SSM Health at Home Health-Illinois

“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 document review and interview, it was determined the Agency failed to establish a bi-annual testing plan for its Emergency Preparedness Program (EPP), inclusive of participation in a full-scale community-based exercise every 2 years. Findings include: 1. On 2/27/2024 at approximately 1:00PM, the agency’s Emergency Preparedness training and testing of staff was reviewed. There was no community-based training or testing of staff documented. 2. On 2/27/2024 at approximately 2:00PM, an interview was conducted with the System Director of Home Health (E #3) reported she was not familiar with the community-based exercise. E #3 was unable to show documentation of bi-annual testing of staff for emergency preparedness plan exercise.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 12 (Pt #7) patients records reviewed, the Agency failed to ensure the initial assessment was conducted within 48 hours of referral. 1. On 02/27/24, at 11:00 AM, the HHA policy “Assessment of Patient and Clent (revised 01/24/24)” was reviewed. The policy stated, “... Process... 2 An initial assessment is made by SN (skilled nurse), PT (physical therapy) or ST (speech therapy) within 48 hours of the verbal start of care date as indicated on the 485. The initial assessment may be delayed beyond the standard 48 hours by physician order or patient/family preference...” 2. Pt #7 Start of Care: 02/20/24 Diagnoses: Pressure ulcer deep tissue right heel. On 02/27/24, at approximately 11:15 AM, the clinical record of Pt #7 was reviewed. Pt #7 was referred to the HHA on 02/07/24. The Plan of Care for certification period 02/20/24 to 04/19/24 indicated the initial assessment was conducted on 02/20/24. There was no physician order changing the start of care date. 3. On 02/27/24 at approximately 11:30 AM, an interview with the HHA Supervisor (E #2) was conducted. E #2 reviewed Pt #1’s record and verbally agreed the initial assessments were conducted more than 48 hours after the referral. E #2 stated “We have had some staff shortages. We should have gotten an order for a delayed start of care and did not.””

“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 document review, observation, and interview, it was determined for 1 of 7 (Pt #3) home visits, the Agency failed to ensure the patient’s home medication list was current and accurately reflected all medication names, dosages, and frequencies. Findings include: Pt #3 Start of Care (SOC): 2/17/2024 Diagnosis: Liver Cell Carcinoma During the home visit on 2/26/2024 at approximately 10:30 AM, a review of Pt #3’s medications were reviewed with the Physical Therapist (E #4). The Agency’s medication list initiated on the SOC and the medication list printed 2/26/2024 for certification period 2/17/2024 to 4/16/2024, listed the same medications. This list of medications was compared to the medication’s available for use in Pt #3’s home. The Agency’s medications list lacked the following medications: Alum-mag hydroxid-simeth 15 ml every 6 hours as needed over the counter medication. Sennosides (Sen-O-tab) 8.6 mg every day as needed over the counter medication. Fludrocotisone 0.1 mg tablet every day filled 2/7/2024. Atorvastatin 80 mg ½ tablet every night filled 1/22/2024. Zonisamide 100mg 2 capsules twice day filled 12/22/2023. Fludrocotisone, Atorvastatin, and Zonisamide are prescription medications with fill dates prior to the SOC. 2. A review of the Facility Visit Notes dated 2/19/2023 by PT and a visit note dated 2/21/2024 by a PTA, and the 2/23/2024 visit note by the RN did not indicate the medications were reconciled on these home visits. The 2/23/2024 home visit by the RN indicated the medications were reconciled and there were “No new/changed medications since last visit.” On 2/26/2024 the home visit with PT identified the above discrepancies. 3. On 2/28/2026 at approximately 10:00AM, an interview was conducted with the System Director (E #3). E #3 reviewed the discrepancies and agreed the medications were not on the medication list.”

“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 document review and interview, it was determined in 2 of 2 (Pt #4 and Pt #6) patients with a CPM (Continuous Passive Motion) machine, the Agency failed to ensure the Plan of Care (POC) included a physician order for a CPM machine and specific instructions for use of the CPM. Findings include: 1. On 2/26/2024 at approximately 10:00 AM, the Home Health Agency policy titled, “Physician Orders” (revised 4/7/2023) was reviewed. The policy required, “Physician orders are obtained for patient care services including treatments, procedures and equipment before such services are furnished. B. Orders will provide specific directions for providing care and services…” 2. Pt#4 Start of Care (SOC): 2/19/2024 Diagnosis: After Care Following Joint Replacement. The record was reviewed on 2/26/2024 at approximately 12:00 PM. The Plan of Care (POC) dated 2/19/2024 to 4/18/2024, indicated under “Durable Medical Equipment”, Pt #4 had a CPM machine. During the Home Visit on 2//26/2023 at 3:00 PM, the CPM was observed. The POC dated 2/19/2024 to 4/18/2024 lacked a physician order and instructions for the use of the CPM. 3. Pt #6 Start of Care (SOC): 2/22/2024 Diagnosis: After Care Following Joint Replacement. The record was reviewed on 2/27/2024 at approximately 10:00 AM. On 2/27/2024, the POC dated 2/22/2024 to 4/21/2024, indicated under “Durable Medical Equipment”, Pt #6 had a CPM machine. The POC dated 2/22/2024 to 4/21/2024 lacked a physician order and instructions for the use if the CPM machine. 4. During an interview on 2/27/2024 at approximately 11:30 AM with the Branch Manager (E #1), E #1 verbally confirmed the Plan of Care for Pt #4 and Pt #6 lacked a physician’s order and instructions for use of the CPM. E #1 stated the physician’s order and instructions were not transferred over from the patient’s hospital discharge summary.”