On Site Rehab and Nursing Care Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 02/24/25 at 11:30 AM. The plan lacked documentation of a Hazard Vulnerability Assessment for 2022, 2023 and 2024. 2. During an interview with the Administrator and Director of Nursing on 02/25/25 at 4:10 PM, the above finding was confirmed.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Error Summary report and Staff interview, it was determined in 68 of 451 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 01/28/24 to 01/28/25, was reviewed on 02/24/25 at 2:30 PM. The report included error # -3330 for 68 of 451 late submissions, 15.08 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Administrator and the Director of Nursing on 02/25/25 at 4:00 PM, it was confirmed that the error occurred.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 3 of 7 (Pts. # 5, 6 and 7) clinical records reviewed, the patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #5 was admitted to the Home Health Services on 09/20/24 with the diagnoses of Unspecified Open Wound Left Buttock, Subsequent Encounter and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 02/25/25. The clinical record included a POC dated 01/18/25, that required the SN to assess the patient’s blood glucose 2 times a week for 2 weeks, and 1 time a week for 7 weeks and notify the physician of glucose above 250 or below 70. The clinical record lacked documentation of a blood glucose assessment from 01/22/25 thru 02/25/25 (weeks #1-5) and the POC was not modified. 2. Pt. #6 was admitted to Home Health Services on 11/09/24 with the diagnoses of Pressure Ulcer Left Buttocks, Stage 2 and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 02/25/25. The clinical record included a POC dated 11/09/24, that required the SN to assess the patient 1 time a week for 9 weeks. The clinical record lacked documentation of an SN visit the week of 11/23/24. 3. Pt. #7 was admitted to Home Health Services on 02/16/24 with the diagnosis of “Wedge Compression Fracture of 3rd Lumbar Vertebrae, Sub for Fracture with Routine Heal”. The clinical record was reviewed on 02/25/25. The clinical record included a POC dated 02/16/24, that required the SN to assess the patient 1 time a week for 9 weeks. The clinical record lacked documentation of an SN visit the week of 03/01/24. 4. The above findings were confirmed, during the interview with the Director of Nursing, on 02/26/25 between 10:15 AM and 11:30 AM.”