Summit Home Health

“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 record review and interview, the Agency failed to develop an emergency preparedness plan that had been reviewed and updated, at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients currently serviced by this Agency in the event of a facility emergency or disaster. Findings include: On 10/1/24 at 2:55 p.m., a request was made to review the agency’s Emergency Preparedness Plan. Upon receipt and review of the provided documents, it was noted that the plan had not been updated. A Hazardous Vulnerability Assessment/Risk Assessment was dated for 11/2018. During an interview on 10/1/24 at 3:15 p.m., the Clinical Manager stated, “It (Emergency Preparedness Plan) has not been updated since 2018 because I didn’t know how to get the updated forms to complete the Risk Assessment. The agency failed to ensure the Emergency Preparedness Plan had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by CM #1 at the time of discovery.”

“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 record review and interview, the Agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 10/1/24 at 2:55 p.m., a request was made to review the agency’s Emergency Preparedness Plan. Upon receipt and review of the provided documents, it was noted that the plan had not been updated. A Hazardous Vulnerability Assessment/Risk Assessment was dated for 11/2018. During an interview on 10/1/24 at 3:15 p.m., the Clinical Manager (CM #1) stated, “It (Emergency Preparedness Plan) has not been updated since 2018 because I didn’t know how to get the updated forms to complete the Risk Assessment. The agency failed to ensure the Emergency Preparedness Plan was based on an updated facility/community-based risk assessment utilizing an all-hazards approach. These findings were reviewed with and acknowledged by CM #1 at the time of discovery.”

“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, interview and record review, the Agency failed to ensure its disciplines utilized Infection Control standards of practice during the provision of care and services for 2 (P-1 and P-8) of 5 patients observed during home visits, from a total of 13 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-1: The patient’s start of care was 9/21/24 with diagnoses that included Lymphedema bilateral lower extremities with drainage and Congestive Heart Failure. During the record review on 9/30/24 at 12:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN) for the following wound care orders: Cleanse with wound cleanser, pat dry, apply Unna boot then Kerlix and Coban then secure with tape. On 9/30/24 at 2:15 p.m., a scheduled survey home visit was conducted with the Registered Nurse (RN #1). During the visit, RN #1 donned a pair of gloves and continued to apply additional pairs of gloves, creating an overlay. RN #1 proceeded to clean the patient’s right leg with wound cleanser and gauze. RN #1 then removed the outer pair of gloves and applied the Unna boot gauze to the patient’s right leg. RN #1 then removed a pair of gloves and applied Kerlix gauze. RN #1 then covered the dressing with Coban elastic wrap. After applying the Coban wrap to the patient’s right leg, RN #1 removed a pair of gloves and donned additional pairs of gloves to his hands. RN #1 did not wash his hands or use hand sanitizer between the donning of gloves. With a remaining pair of gloves on his hands, RN #1 applied additional pairs of gloves to his hands and repeated the process as before. Upon completion of the dressing applications, RN #1 removed the final pair of gloves and sanitized his hands. RN #1 then applied a clean pair of gloves and discarded the dirty items from the floor. Wearing the same gloves used to discard items from the floor, RN #1 retrieved a cleansing wipe and began wiping his stethoscope, blood pressure cuff and pulse oximeter and placed all the items in his bag. RN #1 failed to utilize Infection Control standards of practice during the provision of care and services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 10/3/24 at 8:58 a.m. P-8: This 63-year-old patient was admitted on 9/30/24 with diagnoses including joint replacement of the left knee; atrial fibrillation (abnormal heart rhythm), and high blood pressure. On 10/1/24 at 2 p.m., a joint visit was conducted with the Physical Therapist (PT). During the visit, it was observed that the PT brought a bag from his vehicle and into the home which contained shared patient PT equipment (exercise/safety equipment). The PT retrieved a pair of gloves from the bag he brought, donned them, and began providing direct care to the patient (handling the patient and patient surroundings). It was also observed that the PT reached for items in the bag 3 separate times without first removing the dirty gloves or performing hand hygiene. This finding was reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide documented evidence that Infection Control education was provided to all staff employed by the agency, including contracted staff, resulting in the potential for the development and spread of infection to staff and all patients currently serviced by this agency. Findings include: On 10/1/24 at 2:10 p.m., the Clinical Manager (CM #1) was asked for permission to review the agency’s Infection Control in-services. At 2:15 p.m., upon receipt and review of the provided documents, it was noted that all staff, according to the provided staff list, had not received in-services or training in Infection Control. CM #1 provided a document titled, “Bag Technique.” dated for the month of June 2024, however, all staff were not in attendance and did not receive this education. Further, CM #1 provided a list of typed names of employees reported to have received this training. When asked why all staff had not attended the in-service, CM #1 responded, “They just didn’t attend the meeting.” No other documentation was provided by the end of the survey. The agency failed to ensure all staff, including those granted clinical privileges, received Infection Control in-services and training. The above findings were reviewed with and acknowledged by CM #1 at the time of discovery.