Knox County Health Department 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, review of personnel files, and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire in three of three personnel records reviewed (Employees #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Emergency Preparedness Policy and Procedure,” dated “November 2017,” showed in part, the agency (provider) will ensure that all staff, volunteers, and contractors are trained and oriented about their responsibilities in the agency’s emergency preparedness and response plan (EPRP) upon hire and when the plan is revised. EMPLOYEE #1: Review of Employee #1’s personnel file showed in part: - The date of hire was 10/10/2025; - The employee’s position was physical therapy assistant; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #2: Review of Employee #2’s personnel file showed in part: - The date of hire was 06/27/2022; - The employee’s position was registered nurse; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed in part: - The date of hire was 10/10/2019 - The employee’s position was registered nurse; and - The personnel file failed to contain evidence that EP training was completed upon hire. During an interview on 09/09/2026 at 9:40 AM, the administrator stated that: - The provider did the emergency preparedness training on hire; - The new hires read all the emergency preparedness policies; - They (the provider) did not have documentation that it was completed; and - He/she needed to give the staff a certificate of completion and add that training to an orientation checklist.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) standards of practice, Home Healthcare Now article and American Academy of Family Physicians article, record review, and interview, the home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to have a wound policy or a pressure injury policy. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure damage. Review of the “Back to the Basics: Wound Assessment, Management, and Documentation,” Home Healthcare Now; September/October 2022: 245-251. Copyright @ 2022 Wolters Kluwer Health, Inc. All rights reserved showed in part the following: - The initial assessment should be completed when the wound is first observed; - Follow-up assessments should be completed at least weekly; - Based on the assessment, the clinician can compare data and determine the wound’s response to treatment; - Proper assessment includes location, shape, extent of tissue injury, dimensions (size and depth), presence of undermining or tunneling, wound base characteristics, amount of exudate, wound edges and peri wound skin (surrounding skin) condition; and - Additional considerations include presence of pain and/or infection. Review of the “Pressure Injuries: Prevention, Evaluation, and Management,” (Am Fam Physician. 2023; 108 (2): 166-174. Copyright @ 2023 American Academy of Family Physicians.), showed in part the following: - Clinical guidelines recommend a structured, repeatable approach to evaluating risk of pressure injuries in conjunction with a comprehensive skin examination and clinical judgement; - Following identification of a pressure injury, a comprehensive examination should be performed; - The physical examination should document the location and size of the injury; associated pain; presence of exudate, sloughing, undermining, or tunneling; wound bed color; and integrity of the surrounding skin; and - It is critical to regularly evaluate healing progression, status of dressings and surrounding skin, adequacy of pain control, and presence of potential complications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 09/08/2026 with a primary diagnosis of atrial fibrillation (A-fib; abnormal heart rhythm characterized by rapid and irregular heartbeat), and peripheral vascular disease (PVD) (slow, progressive disease affecting arteries, veins, or lymphatic vessels, most frequently reducing blood flow to the legs and feet) with necrotic (body tissue has died because of a severe lack of blood flow, a deep infection, or physical damage) right great toe and black spot on right fifth toe and left great toe. The patient resided at home alone. Review of the OASIS- (Outcome and Assessment Information Set; a standardized data collection tool) completed by the registered nurse, dated 09/08/2026, showed in part: - The patient had a stage 1 (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) pressure ulcer of the gluteal fold/upper buttocks on both sides. * Length: 3 cm (centimeters); * Width: 1 cm; * Drainage: none; * Odor: none; * Surrounding tissue: intact; * Signs/symptoms of infection: none; * Cleansed with: soap and water; * Filled with: Calmoseptine cream; * Covered with: open to air; * Secured with: depends; * Performed by: nurse and patient; - Admission summary: Prior medical/surgical history: Patient with history of diabetes (a chronic disease that affects how the body uses sugar for energy) mellitus type II and PVD with gangrene (body tissue dies because it loses its blood supply or suffers a severe bacterial infection) in right great toe and black spot on left great toe and fifth toe, the patient denies any pain from this. Recently in hospital with persistent A-fib. Patient cancelled appointment with vascular surgeon and will reschedule for possible right toe amputation or vascular surgery to improve circulation to right foot. - Plans for next visit: Thursday for follow-up visit; - Skilled nurse orders: * Frequency: twice a week times one week then once a week times one week; * Skin assessment with attention to right great toe, fifth right toe and left great toe and stage 1 redness of stage 1 pressure sore on upper buttocks on both sides gluteal fold; - Integumentary orders: * Wound care orders (specify each site): * Calmoseptine cream (moisture barrier and skin protectant cream) to stage 1 pressure sores on bilateral sides upper gluteal fold daily and as needed until healed. Monitor status of right great toe, fifth right toe and left great toe; * Additional wound care orders (select): * Evaluate wound/Decub (decubitus) for healings; and * Measure wounds weekly. Review of the plan of care dated 09/08/2026 to 11/06/2026, showed an order for skilled nurse (SN) to visit twice a week times one week, and once a week times one week to monitor status of right great toe, fifth right toe and left great toe. Evaluate wound/decub for healings. Measure wound(s) weekly. Observation on 09/09/2026 at 10:10 AM, showed the following: - The SN removed the patient’s socks; - The SN viewed the right great toe, and the entire toe was black; - The SN viewed the medial side of the right second toe and it was black; - The SN viewed the distal side of the right fifth toe and it was black; - The SN viewed the left great toe that had a small black spot on the end of the toe; and - The SN looked at the patient’s buttocks and stated the area was less red than it was during the last visit (two days prior). (The provider failed to complete measurements of the wounds). Review of the skilled nurse visit dated 09/10/2026, showed the following: - Integumentary Assessment: * Wound assessment #1: * Type of wound: other: gangrene; * Location of wound: Right great toe black; * Length: entire toe; * Drainage: none; * Odor: none; * Wound bed appearance color: other: black and dry; * Surrounding tissue: intact; * Signs/symptoms of infection: none; - Wound care: * Cleansed with: Keep dry; * Covered with: clean sock; * Wound assessment #2: * Type of wound: other: gangrene; * Location of wound: medial side right second toe; * Length: blank; * Width: blank; * Depth: blank; * Drainage: none; * Odor: none; * Wound bed appearance color: other: black; * Surrounding tissue: intact; * Signs/symptoms of infection: none; - Wound care: * Cleansed with: Keep dry; * Covered with: clean sock; * Performed by: patient; * Wound assessment #3: * Type of wound: other: gangrene; * Location of wound: distal side right fifth toe; * Length: blank; * Width: blank; * Depth: blank; * Drainage: none; * Odor: none; * Wound bed appearance color: other: black dry; * Surrounding tissue: intact; * Signs/symptoms of infection: none; - Wound care: * Cleansed with: Keep dry; * Covered with: clean sock; * Performed by: blank; * Wound assessment #4: * Type of wound: other: gangrene; * Location of wound: left great toe top right corner nail; * Length: blank; * Width: blank; * Depth: blank; * Drainage: none; * Odor: none; * Wound bed appearance color: other: black; * Surrounding tissue: blank; * Signs/symptoms of infection: blank; - Wound care: * Cleansed with: Keep dry; * Covered with: clean sock; * Performed by: blank; and - Narrative: Patient denied any pain and buttocks were healthy pink and reddened areas were resolved. Instructed the patient to continue using Calmoseptine cream if redness returns and continue changing position in his/her chair to prevent skin breakdown. The gangrene was unchanged from last visit. During an interview on 09/11/2026 beginning at 10:48 AM, the administrator stated that there was no wound measurements documented, and he/she would expect the SN to measure the wounds once a week to compare for changes.”

