Phoenix Home Care

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interviews and review of the Emergency Preparedness Plan (EPP) the above-named Home Health agency (HHA) failed to review and update the EPP at least every 2 years. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP) the HHA failed to conduct a review of the entire EPP every 2 years. The EPP documentation showed the last review and update was 11/2019. During an interview on 03/27/24 between at 12:30 PM and 1:30 PM, the Administrator stated that the EPP they provided me was the most recently reviewed EPP that they had.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interviews and review of the Emergency Preparedness Plan (EPP) it was revealed the above-named Home Health agency (HHA), the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, as required by the regulation. This deficiency may hinder the facility’s ability to effectively coordinate with external agencies and respond to emergencies in a unified manner. Findings Include: Review of the agencies Emergency Preparedness Program (EPP) indicated an absence of information addressing cooperation and collaboration with emergency preparedness officials at the local, tribal, regional, State, and Federal levels. During interviews conducted on 03/27/24 with the Administrator, it was confirmed that the EPP did not outline a process for engaging in collaborative planning with relevant emergency preparedness authorities.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interviews and review of the Emergency Preparedness Plan (EPP) and relevant policies and procedures, the agency failed to review and update emergency preparedness policies and procedures at least every two years. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program (EPP) indicated that the last date for review and update of the (EPP) policies and procedures was 11/2019. During interviews conducted on 03/27/24 with Administrator, it was confirmed that the facility did not have any documentation for review more recent than 11/2019.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on observation, record review, interview, and policy review the Home Health Agency (HHA) failed to develop and implement an individual emergency preparedness (EPP) as part of the comprehensive patient assessment for 17 (Patients 1-17) of 17 patients sampled. Failure to provide an individualized EPP places each patient at risk for poor outcomes should a disaster occur. Findings Include: Review of the agencies Emergency Preparedness Program failed to provide plans for the HHA’s individual patients during a natural or man-made disaster. Review of the HHA’s policy titled “6.2 Plan of Care” showed “The individualized plan of care must include the following: … (xi) Safety measures to protect against injury; … Each patient must receive an individualized written plan of care… The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment.” Patient 1 Review of Patient 1’s record showed a start of care date of 02/15/24 with a primary diagnosis of cellulitis (a serious bacterial infection of the skin) of the left lower limb. Patient 1’s plan of care (POC) dated 02/15/24 through 04/14/24 failed to show documentation of an individualized EPP in Patient 1’s record. Patient 2 Review of Patient 2’s record showed a start of care date of 02/12/24 with a primary diagnosis of amyotrophic lateral sclerosis (a progressive neurological disorder that results in weakened muscles and deformity). Patient 2’s POC dated 02/12/24 through 04/11/24 failed to show documentation of an individualized EPP in Patient 2’s record. Patient 3 Review of Patient 3’s record showed a start of care date of 02/15/24 with a primary diagnosis of urinary tract infection. Patient 3’s POC dated 02/15/24 through 04/14/24 failed to show documentation of an individualized EPP in Patient 3’s record. Patient 4 Review of Patient 4’s record showed a start of care date of 06/23/23 with a primary diagnosis of chronic peripheral venous insufficiency (poor blood flow in the legs). Patient 4’s POC dated 06/23/23 through 08/21/23 failed to show documentation of an individualized EPP in Patient 4’s record. Patient 5 Review of Patient 5’s record showed a start of care date of 07/20/23 with a primary diagnosis of unspecified heart failure. Patient 5’s POC dated 07/20/23 through 09/17/23 failed to show documentation of an individualized EPP in Patient 5’s record. Patient 6 Review of Patient 6’s record showed a start of care date of 02/21/24 with a primary diagnosis of sacrococcygeal disorder (wound on the coccyx). Patient 6’s POC dated 02/21/24 through 04/20/24 failed to show documentation of an individualized EPP in Patient 6’s record. Patient 7 Review of Patient 7’s record showed a start of care date of 03/02/24 with a primary diagnosis of noninfective gastroenteritis and colitis (inflammation of the lining of the stomach, intestines, and colon). Patient 7’s POC dated 03/02/24 through 04/30/24 failed to show