Stat Home Health Triton

“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 record review and interview, the agency failed to ensure all new and existing staff and all individuals providing services under arrangement received initial training in Emergency Preparedness policies and procedures, had training at least every 2 years, and documentation of training was maintained with demonstration of staff knowledge of emergency procedures. The agency failed to have documented evidence of Emergency Preparedness training for 2 (S7PT and S8OT) of 10 personnel records reviewed. Findings: Review of the agency’s training logs on 04/18/2024 at 4:05 p.m. with S2RDO revealed no documented evidence of initial training, ongoing training every 2 years, and documentation of demonstrated knowledge of emergency procedures for S7PT and S8OT’s personnel records reviewed for Emergency Preparedness training. An interview was conducted on 04/18/2024 at 4:10 p.m. with S2RDO. She stated Emergency Preparedness training should be completed upon hire and every 2 years thereafter. She confirmed there was no documentation of Emergency Preparedness training on file for S7PT and S8OT and there should have been.”

“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 record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Review of the agency’s undated policy titled, “Reporting of OASIS Information” revealed the following, in part: Policy: The agency will report required data collected for the Outcome and Assessment Information Set items. Procedure: 1. The agency will report electronically all OASIS data collected according to current federal and/or state requirements. 3. Agency will electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the system. 4. OASIS data must be transmitted in accordance with the current CMS transmission policy. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/05/2023 revealed 6 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/06/2023 revealed 11 records were processed with 3 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/09/2023 revealed 19 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/14/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/16/2023 revealed 6 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/20/2023 revealed 16 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 06/28/2023 revealed 3 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 07/12/2023 revealed 13 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 07/15/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 07/25/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 07/27/2023 revealed 5 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/01/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/01/2023 revealed 11 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/03/2023 revealed 6 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/16/2023 revealed 12 records were processed with 4 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/18/2023 revealed 3 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 08/18/2023 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 12/27/2023 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 01/04/2024 revealed 4 records were processed with 2 record receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 02/01/2024 revealed 1 record was processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 03/05/2024 revealed 10 records were processed with 5 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2RDO on 04/18/2024 at 11:00 a.m. She reviewed the above OASIS validation reports and confirmed the records were submitted late, more than 30 days after completion. She confirmed patients’ OASIS should have been submitted within 30 days of completion.”

“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 observations during home visits, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing staff reconciled patients’ medications for 3 (#1, #2, and #3) of 6 (#1, #2, #3, #4, #6 and #7) patients reviewed with home visits. Patient #3 Review of the Clinical Record for Patient #3 revealed he began receiving services from the Home Health Agency on 01/20/2024 and had a current Certification Period of 03/20/2024 – 05/18/2024. Patient #3 had diagnoses which included Pain Due to Internal Orthopedic Prosthesis Device, Arthritis Due to Other Bacteria, Right Knee and Type II Diabetes Mellitus with Diabetic Polyneuropathy. A home visit was conducted with Patient #3 on 04/17/202 at 2:00 pm. Patient #3’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #3’s Current Medication Profile provided by the Home Health Agency: Aspirin 325mg tablet take one tablet by mouth two times a day was on the medication profile with a start date of 03/14/2024, and was not present in the home. Colace100mg capsule take one capsule by mouth twice a day was on the medication profile with a start date of 01/20/2024, and was not present in the home. Crestor 20mg tablet take one tablet daily, and was not present in the home. Cyclobenzaprine 10mg tablet take one tablet every eight hours was on the medication profile with a start date of 03/14/2024, and was not present