Pernet Family Heatlh Services

“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 agency failed to ensure the Emergency Preparedness (EP) plan that included a facility-based and community-based risk assessment, utilizing an all-hazards approach and strategies for addressing emergency events identified by the risk assessment, had been updated every two years as required. Findings include: A review of the agency’s EP plan indicated an undated All-Hazards Risk Assessment. During an interview on 6/11/24 at 11:25 A.M., the Executive Director said the All-Hazards Risk Assessment was developed in May 2022, but had not been updated since, as required.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure complete and appropriately authenticated, dated, and timed documentation for one Patient (#6), out a total sample of 7 patients. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. Findings include: Patient #6 was admitted to the agency in February 2024 requiring skilled nursing services. Review of a nursing Request for Discharge order, dated 4/24/24, indicated a planned discharge from the agency for 5/3/24. Further review of this order indicated it had not been signed and dated by the physician. During an interview on 6/12/24 at 12:20 P.M., Nurse #1 said the discharge order for Patient #6 was faxed to the physician for a signature as required, but the agency did not ensure a signed and dated order was returned.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the initial assessment visit was completed either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner ordered start of care date for 5 Patients (#1, #4, #5, #6, and #7), out of a total sample of 7 patients. Findings include 5. Patient #5 was admitted to the agency in August 2023 due to poor growth, height and oral intake. Review of the clinical record indicated a referral was received by the agency on 7/20/23. Further review of the clinical record indicated an initial assessment visit was completed on 8/2/23, and not within the required 48 hours. During an interview on 6/12/24 at 12:45 P.M., Nurse #1 said the initial assessment visit was completed on 8/2/23 and not within 48 hours, as required. 1. Patient #1 was admitted to the agency in June 2024. Review of the clinical record indicated the patient was referred to the agency on 6/3/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 6/11/24, not within 48 hours of the referral, as required. 2. Patient #5 was admitted to the agency in April 2024. Review of the clinical record indicated the patient was referred to the agency on 4/16/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 5/10/24, not within 48 hours of the referral, as required. 3. Patient #6 was admitted to the agency in February 2024. Review of the clinical record indicated the patient was referred to the agency on 2/7/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 2/15/24, not within 48 hours of the referral, as required. 4. Patient #7 was admitted to the agency in March 2024. Review of the clinical record indicated the patient was referred to the agency on 3/7/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 3/25/24, not within 48 hours of the referral, as required. During an interview on 6/12/24 at 11:20 A.M., the Executive Director (ED) said she was aware the initial assessments were not being done timely, and they should have attempted to do them within the required 48 hours.,”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure the comprehensive assessment was updated within the last 5 days of the last 60 certification period for one Patient (#6), out of total sample of 7 patients. Findings include: Patient #6 was admitted to the agency in February 2024 for skilled nursing services. Review of the clinical record indicated an initial comprehensive assessment was completed on 2/15/24 and a physician’s order was obtained on 2/15/24, for skilled nursing services once a week for 6 weeks, then once every other week, through 4/15/24. Review of the clinical record indicated the patient was seen by a nurse on 5/3/24. Further review of the clinical record indicated the comprehensive assessment had not been updated during the last 5 days of the certification period of 2/15/24 through 4/15/24. During an interview on 6/12/24 at 12:05 P.M., the Executive Director said the comprehensive assessment for Patient #6 had not been updated, 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 clinical record review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care for two Patients (#4 and #6), out of a total sample of 7 patients. Findings include: 2. Patient #4 was admitted to the agency in August 2023 due to poor growth, height and oral intake. Review of the clinical record indicated a signed Physician order for weekly skilled nursing home visit for weight check for 60 days, from 8/2/23 through 10/25/23. Review of the weekly home visits indicated there was no weekly home visit provided from 10/1/23 through 10/7/23 and 10/8/23 through 10/14/23. During an interview on 6/11/24 at 3:40 P.M., Nurse #1 said she received an email from the physician on 9/27/23 to change the weekly home visits to monthly visits, but she failed to write the order and send it to the physician for signature, as required. 1. For Patient #6, the agency failed to obtain a new physician’s order for skilled nursing services, after the initial physician’s order plan of care. Patient #6 was admitted to the agency in February 2024 for skilled nursing services. Review of the clinical record indicated an initial comprehensive assessment was completed on 2/15/24 and a physician’s order was obtained on 2/15/24, for skilled nursing services once a week for 6 weeks, then once every other week, through 4/15/24. Review of the clinical record indicated the patient was seen by a nurse on 5/3/24. Further review of the clinical record indicated no additional physician orders for skilled nursing visits after 4/15/24. During an interview on 6/12/24 at 12:05 P.M., the Executive Director said the skilled nursing visit on 5/3/24 should not have been provided as there was not a physician’s order allowing the visit.”