Chesapeake - Potomac Home Health Agency, Inc.

“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: Review of the agency’s emergency preparedness documentation revealed that the agency had actual emergency’s that required the activation of their relevant emergency plan that exempted engagement in a community-based full-scale exercise in 2021, 2022, and 2023. The agency did not have sufficient documentation of a secondary exercise as required by 484.102(d)(2)(ii).”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation during a home visit with agency clinical staff, (the clinical supervisor and the Registered Nurse (RN) clinician), adequate infection control prevention was not implemented during the provision of wound care by the RN. The RN failed to demonstrate adequate infection control practices. Failure to adhere to infection control standards placed patients at risk for infection. Patient # 17 Findings included: Infection prevention practices require the separation between dirty (contaminated: covered with disease-causing organisms) and clean (reduced level of contamination) tasks and areas during a dressing change an invasive procedure to prevent the transmission (cross-contamination) of bacteria/viruses, which can lead to infection. It means that hands must be washed or sanitized in addition to glove changes between dirty procedures (for example, removing a soiled dressing, cleansing a wound, removing used clinical supplies, cleansing before an invasive procedure and touching a cellular telephone) and clean procedures (for example, inserting a urinary catheter applying new dressing materials or handling new clinical supplies, including medications). Additionally, every attempt should be made to avoid the contamination of sterile (free of bacteria) or clean items. The regulation for standard infection prevention states that the home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This did not occur. 1.During the care visit, on 7/3/2024, with patient #17, the RN performed wound care to the patients’ right foot. The orders were right foot wound to be cleansed with normal saline, pat dry, apply calcium alginate to wound bed, cover with gauze, then wrap with kerlix bandage. a) In two instances during the wound care procedure the RN sanitized hands then fanned hands and recontaminated hands by patting them dry on sides of pant legs before putting on clean gloves. Hand sanitizer that is wiped off before it’s dry may not work well against germs. (cdc.gov) b)The RN kneeled on the patient’s carpeted floor without a barrier. The floor had visible debris. Failure to place a barrier between the RN and the dirty floor placed patients at risk for cross- contamination. c)The RN placed the patient’s foot to be treated on top of the patient’s box of medical supplies (bandages, gloves, treatment medications, saline, syringes, etc.) without use of a barrier. This action had the potential to contaminate the patient’s supplies. d) The RN cleansed used equipment with disinfectant agent and placed the equipment back onto the dirty barrier then placed the instruments into supply bag. During the exit interview on 7/24/2020, the clinical supervisor acknowledged the breaches in universal precautions.”

“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 review of patient records and interview with agency staff, the agency staff did not communicate delays in the start of care were noted for 11 out 17 reviewed placing the patients at risk for adverse or negative health care outcomes. Patients: #4, #5, #6, #7, #9, #10, #11, #12, #13, #15, and #16 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1.All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records on 7/22/2024, 7/23/2024, and 7/24/2024. a) On 7/22/2024, during the review of patient #4 medical record, it is documented that on 6/4/2024 the agency received and accepted a referral to provide physical therapy services for the patient. It was documented on 6/19/2024 that the patient was contacted to verify insurance and demographics. A 6/27/2024 note states that the patient’s family requested a start of care date of 7/12/2023. There was no documentation explaining the delay in contacting the patient from 6/4/2024 to 6/19/2024. No documentation communicating the reason for the fifteen-day delay in communicating with the patient or to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. b) On 7/22/2023, during the review of patient #5 medical record, it is documented that on 6/22/2024 the agency received and accepted a referral to provide physical therapy services for the patient. The start of care date is documented as 6/27/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. c) On 7/23/2024, during the review of patient #6 medical record, it is documented that on 6/13/2024 the agency received and accepted a referral to provide physical therapy services for the patient. The start of care date is documented as 6/17/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the four-day delay in the start of care was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. d) On 7/23/2024, during the review of patient #7 medical record, it is documented that on 2/26/2024 the agency received and accepted a referral to provide skilled nursing and physical therapy services for the patient. The start of care date is documented as 3/1/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the four-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. e) On 7/23/2024, during the review of patient #9 medical record, it is documented that on 10/26/2023 the agency received and accepted a referral to provide skilled nursing, physical and occupational therapy services for the patient. The start of care date is documented as 10/29/2023. There was no documentation explaining the delay in the start of care. No documentation communicating the three-day delay in the start of care was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. f) On 7/24/2024, during the review of patient #10 medical record, it is documented that on 1/29/2024 the agency received and accepted a referral to provide skilled nursing, physical and occupational therapy services for the patient. The start of care date is documented as 2/6/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the nine-day delay in the start of care was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. g) On 7/24/2024, during the review of patient #11 medical record, it is documented that on 3/15/2024 the agency received and accepted a referral to provide skilled nursing and physical therapy services for the patient. The start of care date is documented as 3/19/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the four-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. h) On 7/24/2024, during the review of patient #12 medical record, it is documented that on 3/20/2024 the agency received and accepted a referral to provide skilled nursing services for the patient. The start of care date is documented as 3/29/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the nine-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. i) On 7/24/2024, during the review of patient #13 medical record, it is documented that on 4/9/2024 the agency received and accepted a referral to provide skilled nursing and physical therapy services for the patient. The start of care date is documented as 4/18/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the nine-day delay in the start of care was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. j) On 7/22/2024, during the review of patient #15 medical record, it is documented that on 5/28/2024 the agency received and accepted a referral to provide skilled nursing and home health aide services for the patient. It is documented that the patient was discharged from the hospital on 6/5/2024. The start of care date is documented as 6/9/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the four-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care. k) On 7/22/2024, during the review of patient #16 medical record, it is documented that on 7/18/2024 the agency received and accepted a referral to provide skilled nursing services for the patient. The start of care date is documented as 7/23/2024. There was no documentation explaining the delay in the start of care. No documentation communicating the five-day delay in the start of care to the referring physician was in the record. During the interview, the agency staff did not provide any further information or documentation for the delay in care.”