documentation of an individualized EPP in Patient 7’s record. Patient 8 Review of Patient 8’s record showed a start of care date of 03/22/24 with a primary diagnosis of a displaced intertrochanteric fracture of right femur. Patient 8’s POC dated 03/22/24 through 05/20/24 failed to show documentation of an individualized EPP in Patient 8’s record. Observation during Patient 8’s home visit on 03/27/24 at 1:00 PM, found no written individualized EPP in the patient’s home. Patient 9 Review of Patient 9’s record showed a start of care date of 01/29/24 with a primary diagnosis of bilateral osteoarthritis of the knees. Patient 9’s POC dated 01/29/24 through 03/28/24 failed to show documentation of an individualized EPP in Patient 9’s record. Observation during Patient 9’s home visit on 03/27/24 at 3:00 PM, found no written individualized EPP in the patient’s home. Patient 10 Review of Patient 10’s record showed a start of care date of 01/29/24 with a primary diagnosis of hypertensive heart disease and unspecified stage 1 through 4 chronic kidney disease. Patient 10’s POC dated 01/29/24 through 03/28/24 failed to show documentation of an individualized EPP in in Patient 9’s record. Patient 11 Review of Patient 11’s record showed a start of care date of 02/06/24 with a primary diagnosis of postmastectomy lymphedema syndrome (breast tissue removal causing the disruption lymph flow and swelling of the related extremity). Patient 11’s POC dated 02/06/24 through 04/05/24 failed to show documentation of an individualized EPP in Patient 11’s record. Observation during Patient 11’s home visit on 03/27/24 at 10:40 AM, found no written individualized EPP in the patient’s home. Patient 12 Review of Patient 12’s record showed a start of care date of 03/04/24 with a primary diagnosis of surgical aftercare following surgery on the digestive system. Patient 12’s POC dated 03/04/24 through 05/02/24 failed to show documentation of an individualized EPP in Patient 12’s record. Observation during Patient 12’s home visit on 03/28/24 at 9:00 AM, found no written individualized EPP in the patient’s home. Patient 13 Review of Patient 13’s record showed a start of care date of 04/14/23 with a primary diagnosis of disruption of external operation surgical wound (the unplanned reopening of an incision made during a surgery). Patient 13’s POC dated 04/14/23 through 06/12/2023 failed to show documentation of an individualized EPP in Patient 13’s record. Patient 14 Review of Patient 14’s record showed a start of care date of 03/28/23 with a primary diagnosis of Rhabdomyolysis (a breakdown of skeletal muscle due to injury). Patient 14’s POC dated 03/28/23 through 05/28/23 failed to show documentation of an individualized EPP in Patient 14’s record. Patient 15 Review of Patient 15’s record showed a start of care date of 03/21/24 with a primary diagnosis of Parkinson’s disease (a chronic and progressive movement disorder causing tremors, stiffness and slowing of movements) without dyskinesia (uncontrolled movements of the face, arms, or legs). Patient 15’s POC dated 03/21/24 through 05/19/24, failed to show documentation of an individualized EPP in Patient 15’s record. Observation during Patient 15’s home visit on 03/26/24 at 2:00 PM, found no written individualized EPP in the patient’s home. Patient 16 Review of Patient 16’s record showed a start of care date of 02/24/24 with a primary diagnosis of encounter for surgical aftercare following surgery on the digestive system. Patient 16’s POC dated 02/24/24 through 04/23/24, failed to show documentation of an individualized EPP in Patient 16’s record. Observation during Patient 16’s home visit on 03/26/24 at 12:00 PM, found no written individualized EPP in the patient’s home. Patient 17 Review of Patient 17’s record showed a start of care date of 11/24/23 with a primary diagnosis of alpha-1-antitrypsin deficiency (a genetic condition that causes a lack of the protective protein alpha-1- antitrypsin). Patient 17’s POC dated 03/23/24 through 05/21/24 failed to show documentation of an individualized EPP in Patient 17’s record. Observation during Patient 17’s home visit on 03/26/24 at 10:00 AM, found no written individualized EPP in the patient’s home. During an interview on 03/27/24 between 12:30 PM and 1:30 PM, the Administrator provided documentation that was based on in-home safety with PT/OT. The documentation did not provide individual patient plans for natural or man-made disaster.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on interviews and review of the Emergency Preparedness Plan (EPP) the facility failed to review and update the communication plan in their (EPP). This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program (EPP) indicated that the last date for review and update of the (EPP) communication plan was 11/2019. During interviews conducted on 03/27/24 with Administrator, it was confirmed that the facility did not have any documentation for review more recent than 11/2019.”

