Acton Public Health Nursing SE

“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 interview and policy review the agency failed to ensure the policy and procedure for the Emergency Preparedness (EP) Plan was reviewed and updated every 2 years. Findings include: Review of the agency policy entitled, Emergency Management Plan, revised 11/2021, did not include any identified hazards within the agency’s risk assessment nor the agency’s emergency preparedness program. During an interview on 1/14/26 at 2:45 P.M., the Director said the Emergency Management Plan was too broad and contained information not specific to the agency, as required.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 2 patients (#1 and #2), out of a total sample of 7 patients. Findings include Review of the agency’s policy entitled, Discharge Criteria and Process, dated April 2024, indicated the following: *For Medicare and Medicare HMO patients, the organization will issue a NOMNC at least 48 hours prior to termination. 1.Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of a Physical Therapy note, dated 9/9/25, indicated Patient #1 had met his/her goals and was being discharged from the agency. Further review of the clinical record indicated a NOMNC had not been issued. During an interview on 1/14/26 at 11:15 A.M, the Director said a NONMC had not been issued 48 hours prior to discharge, as required. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of aftercare following joint replacement surgery. Review of a Physical Therapy Assistant note dated 8/25/25, indicated the patient would begin outpatient therapy on 9/3/25. Further review of the clinical record indicated a NOMNC was issued on 8/28/25, the same day Patient #2 was discharged from the agency. During an interview on 1/14/26 at 12:50 P.M., the Director said the NOMNC was not provided 48 hours prior to Patient #2’s discharge from the agency, as required.”

“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 review, policy review and interview, the agency failed to ensure service were provided that were orderd by the physician or allowed practitioner in the plan of care, for 1 patient (#1), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled, Care Planning Process, dated May 2023, indicated the following: *The plan of care (POC) will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies and services required to meet the patient’s needs. Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the physician ordered Home Health Certification and POC, for certification period 8/3/25 through 10/1/25, indicated the following: -Effective 8/4/25, Physical Therapy (PT) visit: 2 times a week for 4 weeks. -Effective 8/17/25, PT visit: once a week for 2 weeks. Review of the clinical record indicated the following: -The week of 8/10/25 only one PT visit was provided on 8/11/25, not 2 as ordered. -The week of 8/24/25 no PT visits were provided. Further review of the clinical record did not include documentation as to why the PT visits were not provided. During an interview on 1/14/26 at 11:15 A.M., the Director said the POC was not followed and PT visits were not provided as ordered by the physician. She also said staff did not document why the visits were not provided as ordered.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to communicate with all physicians involved in the plan of care (POC) or other health care practitioners (as appropriate) related to services not provided, as orderd, in the plan of care, for 1 patient (#1), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled, Monitoring Patient’s Response/Reporting to Physician, dated April 2021, indicated the following: *The patient’s physician (or other authorized licensed independent practitioner) will be contacted on the same day when one of the following occurs: -When there is any problem implementing the plan of care. -When a visit is missed for any reason. Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the physician ordered Home Health Certification and POC, for certification period 8/3/25 through 10/1/25, indicated the following: -Effective 8/4/25, Physical Therapy (PT) visit: 2 times a week for 4 weeks. -Effective 8/17/25, PT visit: once a week for 2 weeks. Review of the clinical record indicated the following: -A missed Physical Therapy Assistant (PTA) note dated 8/6/25 indicated the patient was unavailable for the visit. The note also indicated the physician was not notified of the missed visit. -The week of 8/10/25 only one PT visit was provided on 8/11/25, not 2 as ordered. -The week of 8/24/25 no PT visits were provided. Further review of the clinical record did not include physician notification for the missed PT and PTA visits. During an interview on 1/14/26 at 11:15 A.M., after reviewing the clinical record, the Director said that staff should have notified the physician when the visits were not provided, as ordered, in the POC.”

“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, policy review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient’s discharge, for 2 patient (#1 and #2), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled, Discharge Summary, dated April 2021, indicated the following: *A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within 5 business days of the patient’s discharge. 1.Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the clinical record indicated the patient was discharged from the agency on 9/9/25. Further review of the clinical record did not indicate the discharge summary was sent to the physician responsible for providing care to the patient after discharge. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of aftercare following joint replacement surgery. Review of the clinical record indicated the patient was discharged from the agency on 8/28/25. Further review of the clinical record did not indicate the discharge summary was sent to the physician responsible for providing care to the patient after discharge. During an interview on 1/14/26 at 12:45 P.M., after reviewing both patient records, the Director said neither discharge summary was provided to each patient’s physician, as required.”