“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 review Missouri regulations, policy review, employee file review, and interview, the home health provider failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire in one of three employee files reviewed (Employee #3). This deficient practice had the potential to affect all the 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) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Review of 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 Registry, regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care 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 states 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 nay disqualifying factors listed in Subsection 6 of this section; - (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony 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, 568.175, 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 and 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 192.2490; and - (8) Has a finding on the Child Abuse and Neglect Registry under Sections 210.109 to 210.183.” Review of the provider’s policy titled, “Personnel of the Home Health Agency,” dated/reviewed and approved 06/16/2021, showed “All staff hired by “named home health provider” will meet the standards as set forth in the “Medicare and Medicaid Programs: Conditions of participation for home health agencies” published January 13, 2017, updated 5/28/2020.” Employee #3: Review of the employee file showed: - Date of hire: 10/10/2019; and - Date of EDL check: 10/21/2019 (11 days after hire). During an interview on 09/09/2026 at 9:40 AM, the administrator stated that: - The EDL was done prior to patient contact; - He/she seen that it was done 11 days after hire; and - He/she needed to write that down.”

“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, record review, 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 the patients did not receive visits according to the visit frequency 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, “14 Plan of Treatment/Care,” dated reviewed and approved by Governing Board June 16, 2021, showed: - The plan of care shall include frequency of visits for nursing, home health aide, 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; 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. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 11/17/2023 with diffuse total brain injury (TBI) with loss of consciousness of unspecified duration, diabetes insipidus (an uncommon problem that causes the fluids in the body to become out of balance), intellectual disabilities, cortical blindness (loss of vision without any ophthalmological causes and with normal pupillary light reflexes due to bilateral lesions of the striate cortex in the occipital lobes), and dysphagia (difficulty swallowing). Review of the plan of care dated 11/17/2023 to 01/15/2024 showed: - Physical therapy (PT) one time a week for one week; - Two times a week for four weeks; - Then two times a week for four weeks; - Occupational therapy (OT) one time a week for one week; - Two times a week for four weeks; - Then two times a week for three weeks; - Speech therapy (ST) one time a week for one week; and - Then three times a week for six weeks. Review of the clinical record showed: - The week of 11/26/2023 only one ST visit (order was for three) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 12/03/2023 only two ST visits (order was for three) and one PT visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits; - The week of 12/17/2023 only one OT visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 12/24/2023 only two ST visits (order was for three) and one PT visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits; -The week of 12/31/2023 only one ST visit (order was for three) was completed. There failed to be any communication note or physician order for the missed visit. During an interview on 01/11/2024 at 4:15 PM, the administrator stated, missed visits should be made up in the week, and if the visits are not made up the physician is to be notified.”

“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 state law, the home health provider policy, employee file review, and interview, the provider failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire for two contracted staff of four employee files reviewed (Employee #1 and #2). 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) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Review of the provider’s policy titled “36 Personnel of the Home Health Agency”, dated reviewed and approved by Governing Board June 16, 2021, showed: - All staff hired by the named home health provider will meet the standards as set forth in the “Medicare and Medicaid Programs: Conditions of participation for home health agencies” published January 13, 2017, updated 5/28/2020. EMPLOYEE #1 (E1):Review of the E1’s personnel file showed:- Speech therapist (ST):- Date of hire: November 2, 2023; and - Failed to show EDL results prior to hire. EMPLOYEE #2 (E2):Review of the E2’s personnel file showed:- Certified occupational therapy assistant (COTA);- Date of hire: December 20,2023; and - Failed to show EDL results prior to hire. During an interview on 01/11/2024 at 4:30 PM, the administrator stated that the EDL should be done prior to hire and both the employees were contracted staff and she would be sure to make sure the EDL results were returned prior to signing the contracts.”