Lmr Home Health Care, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the communication plan was complete, provide training to staff, and conduct exercises to test the emergency preparedness plan. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. The Agency failed to ensure the communication plan included a complete list of names and contact information (E0030). 2. The Agency failed to conduct training of the emergency preparedness plan (E0037). 3. The Agency failed to conduct testing of the emergency preparedness plan (E0039). The cumulative effect of these systemic practices, resulted in the Agency’s inability to respond to emergencies effectively.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on review of a clinical record, interviews and observation during a home visit, Agency policy review, and staff interview, it was determined the Agency failed to ensure the comprehensive assessment included the patient’s nursing and social requirements, home health discharge plans, medications review, and contained information regarding caregiver support. This has the potential to affect all patients receiving services. Findings include: 1. In 1 of 1 clinical record reviewed, the Agency failed to ensure the comprehensive assessment included the patient’s nursing and social requirements, and home health discharge plan (G534). 2. In 1 of 1 clinical record reviewed, the Agency failed to ensure the comprehensive assessment included documented medications review (G536). 3. In 1 of 1 clinical record reviewed, the Agency failed to ensure the comprehensive assessment contained information regarding caregiver support (G538). The cumulative effect of these systemic practices, resulted in the Agency’s inability to accurately assess the patient’s status and requirements for establishing a complete and accurate POC for the Pt.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on review of a clinical record, and staff interview, it was determined the Agency failed to ensure the POC included SN interventions, the SN provided care as ordered by the physician, and assess the need for Pneumococcal Pneumonia and/or Influenza vaccines. This has the potential to affect all patients receiving services. Findings include: 1. In 1 of 1 clinical record reviewed, the Agency failed to ensure the POC included SN interventions (G574). 2. In 1 of 1 clinical record reviewed, the Agency failed to ensure the SN provided care as ordered by the physician (G580). 3. In 1 of 1 clinical record reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines (G582). The cumulative effect of these systemic practices, resulted in the Agency’s inability to provide care effectively, and ensure the Pt. received the required care and services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on review of a clinical record, Agency policy, and staff interview, it was determined the Agency failed to ensure Pt. assessments were completed, and maintained in the clinical record; the clinical record contained documentation the SN assessed the patient’s response to the wound care; and ensure that documentation entered into the clinical record was complete. This has the potential to affect all patients receiving services. Findings include: 1. In 1 of 1 clinical record reviewed, the Agency failed to ensure Pt. assessments were completed, and maintained in the clinical record as required by the Agency (G1012). 2. In 1 of 1 clinical record reviewed, the Agency failed to ensure the clinical record contained documentation the SN assessed the patient’s response to the wound care (G1014). 3. in 1 of 1 clinical record reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete. The cumulative effect of these systemic practices, resulted in the Agency’s inability to develop and maintain current, accurate and complete clinical records.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the communication plan was complete. This has potential to affect all Pts. receiving services. Findings include: 1. The Agency’s Emergency Preparedness Plan with revision date October 19, 2023, was reviewed on 6/10/24. The plan lacked the names and contact information of employees, contracted staff, vendors and patient physicians. 2. During an interview with the Administrator and Nursing Supervisor on 6/11/24 at 11:00 AM, the Administrator confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete.”

“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 review of Agency’s Emergency Preparedness Plan, In-services Binder, and staff interviews, it was determined the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. This has the potential to affect patients served by the Agency. Findings include: 1. The Agency’s Emergency Disaster Plan and In-services Binder were reviewed on 6/10/24. The In-services Binder lacked documentation that the Agency conducted Emergency preparedness staff training in 2021, 2022 and 2023. 2. During interview with the Administrator and Agency Supervisor on 6/11/24 at 11:00 AM, the Administrator confirmed the Agency failed to conduct EP training since 2020.”

“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 review of the Emergency preparedness Plan and staff interviews, it was determined that the Agency failed to participate in or conduct testing of the emergency preparedness plan since 2020. This has the potential to affect all employees and patients served by the Agency. 1. The Agency’s Emergency Preparedness Plan was reviewed on 6/10/24. The plan lacked documentation indicating that the Agency conducted/participated in any community-based testing exercises, since 2020. 2. During an interview with the Administrator and Agency Supervisor on 6/11/24 at 11:00 AM, the above findings were confirmed.”

