Summit Home Health Care Inc.

“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 interview and document review, the agency failed to maintain and update their Emergency Preparedness Plan to reflect increased risk of infectious diseases as identified under the agency risk assessment. This had the potential to affect all clients served by the agency. A review of the agency Emergency Preparedness Plan, last reviewed on 3/1/23, included the agency Community All Hazard Vulnerability Assessment. In the assessment, the potential for a biological/environmental event was identified as unlikely. Upon review of the policy section, Emergency by Event, there was a two-page document, titled Influenza. Within this document, the potential for a pandemic was identified as rare, although the risk was identified for severe consequences, including high rates of worker absenteeism, overcrowding at heath care systems and death among residents. The section lacked identification of the recent pandemic related to Covid-19, as well as other respiratory infections which had also increased the potential illness in the population served. During interview on 3/27/24, at 12:00 p.m. the Director of Nursing (DON), provided a policy regarding Covid-19 illness and precautions which were to be implemented. This policy reflected the need for personal protective equipment (masks), social distancing, and isolating from others for a period of 10 days. During a follow up interview at 3/27/24, at 3:41 p.m. DON stated these recommendations were no longer accurate and stated the policy had not been updated to reflect current recommendations for Covid-19, or other infectious diseases.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to actively participate with, or attempt outreach and planning with their collaborative partners in their service area in an effort to maintain an integrated response during a disaster or emergency situation. This had the potential to impact all clients served by the agency. The agency Emergency Preparedness Plan, last updated 3/1/23, was reviewed and was found to lack documentation of participation in collaborative planning and outreach to those in the agency service area. Although basic outreach numbers are provided in the communication, there were no specific listings for the collaborative partners of the agency. In addition, the policy and documents provided lacked evidence of participation in collaborative planning, training, or exercises. During interview on 3/26/24, at 12:00 p.m., Director of Nursing (DON) stated they reached out to the local fire department for review of their agency plan, however, they have not proceeded in further collaboration with planning, training or exercises. DON stated they reached out to the police department; however, they received no response. Although the agency provided services in other communities, outreach had not been initiated in the other areas. DON stated during the pandemic response, the agency received some supplies, as well as information for Covid-19 response from the health care coalition in southern Minnesota, however, has not had recent interaction with them.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview and document review, the agency has failed to identify in their Emergency Preparedness Plan a process to communicate with state and local authorities of potential client needs during an emergency situation or event. The plan lacked identification of a process of communication and coordination with authorities regarding clients the agency was unable to contact or provide services during the emergency/event. The agency Emergency Preparedness Plan, last updated 3/1/23, was reviewed and was found to lack any policies or processes which identified with whom, and how, the agency was to reach out in communication and coordination regarding those clients who were unable to be reached, and/or provided with services in the event of an event/emergency. The communication policy provided only high-level contact information (main numbers listed on website) and lacked local outreach and resources available for emergency response as the agency provides services in multiple communities. During interview on 3/26/24, at 12:00 p.m., the Director of Nursing (DON) stated in the event of an emergency the staff were to utilize their communication plan contact information in outreach for services. DON stated the agency had not met with community partners for planning and processes to coordinate efforts in the event an emergency response was needed.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on interview and record review the agency failed to include in the communication plan for emergency preparedness a means of providing information about the agency’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This had the potential to affect all patients the agency serves. Upon review of the agency Emergency Preparedness Plan, last updated on 3/1/23, it was identified the plan lacked information of how the agency would communicate any needs it may have during an emergency or how they may be able to provide assistance to others in need.During interview 3/26/24 at 12:00 p.m. the Director of Nursing (DON) indicated she could not locate this specific information in the agency’s plan.”

“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: Based on interview and document review the agency failed to complete the required testing exercises for emergency preparedness during the period of the past two years. This had the potential to impact all patients served by the agency. On 3/25/24, at 12:15 p.m. the facility’s Emergency Preparedness and Policy Process, last reviewed 3/1/23, was reviewed. Upon review of the information provided, there were multiple listings of staff signatures during the time frame of 3/29/22 through 3/31/22, with a total of 71 signatures. Although the signature pages were present, the documentation lacked content or information, potential scenarios, goals and objections, outcomes, or an after-action report (AAR) and improvement plan (IP). Additional documentation provided an exercise was completed on 5/10/23, which included an outlined scenario, facilitator prompts, and discussion points outlined, however, there was no documentation to reflect who participated, responses to the scenarios, or an after-action report, or improvement plan. A review of the overall policy lacked the required elements for testing identified as follows: 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. During interview on 3/27/24, at 3:15 p.m., the Director of Nursing (DON) stated although the agency continued with provision of services during the pandemic, they had not reviewed the process formally or completed any documentation to reflect response to the pandemic, development of an after-action report, or development of an improvement plan. The DON stated although the signature pages were present for the time frame of 3/29/22-3/31/22, there was no additional information to reflect what training or exercise had been completed, as well as no AAR/IP’s to be reviewed. DON stated the scenario of the Active Shooter was reviewed 5/10/23, however, lacked any documentation as to who had attended, or AAR/IP.”