in the home. Miralax 17 gram oral powder packet take one packet daily was on the medication profile with a start date of 01/20/2024, and was not present in the home. An interview was conducted with Patient #3 during the home visit. He stated he managed his own medications. He stated the home health nurses do not check his medications. He confirmed the above listed medications were not in his home. He stated he had not been on the medications listed above for over one month. An interview was conducted with S1ED on 04/18/2024 at 2:35 p.m. He was notified of the medication discrepancies found during the home visits for Patient #1, #2, and #3. He stated each patients’ medications should have been reconciled every discipline visit and staff should review the medication bottles each visit. He verified each patients’ Medication Profile should have reflected what the patient was currently taking. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” dated January 2024 revealed the following, in part: Policy: The Agency will reconcile patient’s medications at the time of admission and on an ongoing basis in order to identify potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug reactions, duplicate drug therapy and non-compliance with drug therapy. Purpose: Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated. Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 03/09/2024 and had a current Certification Period of 03/09/2024 to 05/07/2024. Patient #1 had diagnoses, which included Dysphagia, Lumbago with Sciatica Right Side, Chronic Pain, Arthritis, and Spinal Stenosis Cervical Region. A home visit was conducted with Patient #1 and Patient #1’s daughter on 04/17/2024 at 10:00 a.m. with S3RN present in the home. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #1’s Current Medication Profile provided by the Home Health Agency: Cyclobenzaprine 5 mg tablet take one tablet two times daily was on the medication profile with a start date of 03/09/2024, and the patient was taking as needed. Gabapentin 400 mg capsule take two capsules three times daily was on the medication profile with a start date of 03/09/2024, and the patient was taking as needed. Indomethacin 75 mg Extended Release capsule take one capsule daily was on the medication profile with a start date of 03/09/2024, and the patient was no longer taking. Melatonin 3 mg capsule take one capsule at bedtime was on the medication profile with a start date of 03/09/2024, and the patient was no longer taking. An interview was conducted with Patient #1’s daughter during the home visit. She stated she managed Patient #1’s medications and administered his medications through his peg tube. She stated in March 2024, Patient #1’s physician stopped all of his medications that had a sedative effect. She stated Cyclobenzaprine was changed to as needed and he had not taken the medication since his home health admit. She stated Gabapentin was changed to as needed for nerve pain prior to his home health admit. She stated the Indomethacin and Melatonin were stopped completely in March 2024. An interview was conducted with S3RN on 04/17/2024 at 10:15 a.m. during the home visit. S3RN confirmed the above medication discrepancies during the home visit. S3RN stated medications should be reconciled during every home visit. Patient #2 Review of the Clinical Record for Patient #2 revealed he began receiving services from the Home Health Agency on 08/25/2023 and had a current Certification Period of 02/21/2024 to 04/20/2024. Patient #2 had diagnoses, which included Acute Combined Systolic and Diastolic Congestive Heart Failure, End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Other Chronic Pain, Anxiety Disorder, and Orthostatic Hypotension. A home visit was conducted with Patient #2 on 04/17/2024 at 8:00 a.m. with S3RN present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Gabapentin 100 mg capsule take one capsule by mouth three times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Hydrocodone 10 mg-Acetaminophen 325 mg tablet take one tablet by mouth every six hours for pain was on the medication profile with a start date of 08/24/2023, and was not present in the home. Lexapro 10 mg tablet take one tablet by mouth daily was on the medication profile with a start date of 02/14/2024, and was not present in the home. Protonix 40 mg tablet take one tablet by mouth daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Senna Plus 8.6 mg-50 mg capsule take one capsule by mouth two times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. Valium 5 mg tablet take one tablet by mouth every six hours for anxiety was on the medication profile with a start date of 02/14/2024, and was not present in the home. Xanax 0.25 mg tablet take one tablet by mouth two times daily was on the medication profile with a start date of 08/24/2023, and was not present in the home. An interview was conducted with Patient #2 during the home visit. He stated he managed his own medications. He stated the home health nurses never checked his medications. He stated he had not taken Gabapentin in months. He stated he was no longer prescribed Hydrocodone and had not taken the medication in six months. He stated he took Lexapro for the month of February 2024 and then stopped taking it because it wasn’t helping. He stated he was not taking Protonix and confirmed he did not have any in the home. He stated he had stopped taking Senna six months ago. He stated he never filled the prescriptions for Valium and Xanax. An interview was conducted with S3RN on 04/17/2024 at 8:30 a.m. during the home visit. S3RN confirmed the above medication discrepancies during the home visit. S3RN stated medications should be reconciled during every home visit.