“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 review of a clinical record, Agency policy and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the SN visit notes dated 5/14/24, 5/15/24, 5/16/24, and 5/17/24 which lacked a description of the right buttock wound. 2. The Agency’s policy titled, “Clinical Policy & Procedure... Wound Classification” was reviewed on 6/12/24. The policy required: “...Assess wound or pressure ulcer: a. Assess color and drainage of wound. b. Measure diameter of ulcer with measuring device. c. Measure depth of ulcer using sterile, cotton-tipped applicator. d. Measure depth of undermining skin...e. Assess odor, if present...” 3. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, the Agency Supervisor the Agency failed to ensure documentation entered into the clinical record was complete.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of the patient’s admission folder, clinical record, observation during a home visit, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the Pt. was provided a written consent for treatment. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 6/10/24, it contained a form titled “CONSENT - Consent for Services/ Photographs/ Release of Records...Financial Authorization...Frequency/ Rights/ Hotline/ Procedures...” The Agency required the SN to complete this form during the SOC visit. The SN and Pt./patient’s representative are required to sign and date the form. 2. Pt. #1 was admitted to home health services on 4/30/24 with the diagnoses of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record lacked a written consent form to initiate home health services. 3. On 6/12/24, a home visit was conducted with Employee #1. During the home visit, the patient’s admission folder was observed, and lacked a written consent to initiate home health services. 4. During interviews with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM and 6/12/24 at 10:36 AM, both confirmed the clinical record lacked a written consent for services.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on review of a clinical record, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the comprehensive assessment included the patient’s nursing and social requirements, and a home health discharge plan. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with diagnoses of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the Agency’s SOC comprehensive assessment form completed by the SN on 4/30/24. The assessment form lacked documentation of Pt. #1’s skilled nursing need for daily wound care, a social assessment and the initial plans for an Agency discharge. 2. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, both confirmed the Agency failed to ensure that the SOC comprehensive assessment form included the nursing and social requirements, and arrangements for the home health discharge.”

“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 review of a clinical record, interviews and observation during a home visit, Agency policy review, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the comprehensive assessment included a documented medications review. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the SOC comprehensive assessment form completed by the SN and dated 4/30/24. The assessment lacked documentation of the patient’s medications. 2. A home visit was conducted on 6/12/24 with Employee #1. Interviews were conducted with Employee #1, Pt. #1 and Pt. #1’s Power of Attorney, all stated the Pt. takes multiple medications. Unable to observe the individual pill containers, Pt. #1 stated the medications were “locked up” and that a family member fills the pill box every 2 weeks. The patient’s admission folder was reviewed and contained a blank form titled, “Home Medication Schedule”. During the same interview, a request was made to review the patient’s medication schedule/profile form, Employee #1 stated, “I did not make a list of the medications....” 3. The Agency’s policy titled, “Medication Profile” was reviewed on 6/12/24. The policy required: “...1. Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen...2. A drug regimen review will be performed at the time of admission... The review will identify drug/food interactions potential adverse effect and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. 4. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, both confirmed the SOC comprehensive assessment lacked a list of the medications indicating they were reviewed, as required by the Agency.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on review of a clinical record, observation and interviews during a home visit, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the comprehensive assessment contained information regarding caregiver support. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the SOC comprehensive assessment form completed by the SN and dated 4/30/24. The form lacked documentation of caregiver support. 2. A home visit was conducted on 6/12/24 with Employee #1. During the home visit, observed a person providing personal care, this person identified themself as a CNA (Certified Nursing Assistant) from a different company. Interviews were conducted with Employee #1, the Pt. and the patient’s Power of Attorney, the Pt. stated she receives CNA care/services from multiple agencies throughout the day, 6 days a week, “they come in the morning, evening and at night to put me to bed.” Employee #1 stated she was aware that the Pt. receives care from other Agencies throughout the day. The patient’s Power of Attorney stated, “There are family members that live close by, and I live 15 minutes away, I’m here to help also.” 3. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, and 6/12/24 at 10:36 AM, both confirmed the Agency failed to ensure the start of care comprehensive assessment form contained information regarding caregiver support.”

“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 interviews and observation during a home visit, review of a clinical record, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the POC included SN interventions. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. A home visit was conducted on 6/12/24 with Employee #1. During the home vist, interviews were conducted with Employee #1 and Pt. #1 that stated, the SN provides “lymphedema treatments to both arms every Tuesday, Thursday and Saturday”. Observed a lymphedema machine on the patient’s bedside table. The record contained the POC dated 4/30/24 which lacked instructions for the SN to provide “lymphedema treatments”. The SN visit notes dated 5/14/24, 5/15/24, 5/16/24, and 5/17/24 included “Catheter/Device Foley catheter - Last Changed 5/12/24 20 Fr 30 ml”. The POC effective 4/30/24 lacked instructions for care and maintenance the Foley catheter. The POC dated 4/30/24 required the SN to provide service “7 wk 9” (7 times a week for 9 weeks) for daily wound care to the right buttock. The POC lacked a description or instructions for the wound care. 2. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, and 6/12/24 at 10:36 AM, the Agency Supervisor confirmed the Agency failed to ensure the POC included SN interventions,”