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure Occupational Therapy (OT) services were authorized only by the health care professional qualified to do so in 4 (P-5, P-6, P-9 and P-12) of 13 sample records reviewed resulting in a lack of appropriate skilled assessment, and the potential for unmet needs of the patient. Findings include: P-5: The patient’s start of care (SOC) was 9/16/24 with diagnoses that included Fractured Pubis and Fractured Greater Trochanter. During the clinical record review on 10/3/24 at 10:13 a.m., it was noted that the referral for home care dated 9/14/24 ordered Skilled Nursing (SN), Physical Therapy (PT), Home Health Aide (HHa) and Occupational Therapy (OT) services to be provided. Upon further review, it was noted that the Plan of Care (POC) documented, “PT to evaluate for the need for OT.” It was unclear as to what methodology would be used for PT to determine the need for OT services. Additionally, no OT services had been provided at the time of this review. P-6: The patient’s SOC was 9/2/24 with diagnoses that included Covid-19 and Acute Respiratory Failure. During the clinical record review on 10/3/24 at 11:30 a.m., it was noted that the referral for home care dated 8/27/24 ordered PT, OT, SN and OT services to be provided. The POC documented, “PT to evaluate for the need for OT.” It was unclear as to what methodology would be used for PT to determine the need for OT services. Additionally, at the time of this review, no OT services had been provided as ordered. Agency job description for an Occupational Therapist (undated) was reviewed on 10/3/24. On page 1., it stated “Occupational Therapist Reporting to: Nursing Supervisor and/or VP of Operations and/or Administrator… The Occupational Therapist is responsible for providing in home Occupational Therapy services to Agency patients, as prescribed by the attending physician…” P-9: This 92-year-old was admitted to the agency on 8/29/24 with diagnoses including hypertensive heart disease (heart problems associated with high blood pressure); heart failure; and acute kidney failure. The medical record was reviewed on 10/2/24. The physician referral order dated 8/14/24 included orders for the following skilled services: Nursing; Occupational Therapy (OT); and Physical Therapy (PT). The plan of care (POC) developed by the agency on 8/29/24 included orders for PT to evaluate and treat, and for PT to evaluate the need for OT. PT completed an evaluation on 8/30/24 and documented “no need for OT services able to address all therapy needs” [sic]. OT did not perform an assessment of the patient to determine if OT services would benefit the patient. It was unclear how the PT determined that a different skilled professional service (OT) was not needed. P-12: This 56-year-old was admitted to agency on 9/21/24 with diagnoses including chronic pain; back pain; and pain to left shoulder. The medical record was reviewed on 10/2/24. The physician referral order dated 9/18/24 included orders for the following skilled services: Nursing; OT; and PT. The POC developed by the agency on 9/21/24 included orders for PT to evaluate and treat, and for PT to evaluate the need for OT. PT completed an evaluation on 9/23/24 and documented “no need for OT services able to address all therapy needs with PT only” [sic]. OT did not perform an assessment of the patient to determine if OT services would benefit the patient. It was unclear how the PT determined that a different skilled professional service (OT) was not needed. These findings were reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient’s Activity of Daily Living needs were adequately met in the patient’s home for 1 (P-1) of 1 patient observed during a home visit, who required assistance with grooming, from a total of 13 sampled records reviewed, resulting in the potential for loss of self-esteem, poor hygiene and unmet care needs. Findings include: Policy: “Patient Admission Criteria”, undated, stated, “Patients will be accepted for care only if Agency can meet a patient’s identified needs.” P-1: The patient’s start of care (SOC) was 9/21/24 with diagnoses that included Lymphedema and Congestive Heart Failure. During the record review on 9/30/24 at 12:30 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment documented, “Patient depends entirely upon someone else for grooming needs..., dressing upper body..., lower body..., someone must help to maintain toileting hygiene.” Section M1100 stated the patient lives with other persons in the home, however there was no listed, designated caregiver or persons willing to assist with ADL care. On 9/30/24 at 2:15, during a scheduled survey home visit with the Registered Nurse (RN #1), the patient’s daughter, who was present during the visit, expressed her concerns about the patient not being bathed/showered and not knowing who to contact to receive assistance with grooming. During additional review of the record, there was no documented evidence that Home Health Aide services had been offered or provided as part of the patient’s health care coverage. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/3/24 at 8:58 a.m.”

