Beartooth Billings Clinic Home Care

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and record review, the agency failed to report an allegation of abuse and neglect for 1 (#1) of 3 sampled patients. Findings include: Review of an agency document, “Customer Complaint,” dated 3/14/25, showed a family member of patient #1 submitted a complaint regarding the agency’s failure to complete necessary wound care, which resulted in harm to the patient. Review of an agency provided document, “Complaint Review Summary Report, Attachment B,” dated 3/21/25, reflected a complaint of “gross negligent” and “almost scolding” concerns raised by a family member of patient #1. During an interview on 4/21/25 at 3:02 p.m., staff member E stated staff member F was responsible for investigations and reporting allegations to the State Survey Agency. Staff member E stated the agency did not notify the State Survey Agency of the concerns reported for patient #1. Staff member E stated staff member F was out of the country and was not be reachable for an interview. During an interview on 4/21/25 at 3:30 p.m., staff member H stated she had reviewed the complaint documentation for patient #1 and the documents did not show a report was sent to the State Survey Agency. Staff member H stated based on the complaint submitted, dated 3/14/25, and the Complaint Review Summary Report, dated 3/21/25, a report should have been filed with the State Survey Agency for an accusation of abuse and neglect. During an interview on 4/23/25 at 1:02 p.m., NF1 stated she called the agency and reported her concerns about the neglect of care to patient #1’s wounds and the verbal scolding staff member A had given patient #1 on 3/14/25 to staff member E. Review of the agency’s policy, “Reporting Abuse to State and Other Entities/Individuals,” dated October 2018, reflected: “... 1. Should alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including patient to patient abuse) be reported, the facility administrator or his/her designee, will promptly notify the appropriate persons or agencies (verbally and written) of such incident. These may include: a. The State licensing/certification agency responsible for surveying/licensing the facility. ...””

“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 interview and record review, the agency failed to promptly notify the physician of changes in condition for 1 (#1) of 3 sampled patients. This deficient practice delayed the care necessary to prevent further decline in the wound for the patient. Findings include: Review of an agency document, “Customer Complaint,” dated 3/14/25, showed a family member of patient #1 submitted a complaint regarding the agency’s failure to complete necessary wound care for patient #1, which resulted in the patient requiring emergency medical attention. During an interview on 4/22/25 at 8:48 a.m., staff member A stated she was an RN that worked for the agency. Staff member A stated she if she notified the physician of a change in condition for any patient, she would do so via the Cerner messaging system. During an interview on 4/22/25 at 9:26 a.m., staff member E stated she reviewed all Cerner messages from staff member A to the physician for patient #1 and found no notifications to the physician of the patient’s wound changes from 2/13/25 through 3/3/25. Review of patient #1’s EHR, dated 2/13/25 through 3/3/25, reflected patient #1 reported a wound on his left hip on 2/13/25. Staff member A documented the wound was a Stage II pressure wound. The record reflected no documentation of a physician being notified of the wound. During an interview on 4/22/25 at 3:44 p.m., staff member E stated the agency did not have a policy related to physician notifications of a patient’s change in condition.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interviews and record review, the agency failed to ensure physician orders were obtained and followed for wound care for 1 (#1) of 3 sampled patients. This deficient practice delayed the care necessary to prevent further decline in the wound. Findings include: Review of an agency document, “Customer Complaint,” dated 3/14/25, reflected a family member of patient #1 submitted a complaint regarding the agency’s failure to complete necessary wound care, which resulted in the patient requiring emergency medical services. During an interview on 4/22/25 at 8:48 a.m., staff member A stated she was an RN for the agency. Staff member A stated that when she provided wound care for a patient with a pressure ulcer, she would normally put one of two dressing plans in place. Staff member A stated, “One plan would be to use Mesalt if the wound has slough, and the second would be Vaseline gauze to soften if eschar was present, then sharps debridement. Those are the two dressings I use for wounds. We don’t get specific orders from the doctor for any wound care unless they (patients) are already being seen by the wound care specialists.” During an interview on 4/22/25 at 9:26 a.m., staff member E stated she reviewed all Cerner messages from the physician to staff member A for patient #1 and found no wound care orders were received from 2/13/25 through 3/3/25. On 3/3/25 the physician ordered the patient be sent to the hospital. Review of patient #1’s EHR nursing notes, dated 2/13/25 through 3/3/25, reflected patient #1 reported a wound on his left hip on 2/13/25. Staff member A documented the wound was a Stage II pressure wound. The record lacked documentation of a physician being notified of the wound or any orders received for the treatment of the wound. The EHR also reflected the following documentation: - Visit date: 2/13/25 (charted 2/19/25)-recertification visit, new Stage II pressure wound, cleansed and Mepilex dressing placed on wound. The wound bed was pink, wound edges within normal limits, scant serious drainage. The wound measured 3mm x 3mm x 0.1mm. - Visit date: 2/18/25 (charted 2/21/25)- Stage II Pressure wound, cleansed and Mepilex applied, Wound bed was red with slough, small amount of serous drainage. Request for an OT visit for a wheelchair cushion made. The wound measured 3mm x 3mm x 0.1mm. - Visit date: 2/20/25 (charted 2/25/25)- Stage II Pressure wound, cleansed and Mepilex applied, Wound bed was red with slough, small amount of serous drainage and mild odor. The wound measured 3mm x 3mm x 0.1mm. - Visit date: 2/24/25 (charted 2/25/25)- Stage II Pressure wound, cleansed, Mesalt applied, and Mepilex dressing placed on wound. The wound bed had eschar, slough, and red with small amount of serous drainage. - Visit date: 2/27/25 (charted 3/6/25)- Stage II Pressure wound, cleansed and calcium alginate was applied to the wound and Mepilex border placed on the wound. The wound bed had eschar, slough, non-granulating, yellow, dusky, black, with moderate odorous drainage. Patient #1 was told to spend more time off of the wound by laying down. - Visit date: 3/3/25 (charted 3/6/25)- Stage II Pressure wound, cleansed and calcium alginate was applied to the wound and Mepilex border placed on the wound. The wound bed had eschar, slough, non-granulating, yellow, dusky, black, with moderate odorous drainage. The family was notified and instructed to make patient an appointment for the wound. Review of a agency-provided document, “Outlook email Re: Complaint-P2025-020,” dated 3/27/25, reflected: “- ...The wound photo from 2/24/25 shows an infected and likely necrotic wound. It looks like a wound that could have been referred for evaluation by a healthcare provider, assessment for infection, and consideration for sharp or surgical debridement.” - Discharge note: 3/4/25 (charted 3/11/25)- Patient was admitted to the hospital for wound care. During an interview on 4/22/25 at 3:44 p.m., staff member E stated the agency did not have a policy related to physician orders.”

