Crown Home Health Agency, Inc.

“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 a review of the Agency’s Emergency Preparedness Program and staff interview, it was determined the Agency failed to conduct emergency exercises as required. This has the potential to affect Pts. that receive services and Agency staff. Findings include: 1. The Emergency Preparedness Program last updated in 2023 was reviewed on 1/9/24. The Program contained documentation the Agency conducted Fire Drills on 12/8/20, 12/6/21, 12/8/21, 12/9/22, and 11/21/23. The Program lacked documentation the Agency had conducted a full-scale exercise, or an individual facility-based exercise, and/or had activated the Agency’s Emergency Program since the full-scale exercise activation in 2019 for COVID-19. 2. During an interview with the Agency’s Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency failed to conduct emergency exercises as required.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 1/8/24. The folder lacked documentation of the Agency’s transfer and discharge policies. 2. The following home visits were conducted on 1/9/24 from 11:00 AM to 1:15 PM: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. During the home visits, the Pt. admission folders were observed, and lacked documentation the Agency had provided Pts. information, regarding the Agency’s policies pertaining to transfer and discharge. 3. The clinical records of the following Pts. were reviewed from 1/8/24 to 1/9/24: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. Pt. #4. SOC 12/14/23. Pt. #5. SOC 10/4/23. Pt. #6. SOC 6/6/23. Pt. #7. SOC 8/1/23. The records lacked documentation the Agency provided Pts. information, regarding the Agency’s policies pertaining to transfer and discharge. 4. During interviews with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Pt. admission folder reviewed is used for all Pts. admitted to this Agency, and that the Agency failed to provide Pts. information regarding the Agency’s transfer and discharge policies.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Administrator and their contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 1/8/24. The folder lacked documentation identifying the Administrator’s name, address and phone number for the Pt. and/or legal guardian to contact. 2. The following home visits were conducted on 1/9/24 from 11:00 AM to 1:15 PM: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. During the home visits, the Pt. admission folders were observed and lacked the name of the Administrator, their address and phone number. 3. The clinical records of the following Pts. were reviewed from 1/8/24 to 1/9/24: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. Pt. #4. SOC 12/14/23. Pt. #5. SOC 10/4/23. Pt. #6. SOC 6/6/23. Pt. #7. SOC 8/1/23. The records lacked documentation the Agency had provided the name of the Administrator, their address and phone number. 4. During interviews with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide information regarding the Administrator.”

“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 observation and interviews during home visits, clinical record reviews, and staff interview, it was determined the Agency failed to ensure the medications in the PsOC are accurate. This was found in 2 of 7 (Pts. #2 and 3) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to home health services on 10/20/23 with the diagnoses of Bilateral Primary Osteoarthritis of Knee, Type 2 Diabetes Mellitus with Lumbar Region Diabetic Polyneuropathy, and Mixed Hyperlipidemia. A home visit was conducted on 1/9/24 with the Director of Nursing. During the home visit, the patient’s medications were observed, and an interview was conducted with the patient’s caregiver. Observed the prescription bottle labeled “Atorvastatin 40 mg once daily by mouth date filled 12/18/23,” the prescription bottle labeled “Gabapentin 300 mg capsule once daily by mouth dated filled 12/6/23,” the prescription bottle labeled “Meclizine 12.5 mg 2 tablets once daily by mouth as needed for dizziness date filled 12/6/23,” and “Vascepa 1 GM capsule Take 2 times a day date filled 11/20/23.” The clinical record was reviewed on 1/9/24 and included a Physician order dated 12/6/23 which contained, “Medication update: Gabapentin 300 MG oral capsule 1 once daily PO by mouth” and signed by the physician on 1/2/24. The POC effective 12/19/23 was inaccurate to include Atorvastatin 20 MG, and lack Gabapentin, Meclizine and Vascepa. 2. Pt. #3 was admitted to home health services on 10/20/23 with the primary diagnosis of Type 2 Diabetes with Diabetic Autonomic (Poly) Neuropathy. The clinical record was reviewed on 1/9/24. A home visit was conducted on 1/9/24 with the Director of Nursing and E#5. During the home visit, the patient’s medications were observed, and interviews were conducted with the Pt., Director of Nursing and E#5. Observed the prescription bottle labeled “Daily-Vite Take 1 tablet everyday by mouth date filled 11/13/23. Other medications observed included: Turmeric Curcumin, the Pt. stated 1 capsule is taken once daily by mouth for the past 3 months; Probiotic 100 million organisms, the Pt. stated 1 tablet is taken at night by mouth for the past 3 months; and Zyrtec 10 mg per tablet, the Pt. stated 1 tablet is taken twice a day by mouth, the Director of Nursing stated the Pt. had been taking Zyrtec for the past 3 to 4 weeks. The clinical record was reviewed on 1/9/24 and included the POC effective 12/19/23 which lacked: Daily-Vite, Turmeric Curcumin, Probiotic and Zyrtec. 3. During an interview with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency failed to ensure the medications contained in the PsOC were accurate.”

“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 clinical record review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 1 of 2 (Pt. #7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #7 was admitted to home health services on 8/1/23 with the primary diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 1/8/24. The record contained SN, OT, PT assessments and visit notes indicating services were provided from 8/1/23 to 11/17/23. The “SN Discharge Summary” dated 11/21/23 included documentation the Pt. was transferred to the hospital and discharged from the Agency. As of 1/8/24, the Agency lacked any documentation indicating a copy of the “SN Discharge Summary” was sent to the Physician. 2. During an interview with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency lacked any record that a copy of the Discharge Summary was sent to the Physician.”