Jefferson County Home Health Agency

“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 document review and staff interview, the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that was based on and included a documented, facility-based and community-based risk assessment, that utilized an all-hazards approach and included strategies that addressed emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agency’s Emergency Preparedness Program failed to show evidence of a facility and community-based risk assessment performed annually. Review of a document titled, “Emergency Preparedness Plan - Hazard Vulnerability Analysis,” showed, “ ...1. The Administrator or designee is responsible for conducting the Hazard Vulnerability Analysis initially and annually prior to the start of the new calendar year. The document showed a facility and community-based risk assessment, dated 2017, was completed, however, there was no documentation to support a risk assessment had been completed annually since that date. During an interview on 09/19/24 at 1:30 PM, Staff A, Administrator, confirmed the above finding of no updated hazard vulnerability risk assessment being performed annually.”

“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 record reviews and staff interview, the agency failed to provide services as ordered by a physician for 3 (Patients 1, 2, and 5) of 7 sample patients. This failed practice had the potential to place patients at risk for unmet needs and services, as well as adverse outcomes. Findings Include: Patient 1 Review of Patient 1’s, “Home Health Certification and Plan of Care (POC),” dated 07/25/24, showed that Patient 1 was admitted with a primary diagnosis of cellulitis to right lower limb with orders for Skilled Nurse two times per week to perform wound care, and included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented on the two visits made during the week of 07/28/24. There was no documentation to support wound measurements were completed for the two scheduled visits or the two “PRN” (as needed) visits made during the week of 08/11/24. Patient 2 Review of Patient 2’s, “Home Health Certification and Plan of Care (POC),” dated 04/01/24, showed that Patient 2 was admitted with a primary diagnosis of lymphedema with orders for Skilled Nurse three times per week to apply and monitor compression wraps. Orders included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented during the first three weeks of the episode period, dated from 07/30/24 through 09/27/24. Patient 5 Review of Patient 5’s, “Home Health Certification and Plan of Care (POC),” dated 06/26/24, showed that Patient 5 was admitted with a primary diagnosis of diabetes with chronic ulcer and orders for Skilled Nurse three times per week to perform wound care, that included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented on the three visits made during the week of 09/01/24. During an interview on 09/19/24 at 2:30 PM, Staff A, Administrator, confirmed the above findings that skilled nursing failed to measure patient wounds as ordered on the Plans of Care.”

“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 record review and staff interview, the Home Health Agency (HHA) failed to ensure a discharge summary was sent to the physician within 5 business days of the date of discharge for 1 (Patient 7) of 2 discharged patients. This failed practice had the potential to affect patient safety and to place all patients at risk for adverse outcomes across the health care spectrum. Findings Include: Patient 7 Review of Patient 7’s clinical record showed the “Home Health Certification and Plan of Care,” with a Start of Care date of 07/11/24. Review of visit notes for the current certification period showed the patient died at home on 08/05/24. There was no documentation to support a discharge summary was sent to the physician. There was no documentation to support the agency notified the physician of the patient’s death. During an interview on 09/19/24 at 10:30 AM, Staff A, Administrator, confirmed the agency had not send a discharge summary to the physician for the patient.”