dated 1/18/2024 and closed on 1/26/2024. Scheduled physical therapy visit dated 1/19/2024 and closed on 1/30/2024. Physical therapy visit dated 2/1/2024 and closed on 2/12/2024. 3. The clinical record of Pt #3 was reviewed on 2/21/24 at approximately 2:00 PM. Pt #3 SOC was on 1/27/24 with the diagnosis Idiopathic Aseptic Necrosis of Left Femur. It was noted 1 SN (Skilled Nurse) visit dated 2/15/24 was closed on 2/20/24 and 1 PT (Physical Therapist) visit note dated 2/15/24 was closed on 2/20/24. 4. The clinical record of Pt # 6 was reviewed on 2/21/2024 at approximately 1:30 PM. Pt #6 was admitted on 12/5/2023 with the diagnosis of Alzheimer’s disease with late onset. Pt #6’s clinical noted 2 of 12 clinical visits reviewed were not locked and closed within 24 hours. Scheduled skilled nursing visit dated 12/5/2023 was closed on 12/12/2023. Physical therapy visit note dated 12/19/2023 was closed on 12/26/2023. 5. During an interview on 2/21/2024 at approximately 11:00AM, E #1 (Director of Nursing) reviewed Pt #1, Pt#3 and Pt #6’s record and verbally agreed that the clinical visits were not locked and closed within 24 hours.”