“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 interviews and review of the Emergency Preparedness Plan (EPP), There was no documentation for review of the facility’s efforts to identify a full-scale community-based exercise. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program (EPP) indicated that the facility failed to participate in a full-scale community-based exercise. During interviews conducted on 03/27/24 with the Administrator, it was confirmed that the facility did not participate in a full-scale community-based exercise.”

“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, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that the individualized plan of care included all medications and treatments for 1 (Patient 17) of 17 patients reviewed. Failure to ensure that the care plan includes all medications and treatments does not allow for review of medications and treatments to identify any potential adverse effects or interactions jeopardizing the quality and safety of patient care. Findings Include: Review of HHA policy titled “6.2 Plan of Care” revised in June of 2018 states “The individualized plan of care must include the following:” … “(x) All medications and treatments”. Review of HHA policy titled “6.3 Medication Reconciliation” revised in November of 2019 states “Medication reconciliation is required at Start of Care and Discharge, and at least every 60 days, and must be documented in the clinical record. Medications included shall be all prescriptions, over the counter and herbal supplements being taken by the patient.” It also states, “Medication review shall be conducted periodically throughout the episode of care to determine if the consumer has added or eliminated medications…”. Review of Patient 17’s record showed a start of care date of 11/24/23 with a primary diagnosis of alpha-1-antitrypsin deficiency with a current certification period of 03/23/24 to 05/21/24. Review of the current plan of care and medication profile for certification period of 03/23/24 to 05/21/24 did not show morphine listed as a medication. Review of the plan of care certification period of 01/23/24 to 03/22/24 did not show morphine listed as a medication. Review of the plan of care certification period of 11/24/23 to 01/22/24 did not show morphine listed as a medication. Observation during Patient 17’s home visit on 03/26/24 at approximately 10:00 AM, a bottle of liquid morphine was on Patient 17’s nightstand at her bedside. The care plan with a certification period of 03/23/24 to 05/21/24 was compared to the handwritten medication list provided by the husband. It was noted that morphine was not noted on either list. When discussing the medication list, the husband mentioned getting a refill on her liquid morphine and presented the bottle for review. The bottle read morphine 10 milligrams (mg) per 5 milliliters (ml) take 5ml as needed (PRN) every 3 hours for shortness of breath. The fill date on the bottle was 03/18/24. The husband stated that this was not a newly started medication, and Patient 17 had been taking it PRN since October of 2023. During the observation, Staff D, Registered Nurse (RN) stated that it should be listed on the care plan and the medication list as a PRN medication. During an interview on 03/28/24 at approximately 1:30 PM, Staff A, Executive Director (ED), Staff B, Director of Nursing (DON), and Staff C, Director of Operations (DOO) regarding patient medication reconciliation, Staff B stated that each patient admitted has a full medication list entered for review during the admission visit. If a medication change occurs during their certification period, then the care plan and medication list are updated to reflect the change. The DOO stated that the medication was listed on the current medication list in the electronic medication record under long standing (LS) medication, however the medication profile for 03/23/24 to 05/21/24 that was printed on 03/25/24 prior to home visit and it did not have morphine listed as a medication.