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure services ordered by the Physician were provided as indicated in the Plan of Care as evidenced by: 1. Medical Social Worker (MSW) visits were not conducted as ordered for 1 (Patient #4) of 2 (Patients #4 and #5) patient records reviewed with orders for MSW services; and, 2. Home Health Aide (HHA) visits were not conducted as ordered for 2 (Patients #12 and #17) of 3 (Patients #11, #12, and #17) patient records reviewed with orders for Home Health Aide services. Patient #12 Review of Patient #12’s Clinical Record revealed he was admitted to the agency on 03/08/2024 with diagnoses which included Hemiplegia following Cerebral Infarction affecting Right Dominant Side, Hemiplegia following Cerebral Infarction affecting Left Non Dominant Side, Chronic Obstructive Pulmonary Disease, and Dementia with Mood Disturbance. Review of Patient #12’s Plan of Care for certification period of 03/08/2024 – 05/06/2024 revealed Physician Orders which included the following, in part: HHA effective 03/24/2024 1 time a week for 1 week, 1 every other 2 times a week for 2 weeks, and 1 time a week for 1 week. Review of the Client Calendar Report for Patient #12 revealed no documentation of a HHA visit for the Certification Period 03/08/2024 – 05/06/2024. An interview was conducted on 04/18/2024 at 1:50 p.m. with S2RDO. She reviewed Patient #12’s Clinical Record and confirmed HHA visits were ordered for 1 time a week for 1 week, 1 every other 2 times a week for 2 weeks, and 1 time a week for 1 week effective 03/24/2024 and were not completed. She confirmed the agency did not follow the physician’s orders and should have. Patient #17 Review of Patient #17’s Clinical Record revealed he was admitted to the agency on 11/14/2023 with diagnoses which included Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Right Heel Stage 1, Paraplegia, Chronic Diastolic Congestive Heart Failure, and Obesity. Review of Patient #17’s Plan of Care for Certification Period of 11/14/2023 – 01/12/2024 revealed Physician Orders which included the following, in part: HHA needed for help with patient personal care assistance written on 11/30/2023. Further review of the Clinical Record revealed an additional order for a HHA visit written on 01/08/2024. Review of the Client Calendar Report for Patient #17 revealed no documentation HHA services were provided from 11/30/2023 until discharge on 01/12/2024. An interview was conducted on 04/18/2024 at 12:15 p.m. with S2RDO. She reviewed the physician orders for HHA services dated 11/30/2023 and 01/08/2024 for Patient #17. She confirmed there was no documentation in Patient #17’s Clinical Record why the HHA services were not provided and there should have been. She confirmed the agency did not follow the physician’s orders and should have. An interview was conducted on 04/18/2024 at 2:21 p.m. with S1ED. S1ED verified the aforementioned clinical records failed to include documentation why services were not provided. He confirmed the agency did not follow the physician’s orders for Patients #4, #12, and #17 and should have. Review of the agency’s policy titled “Plan of Care and Physician/Practitioners Orders” dated February 2024 revealed the following, in part: Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range needs and resources. Procedure: 3. 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. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 03/27/2024 with diagnoses which included Polyneuropathy, Alcohol Dependence, Essential Hypertension and History of Transit Ischemic Attacks. Review of Patient #4’s Plan of Care for certification period of 03/27/2024 – 05/25/2024 revealed Physician Orders which included the following, in part: MSW effective 03/31/2024 1 time a week for 1 week. Further review of the Clinical Record revealed an additional order for a MSW visit written on 04/03/2024. Review of the Client Calendar Report for Patient #4 revealed no documentation of a MSW visit for the Certification Period 03/27/2024 – 05/25/2024. There was no documentation of the reason for the missed visit. An interview was conducted on 04/17/2024 at 1:15 p.m. with S2RDO. She reviewed Patient #4’s Clinical Record and confirmed a MSW visit was ordered for 1 time a week for 1 week effective 03/31/2024 and was not completed. She confirmed an additional MSW visit was ordered on 04/03/2024 and was not completed. She said there were no missed visit notes by the MSW and there should have been. She confirmed the order for a MSW visit on 04/03/2024 was denied by the Registered Nurse that approved visits.”