“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 record review and interview, the agency failed to ensure the plan of care was complete and included all the required diagnoses, interventions and associated measurable goals to address the identified needs of the patient in 1 (P-1) record of a patient who required specialized care and monitoring from a total of 13 sampled records reviewed, resulting in the potential for untreated health concerns, decline in health and unmet care needs. Findings include: Policy: ‘Plan of Care-CMS #485 and Physician Orders”, undated, stated, “The Plan of Care includes: Diagnoses (primary and secondary), types of services and equipment required, expected goals or outcomes to be achieved.” P-1: The patient’s start of care was 9/21/24. According to the hospital documents, the patient was admitted with diagnoses that included Lymphedema bilateral lower extremities and Congestive Heart Failure. During a review of the clinical record on 9/30/24 at 12:30 p.m., it was noted that Plan of Care (POC) was incomplete and void of any diagnoses. Further, there were no interventions, patient teaching, reportable parameters or associated measurable goals that addressed the patient’s diagnosis of Congestive Heart Failure. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 10/3/24 at 8:58 a.m.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure verbal physician orders were accepted only by personnel authorized to do so according to agency policy in 1 (P-8) of 13 sample records reviewed resulting in unqualified personnel receiving physician referral orders and potentially resulting unmet needs for the patient. Findings include: Agency policy titled “Plan of Care-CMS #485 and Physicians Orders” revised 11/14/2018, was reviewed on 10/3/24. On page 2., it stated “8. Verbal orders are: Spoken to appropriate clinicians and later put in writing, signed, timed and dated with date of receipt by a RN or therapist responsible for furnishing or supervising ordered services.” Agency policy titled “Patient Admission Criteria” revised 03/26/24, was reviewed on 10/3/24. On page 2., it stated “When a telephone referral is received by the Agency, a referral form is completed by a RN.” P-8: This 63-year-old patient was admitted on 9/30/24 with diagnoses including joint replacement of the left knee; atrial fibrillation (abnormal heart rhythm), and high blood pressure. The clinical record was reviewed on 10/2/24. During review, it was noted that the physician referral dated 9/27/24 included orders for Skilled Nursing and Physical Therapy (PT) services. On 9/27/24, a “Patient Communication” note was entered by the agency intake coordinator which stated that clarification was made of the homecare orders from the physician’s office and the patient would be receiving PT services only. The PT completed the comprehensive assessment of the patient on 9/30/24 and no nursing visits were scheduled. During interview with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m., CM#1 was queried to whether the intake coordinator had appropriate credentials to take a verbal physicians order or change of referral orders over the phone. CM#1 stated that the intake coordinator is not a licensed nurse and acknowledged that the registered nurse was the appropriate personnel to take the referral clarification per agency policy.”