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on interview, record review, and policy review, the agency failed to coordinate care to meet the patient’s needs for 1 (Patient 13) of 17 patients reviewed. This failure had the potential for the patient’s wound to not heal and for the patient’s health to decline. Findings Included: A review of an agency policy titled, “Coordination of Care,” revised in November 2019, revealed, “5. Agency staff will communicate any patient concerns and patient progress toward the goals of the plan of care with other involved in the patient’s care, including all physicians involved with the plan of care.” A review of Patient 13’s “Home Health Certification and Plan of Care,” dated 04/14/23, revealed the agency admitted the patient on 04/14/23, with diagnoses that included disruption of an external operation wound (the unplanned reopening of an incision made during a surgery), non-pressure ulcer of the left ankle with fat exposed (damage to the skin and underlying tissue not caused by pressure), and generalized anxiety disorder (a condition with exaggerated tension, worrying, and nervousness about daily life events). The Home Health Certification and Plan of Care directed skilled nursing to assess/evaluate wound(s) at each dressing change and as needed for signs/symptoms of infection, report to the physician increased temperature, chills, increased in the amount or color of drainage, foul odor, redness, swelling, unrelieved pain, and any other significant changes. Review of Patient 13’s “RN [registered nurse]-Skilled Nursing Visit,” dated 04/21/23, revealed the patient’s left lateral ankle wound had a foul odor. Review of Patient 13’s “LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse]-Skilled Nursing Visit,” dated 04/24/23, revealed the patient’s left lateral ankle wound had a foul odor. Review of Patient 13’s “Patient Communication,” dated 04/24/23, revealed a nurse contacted Patient 13’s Primary Care Physician (PCP) on 04/24/23 to report the foul odor of the patient’s wound and the PCP stated the patient needed to be seen at wound care clinic for management of their wounds. Review of Patient 13’s clinical record, “RN-Skilled Nursing Visit,” dated 04/27/23, revealed the patient’s left lateral ankle wound had a foul odor. Review of Patient 13’s “LPN/LVN-Skilled Nursing Visit,” dated 04/28/23, 05/02/23, 05/05/23, 05/08/23, and 05/15/23, revealed the patient’s left lateral ankle wound had a foul odor. Review of Patient 13’s clinical record, “RN-Skilled Nursing Visit,” dated 05/11/23, revealed the patient’s left lateral ankle wound had a foul odor. Per the RN-Skilled Nursing Visit, the nurse instructed the patient to make sure the infectious disease doctor observed their left ankle wound as the drainage was foul and the wound appeared to be getting bigger during their appointment next week. Review of Patient 13’s “LPN/LVN-Skilled Nursing Visit,” dated 05/18/23, revealed the patient’s left lateral ankle wound had a foul odor. Per the LPN/LVN-Skilled Nursing Visit, the patient did not see the infectious disease doctor on 05/17/24 as they did not have a ride to the appointment. Review of Patient 13’s “LPN/LVN-Skilled Nursing Visit,” dated 05/25/23, 05/30/23, 06/02/23, and 06/05/23, revealed the patient’s left lateral ankle wound had a foul odor. Review of Patient 13’s clinical record revealed no evidence to agency notified a physician after 04/24/23 of the resident’s foul odor from their left lateral ankle wound or evidence to indicate the patient was referred to a wound care clinic for the management of their wounds. During an interview on 03/28/24 at 2:00 PM, the Director of Nursing (DON) stated that the agency expectation was if a care provider refused to provide orders or oversight of the home health plan of care, staff should notify the DON. The DON stated the agency did not have documentation to indicate the agency contacted a provider regarding Patient 13’s foul smelling ankle wound after 04/24/23, when Patient 13’s PCP indicated the patient should be seen at a wound care clinic for the management of their wounds.”