Innova Care

“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 the review of the EP documents, personnel files and Staff interview, it was determined the Agency failed to ensure EP training was conducted and documented biannually. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. On 12/06/23 at 11:00 AM, the EP training was requested. As of 12/08/23, the requested training was not provided. 2. On 12/08/23 at 9:30 AM, the personnel files were reviewed and lacked documentation of the EP training. 3. The above findings were confirmed during interviews with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 12:30 PM and again with the Acting Director of Nursing on 12/08/23 at 9:50 AM.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on clinical records review and Staff interview, it was determined the Agency failed to ensure that Staff provided services as ordered in the Plans of Care. This was found in 3 of 10 (Pts. #2, #6 and #9) clinical records reviewed. Findings include: 1. Patient #2, was admitted to Home Health services on 02/17/23 with Diagnoses: Multisystem Degeneration of the Autonomic Nervous System and Heart Failure. The clinical record was reviewed on 12/05/23. The signed Plans of care effective 08/16/23 and 10/15/23 which required: “SN to instruct patient on daily weight self-monitoring program…Report to SN weight gain….” The record lacked weight assessments for recertification assessment dated 10/11/23 and SN clinical notes dated 10/16/23, 10/27/23, 10/30/23, 11/06/23, 11/13/23, 11/20/23, 11/27/23 and 12/04/23, as ordered by the physician. 2. Patient #6, was admitted to Home Health services on 11/17/23 with Diagnoses: Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23. The signed Plan of care effective 11/17/23 required: “….Notify physician of:….Systolic BP greater than (>) 160 or less than()90 or less than ( The SN note dated 11/29/23 indicated only a systolic BP of 145, and lacked a diastolic BP assessment to report, as ordered by the physician. 3.Patient #9, was admitted to the Home Health Services on 01/23/23 with the Diagnoses: Hypertensive Heart and Chronic Kidney Disease without Heart Failure with Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 12/06/23. The Physician orders dated 05/17/23 included orders for the ST to evaluate the Patient. The ST frequency was 1 time a week for 6 weeks. The ST failed to assess the Patient, during the week of 05/29/23 ( week #4). 4.The findings were confirmed during the interview with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 11:30 AM. Findings include: 1. Patient #2 was admitted to Home Health services on 02/17/23 with Diagnoses of Multisystem Degeneration of the Autonomic Nervous System and Heart Failure. The clinical record was reviewed on 12/05/23. The signed Plans of care effective 08/16/23 and 10/15/23 required, “SN to instruct patient on daily weight self-monitoring program…Report to SN weight gain….” The record lacked weight assessments for recertification assessment dated 10/11/23 and SN clinical notes dated 10/16/23, 10/27/23, 10/30/23, 11/06/23, 11/13/23, 11/20/23, 11/27/23 and 12/04/23, as ordered by the physician. 2. Patient #6 was admitted to Home Health services on 11/17/23 with Diagnoses of Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23. The signed Plan of care effective 11/17/23 required, “….Notify physician of:….Systolic BP greater than (>) 160 or less than()90 or less than ( The SN note dated 11/29/23 indicated only a systolic BP of 145, and lacked a diastolic BP assessment to report, as ordered by the physician. 3. Patient #9 was admitted to the Home Health Services on 01/23/23 with the Diagnoses of Hypertensive Heart and Chronic Kidney Disease without Heart Failure with Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 12/06/23. The Physician orders dated 05/17/23 included orders for the ST to evaluate the Patient. The ST frequency was 1 time a week for 6 weeks. The ST failed to assess the Patient, during the week of 05/29/23 (week #4). 4. The findings were confirmed during interviews with the Acting Administrator and Acting Director of Nursing, on 12/07/23 between 10:00 AM and 11:30 AM.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined the Agency failed to ensure the Aide Supervision was conducted in the patient’s home every 14 days. This was found for 2 of 5 Patients (Pt. #4 and 2) with Aide services. 2. Patient #2, was admitted to Home Health Services on 02/17/23 with Diagnosis: Multisystem Degeneration of the Autonomic Nervous System. The clinical record was reviewed on 12/05/23. The signed Plan of care effective 08/16/23 required Aide services 1 time a week for 9 weeks. The clinical record lacked an Aide’s supervision between 09/04/23 and 10/30/23 (more than 14 days). 3. During interviews with the Acting Administrator and Acting Director of Nursing on 12/07/23 from 10:00 AM to 11:30 AM, both confirmed the above findings. Findings include: 1.Patient #4, was admitted to the Home Health Services on 11/18/22 with the Diagnoses: Unspecified Atrial Fibrillation and Alzheimer’s Disease. The clinical record was reviewed on 12/06/23 and lacked the Aide’s supervision every 2 weeks. As of 12/07/23, the last supervisory visit by the RN was dated 11/17/23 (more than 14 days).”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined the Agency failed to ensure the clinical records included all the required items. This was found in 3 of 10 records reviewed (Pt. #3, 4 and 8). Findings include: 1.Patient #3 was admitted to Home Health Services on 11/18/22 with the Diagnoses of Polyosteoarthritis and Hypertension. The clinical record was reviewed on 12/06/23 and lacked the signature of the SN on the supervisory notes dated 11/08/22 and 11/22/23. 2. Patient #4 was admitted to Home Health Services on 11/18/22 with the Diagnoses of Unspecified Atrial Fibrillation and Alzheimer’s Disease. The clinical record was reviewed on 12/06/23 and lacked an order for the Home Health Aide for the recertification period of 11/08/23 to 01/06/24. 3.Patient #8 was admitted to Home Health Services on 11/18/22 with the Diagnosis of Pressure Ulcer of Sacral Region, Stage 2. The clinical record was reviewed on 12/06/23 and lacked the frequency orders of the Aide, OT and MSW services assessed in the comprehensive assessment dated 05/01/23. 4. The findings were confirmed during the interview with the Acting Administrator and Acting Director of Nursing on 12/07/23, between 10:00 AM and 11:30 AM.”