“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 review of a clinical record and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the SN provided services as ordered by the physician. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained an order for wound care, signed by the Nurse Practitioner on 5/2/23 that included: “Skilled Nursing Orders Wound Care: Wound #1 Location: Sacrum Clean with Normal Saline Apply Primary Dressing / Topical Medication: Medihoney Secure with Mepilex Frequency of Dressing Change: Daily”. The SN visit note dated 5/19/24 included, “Wound cleansed with NSS (Normal Sterile Saline) wet to dry and Mepilex covering.” The SN visit note lacked documentation the SN provided wound care as ordered by the Nurse Practitioner. The record contained the POC dated 4/30/24 requiring the SN to provide service “7 wk 9” (7 days a week for 9 weeks) for daily wound care. The record lacked documentation the SN visited or provided any services on 5/18/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24, 5/24/24, 5/27/24, 5/28/24, and 5/29/24. 2. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, the Agency Supervisor confirmed the SN failed to provide wound care as ordered.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on review of a clinical record and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the diagnoses of Not Elsewhere Classified Lymphedema and Stage 1 Pressure Ulcer of Right Buttock. The clinical record was reviewed on 6/10/24. The record lacked documentation the SN assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. 2. During the entrance interview with the Administrator on 6/10/24 at 9:45 AM, the Administrator stated the patient’s admission folder contains a vaccination form which is completed during the SOC visit by the SN, after completion, the form is maintained in the clinical record. 3. During an interview with the Administrator and Agency Supervisor on 6/10/23 at 2:45 PM, the Agency Supervisor confirmed the record lacked a “Influenza/ Pneumonia Vaccination Check-Off Form”, and/or any written inquiry regarding the need, administration, refusal or contraindication for the Influenza and Pneumonia vaccines.”

“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 review of a clinical record, Agency policy, and staff interview, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure Pt. assessments were completed, and maintained in the clinical record as required by the Agency. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the “Verification of Skilled Nurse Visit” forms completed by the SN and dated: 5/1/24, 5/2/24, 5/3/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/9/24, 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/25/24, 5/26/24, 5/30/24, 5/31/24 and 6/1/24. As of 6/10/24, the record lacked documentation of the Skilled Nurse visit notes. The SOC comprehensive assessment form completed by the SN and dated 4/30/24 lacked documentation of vital signs (blood pressure, heart rate, respiratory rate, and temperature), an initial or baseline description of the right buttock wound, and an assessment of Pt. #1’s pain. 2. The Agency’s policy titled, “Clinical/Inservice Data Collection” was reviewed on 6/12/24. The policy required: “...Documentation in the clinical/service record will be timely, detailed... 6. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday...” 3. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, the Administrator stated “we know the nurse made the visits, but the notes have not been completed.” During the same interview, both confirmed Pt. assessments were incomplete, and not placed in the clinical record as required by the Agency.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on review of a clinical record, Agency policy, and staff interviews, it was determined in 1 of 1 (Pt. #1) clinical record reviewed, the Agency failed to ensure the clinical record contained documentation the SN assessed the patient’s response to the wound care. Findings include: 1. Pt. #1 was admitted to home health services on 4/30/24 with the primary diagnosis of Not Elsewhere Classified Lymphedema, Encounter for fitting and adjustment of Urinary Device, and Stage 1 Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 6/10/24. The record contained the SN visit notes dated 5/14/24, 5/15/24, 5/16/24, and 5/17/24. The SN visit notes lacked documentation that the SN provided any wound care, and whether the Pt. responded to the wound care regimen that was being used. The POC effective 4/30/24 required: “...SN indicated for wound care management... assess wound progression or decline...” and for the SN to provide wound care 7 days a week for 9 weeks, The record lacked documentation the SN assessed the wound weekly as required by the POC and Agency’s policy. 2. The Agency’s policy titled, “Clinical Policy & Procedure... Wound Classification” was reviewed on 6/12/24. The policy required: “...8. Document in the clinical record: a. Wound/ulcer assessment, including color, drainage, odor, and size. b. Wound ulcer classification. c. Wound care and dressing change procedure. d. Client symptoms an response to the procedure 3. During an interview with the Administrator and Agency Supervisor on 6/10/24 at 2:45 PM, both confirmed the SN visit notes lacked documentation the SN assessed the patient’s response to the wound care procedure. 4. During an interview with the Administrator and Agency Supervisor on 6/12/24 at 1:50 PM, the Agency Supervisor stated the SN is required to document on the SN visit note a description of the wound “weekly, every Tuesday”.”