“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 observation, interview, and record review the facility failed to ensure medication reconciliation was completed to include as needed medications and ensure medication changes were updated for 1 of 2 patients (P3) observed during medication set up. Findings include: P3’s plan of care (POC) for certification period 2/6/24-4/5/24, indicated P3 had diagnoses of peripheral vascular disease, heart disease and kidney failure. Furthermore, P3’s POC indicated P3 required weekly skilled nursing services for medication set up. P3’s medication report updated 2/1/24, indicated P3 was currently taking: -warfarin (medication to thin blood) 2.5 milligrams (mg) daily. -lidocaine pain relief 4% topical patch 1 patch as needed daily. -oxycodone (narcotic pain medication) 5mg every 6 hours as needed for pain. -clotrimazole (antifungal ointment) 1% topical cream apply 1 inch daily. -Loperamide (medication to decrease episodes of diarrhea) take 2-4 mg as needed. During an observation on 3/25/24 at 1:45 p.m., P3’s medications were being set up by registered nurse (RN)-B. RN-B opened a case on P3’s table and took out the medication bottles. An after-visit summary (AVS) from a clinic appointment in January 2024 was on the table. RN-B reviewed the list. RN-B asked P3 to verify the current warfarin dose. P3 stated 3 mg daily on Monday and Wednesday and a half tablet the other days. RN-B clarified one tablet was taken on Monday and Wednesdays and a half tablet all other days. P3 stated yes. P3’s warfarin bottle directed P3 to take 2.5 mg (one tablet) daily. When writer questioned about the directions on the bottle, RN-B stated P3 stated one tablet was taken and may have been confused on the dose of the actual pills. RN-B stated R3 “pretty much knows what she is taking”. RN-B again asked P3 what dose was being taken and P3 stated 3mg. RN-B verified P3’s clinic AVS and medication list in the electronic medical record (EMR) directed P3 to take 2.5 mg daily. RN-B verified P3’s back up medication box also contained warfarin one 2.5mg tablet on Monday and Wednesday and a half tablet the other days and did not match P3’s medication orders in the EMR or AVS. RN-B verified with P3’s warfarin clinic the directions were 2.5 mg on Monday and Thursday and 1.25 mg the remainder of the days. RN-B wrote a note on the AVS indicating the change in dose for warfarin. RN-B continued to fill P3’s medication box using the AVS and EMR as a guide. RN-B did not ask P3 about their oxycodone, lidocaine patch, or loperamide medications that were listed on P3’s medication report. When interviewed on 3/25/24 at 4:05 p.m., RN-B stated any medication changes, such as P3’s warfarin dosing needed to be updated when doses are changed. RN-B was not sure when P3’s warfarin dose was changed and why the EMR and AVS mediation sheet did not reflect the change. RN-B stated the agencies new electronic health record system was not user friendly and updating the AVS was easier to follow. Furthermore, RN-B acknowledged P3’s as needed medications and ointments had not been reviewed and acknowledged they should have been discussed during the visit. When interviewed on 3/28/24 at 11:47 a.m. RN-A expected staff to be reviewing all medications that were potentially taken in the home during medication set up. This included both as needed medications and inhalers or ointments that were not set up by staff. Furthermore, RN-A expected any medication changes needed to be updated in the EMR when the change was noted. RN-A stated this was important to ensure the patient had the correct medications and doses needed. An agency policy titled medication set up, no date, directed staff to ensure patients medications, including over the counter medications were reviewed during medication set up. The policy further directed staff to ensure the medication list was current and updated with orders and provider change orders as needed.”

