Scotland County Home Health Agency

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on policy review, employee file review and interview, the home health provider failed to ensure emergency preparedness (EP) training was documented on hire of two employees (RN (registered nurse) A and Clinical Manager) and failed to ensure a contract employee received the provider’s EP training every two years (Contract PT (physical therapist)). This deficient practice has the potential to delay staff response in the event of an emergency and affect all the patients served by the provider. Findings included: Review of the provider’s policy, last updated November 2017, titled, “5.2 Emergency Preparedness Policy and Procedure,” showed in part, the agency (provider) will ensure that all staff, volunteers and contractors are trained about their responsibilities in the agency’s EPRP (Emergency Preparedness Response Plan) upon hire and when the plan is revised. Review of the provider’s policy dated approved 07/07/1997, titled, ” Emergency Procedures”, showed in part: - The named provider will incorporate the emergency response plan into their new employee orientation; and - It failed to address the frequency of ongoing training to be provided. Review of RN A’s employee file showed: - Date of hire: 11/16/2020; and - A partially completed orientation checklist that failed to include EP training on hire. Review of the clinical manager’s employee file showed: - Date of hire: 10/05/2020; and - A blank orientation checklist that failed to include EP training on hire. Review of the contract PT’s employee file showed: - Date of hire: 12/1999; and - It failed to contain documentation of every two year EP training. During an interview on 02/21/2024 at 12:10 PM the administrator stated that: - The prior administrator hired RN A and the clinical manager; - He/she was unsure of what training was provided to RN A and the clinical manager on hire; and - He/she was unable to find any annual EP training documented for the contract PT.”

“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 policy review, review of the provider’s emergency preparedness (EP) information and interview, the home health provider failed to maintain documentation of exercises conducted annually to test the emergency plan and analyze the provider’s response to all drills, tabletop exercises, and emergency events and revise the emergency plan as needed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy, last updated November 2017, titled, “5.2 Emergency Preparedness Policy and Procedure,” showed in part: - The administrator and/or supervising nurse and other individuals designated by the administrator will review the plan annually and after each actual emergency response to evaluate its effectiveness and to update the plan as needed; - As part of the annual internal review, the agency (provider) will test the response phase of the EPRP (Emergency preparedness and response plan) in a planned drill if not tested in an actual emergency response; and - The provider will make a good faith effort to comply with the requirements of this policy during a disaster and if unable to comply with any of the requirements of this policy, the provider will document in their records attempts of staff to follow procedure as outlined in the EPRP. Review of the provider’s policy dated approved 07/07/1997, titled, ” Emergency Procedures”, showed in part: - All provider personnel shall participate in the annual tornado exercise normally held in March; and - All provider employees shall participate in annual fire drills. Review of the provider’s EP information showed: - Documentation of a tabletop “Fire at the theatre” completed with the local hospital 12/15/2022; - There failed to be documentation of an analysis of the provider’s response to the tabletop exercise; and - There failed to be any further documentation of any additional exercises or analysis completed. During an interview 02/21/2024 at 10:06 AM the administrator stated that: - He/she was unable to find any other exercises documented or after action report for the tabletop; - The provider had switched emergency planners five times in the last five years; and - The provider did a mass vaccine clinic at the airport in 2020 or 2021 but was unable to find the documentation.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care when wound care was not received as ordered on the plan of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider’s policy, titled “Plan of Treatment/Care”, undated, showed in part the following: - The plan of treatment used for all clients shall include medications and treatments ordered; - All personnel making home visits must conform to all physician’s orders; and - The agency staff administers medications and treatments only as ordered. Review of the provider’s policy, titled “Conformance With Physicians Orders,”’ revised June 6, 2014, showed in part the following: - Drugs and treatment are administered by agency staff only as ordered by the physician; and - All personnel making home visits (registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech therapist, home health aide, ect.) must conform to all physicians orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 