“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 and interview, the Agency failed to ensure the patient received services as ordered by the physician and indicated in the plan of care for 3 (P-1, P-7, P-12) of 13 sampled records reviewed potentially resulting in unmet care needs for the patient. Findings include: P-1: The patient’s start of care was 9/21/24 with diagnoses that included Lymphedema and Congestive Heart Failure. During the clinical record review on 9/30/24 at 12:30 p.m., it was noted that the referral for home care dated 9/19/24, ordered Skilled Nursing, Physical Therapy and Occupational Therapy services to be provided. At the time of this review, no Occupational Therapy services had been provided as ordered. These findings were reviewed with the Clinical Manager (CM #1) during an interview on 10/3/24 at 8:58 a.m. P-7: The patient’s start of care was 9/2/24 with diagnoses that included Malignant Neoplasm of Brain and Cognitive Disorder. During the record review on 10/3/24 at 1:00 p.m., it was noted that the referral for home care dated 8/30/24, ordered Physical Therapy, Occupational Therapy and Speech Therapy services to be provided. At the time of this review, no Speech Therapy services had been provided as ordered. These findings were reviewed with and acknowledged by CM #1 during an interview on 10/3/24 at 2:14 p.m. Agency policy titled “Plan of Care-CMS #485 and Physicians Orders” revised 11/14/2018, was reviewed on 10/3/24. On page 3., it stated “12. The Agency alerts the physician to any changes that suggests a need to alter the plan of care. If the Agency provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified.” P-12: This 56-year-old was admitted to agency on 9/21/24 with diagnoses including chronic pain; back pain; and pain to left shoulder. The medical record was reviewed on 10/2/24. Physical Therapy (PT) completed an evaluation on 9/23/24 and included a frequency of 2 times a week for 3 weeks, and then 1 time a week for 1 week. During the first week of care (9/22/24 through 9/28/24), the PT made only 1 visit on 9/23/24. The PT entered a “Missed Visit” note on 9/26/24 and documented that the patient refused the visit due to having back soreness (diagnosis warranting home health care). Additionally, the PT marked “No” to the question of whether the physician was notified of the missed visit. There was no evidence that the PT attempted to reschedule the visit to meet frequency for the week. This finding was reviewed and acknowledged during review with the Clinical Manager (CM#1) on 10/3/24 at 1:30 p.m.”

“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 and interview, the agency failed to ensure a completed Discharge/Transfer summary was sent to the Physican within the required time frame, for 2 (P-3, P-7) patients who were either transferred to an inpatient facility or discharged from the agency’s services, from a total of 13 sampled records reviewed, resulting in the Physician not having a clear clinical picture of the status of the patient at the time of transfer/discharge and the potential for unidentified continuing health needs. Findings include: Policy: “Transfer/Referral Criteria” undated, stated, “A written Transfer Summary concerning the agency’s involvement with the patient, e.g., summary of care/services provided, patient’s current physical and psychosocial status, reconcile and review medication list, advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea and reasons for transfer or referral will be forwarded to the new health care provider.” P-3: The patient’s start of care (SOC) was 6/5/24 with diagnoses that included Radiculopathy and Low Back Pain. During the record review on 9/30/24, it was noted that Physical Therapy services were ordered to be provided. The patient was discharged from PT services on 6/26/24. There was no documented evidence that the PT Discharge Summary dated 6/26/24 was sent to the Physician within 5 days of the patient’s date of discharge. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 10/3/24 at 9:30 a.m. who reported, “The summary went out on 7/8/24, so it was after 5 days.” P-7: The patient’s SOC was 9/2/24 with diagnoses that included Malignant Neoplasm of Brain and cognitive Disorder. During the record review on 10/3/24 at 1:00 p.m., it was noted that the patient was transferred to an inpatient facility on 9/18/24 due to convulsions. Upon further review, there was no documented evidence that the Transfer Summary, dated 9/18/24, had been sent to the receiving facility within 2 days of becoming aware of the transfer to an inpatient facility. On 10/324 at 2:14 p.m., during an interview, CM #1 reported, “I thought we only had to send it to the Physician. I guess I misinterpreted it.” CM #1 then stated, “We sent the summary/notification to the Physician the following week on 9/26/24.”