“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 observation, interview, and record review the agency failed to ensure the plan of care (POC) included and individualized interventions and goals for skilled nursing services for 1 of 3 patients (P3) observed during home visits. Furthermore, the agency failed to include medical supplies and durable medical equipment needed for 3 of 3 patients (P3, P4 and P5) observed during home visits. P4’s plan of care (POC) for certification period 3/2/24-4/30/24, indicated P4 had diagnoses of Parkinson’s disease without dyskinesia, without mentions of fluctuation, major depressive disorder, recurrent in partial remission, traumatic ischemia of muscle, essential primary hypertension, orthostatic hypotension, hyperlipidemia, overactive bladder, problems related to health literacy, social exclusion and rejection, and history of falling. P4’s POC indicated the following services: P4’s POC indicated P4 required weekly skilled nursing (SN) services. P4’s POC included skilled nursing order that directed nurses to “perform multifactor fall, risk assessment and implement interventions to decrease risk of falls. Skilled nurse to instruct on home safety, impact of polypharmacy, environmental safety and fall prevention. Additionally, the SNV was to assess/evaluate comorbid (conditions existing together) including hypertension, orthostatic hypotension, Parkinson’s disease, and other conditions as they present. P4’s POC identified orders for physical therapy weekly on week one, twice weekly for four weeks, and weekly on week five. The POC directed the therapist to evaluate to determine condition, physical therapy plans and rehabilitation potential; evaluate home environment to eliminate structural barriers and improve safety to increase functional independence (ramps, adaptive wheelchair, bathroom aides). P4’s POC identified orders for Occupational Therapy (OT) twice weekly for four weeks, and once weekly on the fifth week. The POC directed OT to evaluate for OT services to include physical and psychosocial test results, establishment of a plan of treatment, rehabilitation goals, and evaluation of the home environment for accessibility and safety and recommending modification. P4’s POC identified P4 was to receive personal assistance weekly to provide assist with personal care and activities of daily living. A review of the visit notes of 3/2/24 from the registered nurse visit identified a standard walker was available for P4’s use. The visit note went on to identify recommendations for an elevated toilet seat, and tub chair. P4’s POC for the period of 3/2/24 to 4/30/24, lacked any indication of durable medical equipment (DME). During observation of physical therapy (PT) visit on 3/27/24, at 12:15 p.m. P4 was observed throughout her therapy session. During this time frame, P4 was observed to ambulate with the use of a rolling walker. During this observation, P4 was observed to be walking with a rolling walker. Upon observation of client walking up and down steps, a transfer belt was placed for safety (a belt used to allow assistance and support when held by the second person). P4 was observed as she got in to and out of bed, and a siderail was secured to the side of the bed to aide in the process. P3’s plan of care (POC) for certification period 2/6/24-4/5/24, indicated P3 had diagnoses of chronic wound on buttock, peripheral vascular disease, heart disease and kidney failure. Furthermore, P3’s POC indicated P3 required weekly skilled nursing services. P3’s POC included skilled nursing order that directed nurses to “assess/evaluate comorbid conditions including medication set up, skin integrity and other conditions that present themselves during this episode to identify changes and minimize complications. Furthermore, P3’s POC lacked the following information: -individualized assessment and treatment interventions that were reflective of P3’s health status, including any wound treatments/assessments, education, or other assessments or treatments pertinent to P3 -individualized goals of care for skilled nursing services provided -P3’s required DME to assist in maintaining P3’s current health status or wound/dressing supplies. During an observation on 3/25/24 at 1:45 p.m., P3 had a skilled nurse visit. P3 had a folded wheelchair near the apartment door entrance. P3 also had a four wheeled seated walker next to the chair where P3 was sitting. Registered nurse (RN)-B assisted P3 to use the walker to stand. RN-B was then able to complete a dressing change to P6’s wound. A foam dressing was removed. P6’s wound was cleaned, and triad paste applied before a new foam dressing was applied. When interviewed on 3/25/24 at 4:05 p.m., RN-B verified P3’s POC lacked DME and dressing supplies. RN-B further stated these items should be listed and was not sure why they were not. RN-B also verified P3’s POC did not include skilled nursing interventions or goals. RN-B stated there were newer nurses and thought maybe they had completed them but was not sure. RN-B stated if the goals were met, then care was no longer needed and P3 was not at a point to manage wound care or medications on their own. P5’s POC for certification period 2/16/24-4/15/24, indicated P5 had diagnoses of diabetes, kidney disease, and depression. Furthermore, P5’s POC indicated P5 required weekly skilled nursing services. P5’s POC lacked indication P5 required diabetic supplies or equipment to assist in maintaining P5’s current health status. During an observation on 3/28/24 at 3:25 p.m., P5 had a four- wheel seated walker in the entryway of their apartment. P5 stated the walker was used when walking longer distances. RN-C assessed P5’s blood glucose readings and P5 verified they were taken twice a day and ranged from 180-230. When interviewed on When interviewed on 3/28/24 at 4:15 p.m., RN-C stated acknowledged the walker in P5’s apartment. RN-C also stated P5 used a glucometer for glucose testing. RN-C verified the walker and diabetic supplies were not included on P5’s POC. When interviewed on 3/28/24 at 11:47 a.m., RN-A stated a patient’s treatments and goals were identified at the start of care. Once goals have been obtained, care may lessen or end. RN-A expected staff to ensure all needed DME and supplies as well as the patient’s treatments and individualized goals were maintained on the POC. This was important for staff know so the support needed for the patient was understood when care was provided.”