01/02/2024 after an inpatient rehabilitation unit stay for aftercare of a wound to hernia on abdomen and cardiovascular accident. The patient was alert and orientated times three (person, place, time). The patient lived at home alone. The patient received skilled nursing, physical therapy and occupational therapy services. Review of the Plan of Care (POC), dated 01/02/2024 to 03/01/2024, showed in part: - Skilled nurse (SN) one time a week for one week, two times a week for two weeks, two times a week for three weeks; and - SN to apply Cavilon (durable, non-sticky, fast-drying, waterproof barrier) to peri wound, silver alginate (antibacterial dressing) to wound bed, cover with mepilex (absorbent foam dressing), change every three days and as needed. Observation and interview on 2/20/2024 at 1:50 PM, during the patient’s home visit, showed the following discrepancies with the wound treatment: - Registered nurse (RN) A placed a barrier on patient’s lap; - RN A placed wound dressing supplies (wound cleanser, cotton tipped applicator, gauze, scissors, silvercel and mepilex) on the barrier; - RN A donned gloves; - RN A cleaned the wound with wound cleanser and gauze; - RN A removed gloves, sanitized his/her hands and donned gloves; - RN A measured wound with the cotton tipped applicator packaging; - RN A cut the silvercel to size and applied to wound; and - RN A applied the mepilex foam dressing. RN A failed to apply the Cavilon as ordered. During an interview on 02/22/2024 at 10:10 AM, RN A stated, he/she missed applying the Cavilon during the dressing change as ordered. During an interview on 02/22/2024 at 11:49 AM, the administrator stated staff should follow orders as written and the RN should have used the Cavilon.”

“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 policy review, clinical record review, observation, and interview, the home health provider failed to ensure staff followed infection control standards of practice in two of three home visit observations (Records/Patients #1 and #2). This deficient practice has the potential to affect the health and safety of all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Infection Control Plan for Home Care Agency”, showed in part the following: Medical Equipment: - All reusable medical equipment must be cleaned and maintained according to the manufacturer’s instructions to prevent patient-to-patient transmission of infectious agents; - Noncritical items (such as blood pressure cuffs) are those that may come in contact with intact skin but not mucous membranes and should undergo low or intermediate-level disinfection depending on the nature and degree of contamination; - Environmental services (such as nursing bags) are those that generally do not contact the patient during delivery of care. Cleaning may be all that is needed for the management of these surfaces but if disinfection is indicated, low-level disinfection is appropriate; - Manufacturer’s instructions for reprocessing any reusable medical equipment by the agency will be followed; - Responsibility for cleaning, disinfection and/ or sterilization of medical equipment will be provided by the Healthcare Provider (HCP) through agency training; and - Training of HCP will occur initially upon assignment of duties and whenever new equipment is introduced and periodically as needed. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 01/02/2024 after an inpatient rehabilitation unit stay for aftercare of a wound to hernia on abdomen and cardiovascular accident. The patient lived at home alone. The patient received skilled nursing, physical therapy and occupational therapy services. Observation on 02/20/2024 at 1:50 PM, during the patient’s home visit, showed the following: - Registered nurse (RN) sat on the patient’s floor with his/her legs folded like a pretzel with no barrier; and - RN A reviewed the patient’s medication bottles sitting on the floor. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/01/2024 with a primary diagnosis of laminectomy (remove the back of one or more vertebrae) with spinal fusion (surgical procedure to permanently join together two or more bones in the spine), and additional diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and hypertension (elevated blood pressure). The patient lived at home with his/her spouse. The patient received physical therapy services. Observation on 02/21/2024 at 2:14 PM, during the patient’s home visit, showed the following: - Contract physical therapy (PT) placed his/her nursing bag directly on the patient’s floor with no barrier; - Contract PT removed a blood pressure cuff from the nursing bag and performed a blood pressure check on the patient; - Contract PT placed the blood pressure cuff back into the bag and failed to disinfect the blood pressure cuff; and - Contract PT removed his/her bag off the floor and placed the strap on his/her shoulder, failing to disinfect the nursing bag prior to exiting the patient’s house. During an interview on 02/22/2024 at 11:49 AM, the administrator stated staff should not sit on the floor, equipment should be cleaned before putting back in the nursing bag and bags should not be placed on the floor without a barrier.”

“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 employee file review and interview, the home health provider failed to ensure staff were provided infection control training on hire in two of three employee files reviewed (RN A and clinical manager). This deficient practice has the potential to affect all patients served by the provider. Findings included: RN A: Review of RN A’s personnel file showed: - Date of hire: 11/16/2020; and - A partially completed orientation checklist that failed to include a date for completion of infection control training on hire. Clinical manager: Review of the clinical manager’s employee file showed: - Date of hire: 10/05/2020; and - A blank orientation checklist that failed to include any dates for completion of infection control training oh hire. During an interview on 02/21/2024 at 12:10 PM the administrator stated that: - The prior administrator hired RN A and the clinical manager; and - He/she was unsure of what training was provided to RN A and the clinical manager on hire. During an interview on 02/21/2024 at 12:30 PM the administrator stated that: - He/she had the trainings the clinical manager brought from his/her prior place of employment. (Those trainings were dated 01/23/2019 to 03/18/2020. Seven months prior to hire).”

“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 policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, two of three home visit observations (Records/Patients #1 and #2). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Findings included: Review of the provider’s policy, titled “Use of Medication and Treatment Profile,” undated, showed in part: - All drugs will be entered into the medication profile of the electronic health information system used; - It shall be updated whenever any changes in medications occur; - Medications and treatments will be reviewed by a skilled nurse at each home visit for any changes; and - Nurses will update medication profile at each visit, and medications that are discontinued or added will be added to the profile upon completion of every visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 01/02/2024 after an inpatient rehabilitation unit stay for aftercare of a wound to hernia on abdomen and cardiovascular accident. The patient was alert and orientated times three (person, place, time). The patient lived at home alone. The patient received skilled nursing, physical therapy and occupational therapy services. Observation and interview on 02/20/2024 at 1:50 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The provider’s medication profile showed an order for acetaminophen (analgesic and antipyretic) 500 milligrams (mg) two tablets two times a day for mild pain. The patient stated he/she had taken a half a tablet two times a day and had been doing so for a month; - The provider’s medication profile showed an order for cyanocobalamin (vitamin B) tablet 500 micrograms (mcg) one by mouth daily. The patient stated he/she had taken a complete vitamin with vitamin B 125 mcg included daily and had been taking for thirty plus years; - The provider’s medication profile showed an order for diclofenac (reduces swelling and pain) topical solution 2% one unit topically twice a day to knees. The patient stated he/she had not used since he/she returned home from the hospital; - The provider’s medication profile showed an order for lidocaine (local anesthetic) topical (lidocaine patch) film 5% one every 24 hours topically. The patient stated he/she had not used since he/she returned home from the hospital; and - The provider’s medication profile showed an order for metoclopramide (treat nausea and vomiting) tablet 10 mg one before meals and at bedtime. The patient stated he/she had taken one in the AM (morning) and one at bedtime, as he/she forgot to take at lunch and did not eat supper. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/01/2024 with a primary diagnosis of laminectomy (remove the back of one or more vertebrae) with spinal fusion (surgical procedure to permanently join together two or more bones in the spine), and additional diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe) and hypertension (elevated blood pressure). The patient lived at home with his/her spouse. Observation and interview on 01/21/2024 at 2:14 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The patient stated that he/she was taking Melatonin 10 mg one by mouth at bedtime and had been taking it for years. The medication failed to be on the provider’s medication profile; and - The patient stated that he/she was taking testosterone 200mg/milliliter (ml), taking 75 mg intramuscular (IM) alternating with 100 mg IM every two weeks and had taken a long time. The medication failed to be on the provider’s medication profile. During an interview on 02/22/2024, at 11:49 AM, the administrator stated that he/she expected the medications to be reconciled when the staff go into the patient’s home and notify the physician if there are any discrepancies. Medications are to be reconciled weekly by nursing and physical and occupational therapy are to reconcile medications weekly too.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on policy review, clinical record review, home visit observation and interview, the home health provider failed to obtain medication orders in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect physician driven care of all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Coordination of Care,” showed the home health agency (provider) must ensure that each patient and his/her caregiver or caregivers where applicable, receive ongoing education and training provided by the home health agency as appropriate, regarding the care and services identified in the plan of care (POC). Review of the provider’s undated policy titled, “Plan of Treatment/Care,” showed in part: - The plan of treatment used for all clients shall include: * Medications and treatments ordered; and * Patient and caregiver education and training to facilitate timely discharge. - All personnel making home visits must conform to all physician’s orders; - The agency staff administers medications and treatments only as ordered; - Drugs and treatments shall be administered by appropriate agency personnel only as ordered by physician; - If changes are needed after the initial evaluation visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders; and - The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. Review of the provider’s undated policy titled, “Policy for Use of Medication and Treatment Profile,” showed in part: - All drugs will be entered into the medication profile of the electronic health information system used; - It shall be updated whenever changes in medications occur; - Medications and treatment will be reviewed by a skilled nurse at each home visit for any changes; and - Nurses will update medication profile at each visit, and medications that are discontinued or added will be added to the profile upon completion of each visit. Review of the provider’s policy dated revised “6-12-00”, titled “Duties of the Registered Nurse,” showed in part, the Registered Nurse (RN): - Initiates the POC and necessary revisions; - Informs the physician and other personnel of changes in the patient’s condition and needs; and - Counsels the patient and family in meeting nursing and related needs. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to services 10/19/2023 with a primary diagnosis of Type II Diabetes Mellitus (adult onset of a group of diseases that results in too much sugar in the blood) without complications and malignant neoplasm of the oropharynx (throat cancer) listed as: other pertinent diagnosis. Review of the POC dated 02/16/2024 to 04/15/2024 failed to include the medications, Tylenol (medication for the relief of pain) or Motrin (Non-steroidal anti-inflammatory given for pain). Review of the current medication profile provided to the surveyor failed to include Tylenol or Motrin. Observation on 02/22/2024 at 9:00 AM, during the patient’s home visit, the patient was instructed by the RN clinical manager to take Tylenol or Motrin until the doctor ordered something else for pain. Per interview conducted with the clinical manager during the home visit observation, regarding the education he/she provided to the patient to take Tylenol or Motrin which was not on the current medication list or the current POC, he/she stated that: - He/she thought those medications were on the current medication list; and - He/she would contact the doctor.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to promptly alert the physician when one patient had elevated blood sugars out of the parameters and missed visits due to patient refusing visits in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s policy, titled “Plan of Treatment/Care,” undated, showed in part the following: - The plan of treatment used for all clients shall include frequency of visits for nursing, home health aides and therapists; - All personnel making home visits must conform to all physician’s orders; - Changes in Plan of Treatment - If changes are needed after the initial evaluation/visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders. The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. Any revision to the plan of care, including changes in discharge plan, due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the home health agency (HHA) plan of care; and Therapy Services - Therapy orders will include the specific procedures and modalities to be used and the amount. Verbal orders will be obtained and documented for any change in therapy services before the change is implemented. Review of the provider’s policy, titled “Conformance With Physicians Orders,”’ revised June 6, 2014, showed in part the following: - Drugs and treatment are administered by agency staff only as ordered by the physician; and - All personnel making home visits (registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech therapist, home health aide, ect.) must conform to all physician’s orders. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the home health provider on 01/08/2024 after a short acute hospital stay for a surgical procedure and skilled nursing to provide wound care to feet, and Type Two Diabetes Mellitus (adult onset of a group of diseases that results in too much sugar in the blood). The patient was alert and orientated times three (person, place, time) and uncooperative at times. The patient lived at home with his/her daughter staying at this time for assistance. Review of the POC, dated 01/08/2024 to 03/07/2024, showed in part: - Skilled nurse (SN) three times a week for four weeks; and - Vital sign parameters - contact physician if the following is outside of parameters: *Fasting blood sugar (FBS): low value 60.0 to high value 200.0 *Random blood sugar (RBS): low value 60.0 to high value 200.0. Review of the clinical record showed an order received on 01/08/2024 for referral for occupational therapy (OT) visits. Review of the skilled nurse assessment service note dated 01/08/2024, showed in part, FBS of 245, was reported per patient. Documentation failed to show the physician was notified. Review of the skilled nurse service note dated 01/15/2024, showed in part, RBS of 437, was reported per patient. Documentation failed to show the physician was notified. Review of the skilled nurse service note dated 01/22/2024, showed in part, RBS of 250, was reported per patient. Documentation failed to show the physician was notified. Review of the clinical record failed to show any OT assessment or notes (a total of 43 days from the referral order). Review of the communication note dated 02/20/2024 (the day the surveyors entered the provider’s facility) and faxed to the physician, showed the SN was notified by therapy that the patient had refused to be seen. Therapy stated that the patient had called and rescheduled three times and was now stating he/she would let the therapist know when he/she was ready for therapy. The patient had still not had an OT evaluation. During an interview on 02/22/2024 at 12:14 PM, the administrator stated staff should follow orders and notify the physician when blood sugars are out of the parameters and for missed visits.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on employee file review, and interview, the home health provider failed to ensure contract staff were provided annual agency in-service training in one of one contract employee files reviewed (Contract PT). This deficient practice has the potential to affect all patients of the provider served by contract employees. Findings included: Contract PT: Contract PT Employee file review showed: - The contract PT had been hired in 1999 by the contracting provider and had been seeing home health patients since 2000; and - There failed to be any evidence of annual agency (provider) in-service training. During an interview on 02/21/2024 at 2:10 PM the administrator stated that he/she did not have documentation of any annual home health agency in-service training provided to the contract PT.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on nationally recognized standards, policy review, employee file review and interview, the home health provider failed to: - Request and obtain results of findings of the Employee Disqualification List (EDL) prior to hire in one of three employee files reviewed (clinical manager (CM)); and - Show documentation of Alzheimer’s training upon hire in two of three employee files reviewed (Registered Nurse (RN) A and CM). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183 Review of Chapter 26 Home Health Agencies, 19 CSR 30.26.010 (1) (B) (2) (A and B) (3) showed: (B) Licensed home health agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients, or consumers with Alzheimer’s disease or related dementias; (2) Employees or independent contractors who do not provide direct care for, but may have daily contact with persons with Alzheimer’s disease or related dementias shall receive dementia-specific training that includes at a minimum: (A) An overview of Alzheimer’s disease and related dementias; and (B) Communicating with persons with dementia; and (3) Dementia-specific training about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer’s disease and other related dementias. The training shall be provided annually and updated as needed. Review of the provider’s policy dated revised “7-14-09”, titled, “Hiring”, showed in part: - The provider will do criminal background checks and an employee disqualification check with the Department of Social Services along with checking the Family Care Safety Registry to see if the employee is registered; and - It failed to show when the checks would be completed. Clinical Manager: Review of the CM’s employee file showed in part: - The CM’s date of hire was 10/05/2020; - It failed to contain an EDL prior to hire; and - It failed to contain documentation of Alzheimer’s training upon hire. RN A: Review of RN A’s employee filed showed in part: - RN A’s date of hire was 11/16/2020; and - It failed to contain documentation of Alzheimer’s training upon hire. During an interview on 02/21/2024 at 12:10 PM the administrator stated that: - He/she was unable to find an EDL prior to hire for the CM; - The provider had done one (EDL) “since then”; - The prior administrator hired RN A and the CM; and - He/she was unsure of what training was provided to RN A and the CM on hire.”