“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 interview and record review, the agency failed to follow clinical practice guidelines for caring for a pressure wound for 1 (#1) of 3 sampled patients. This deficient practice contributed to a Stage II pressure wound declining to a Stage IV pressure wound, requiring hospitalization, surgical debridement, and a wound vac for the patient. Findings include: Review of an agency document, “Customer Complaint,” dated 3/14/25, reflected a family complaint regarding failure to complete necessary wound care leading to harm. Review of patient #1’s EHR nursing notes, dated 2/13/25 through 3/3/25, reflected patient #1 documented a wound on left hip on 2/13/25. Staff member A documented the wound was a Stage II pressure wound. The record reflected no documentation of a physician being notified of the wound or order received for the treatment of the wound. The EHR also reflected: - Visit date: 2/13/25 (charted 2/19/25)-recertification visit, new Stage II pressure wound, cleansed and Mepilex dressing placed on wound. The wound bed was pink, wound edges within normal limits, scant serious drainage. The wound measured 3cm x 3cm x 0.1cm. - Visit date: 2/18/25 (charted 2/21/25)- Stage II Pressure wound, cleansed and Mepilex applied, Wound bed was red with slough, small amount of serous drainage. Request for an OT visit for a wheelchair cushion made. The wound measured 3cm x 3cm x 0.5cm. - Visit date: 2/20/25 (charted 2/25/25)- Stage II Pressure wound, cleansed and Mepilex applied, Wound bed was red with slough, small amount of serous drainage and mild odor. The wound measured 3cm x 3cm x 1.0cm. - Visit date: 2/24/25 (charted 2/25/25)- Stage II Pressure wound, cleansed, Mesalt applied, and Mepilex dressing placed on wound. The wound bed had eschar, slough, and red with small amount of serous drainage. - Visit date: 2/27/25 (charted 3/6/25)- Stage II Pressure wound, cleansed and calcium alginate was applied to the wound and Mepilex border placed on the wound. The wound bed had eschar, slough, non-granulating, yellow, dusky, black, with moderate odorous drainage. Patient #1 was told to spend more time off the wound by laying down. - Visit date: 3/3/25 (charted 3/6/25)- Stage II Pressure wound, cleansed and calcium alginate was applied to the wound and Mepilex border placed on the wound. The wound bed had eschar, slough, non-granulating, yellow, dusky, black, with moderate odorous drainage. The family was notified and instructed to make patient an appointment for the wound. During an interview on 4/22/25 at 8:48 a.m., staff member A stated she was an RN for the agency. Staff member A stated that when she provided wound care for a patient with any pressure ulcer, she would normally put one of two dressing plans in place: “One wound be to use Mesalt if the wound has slough and the second would be Vaseline gauze to soften if eschar was present, then sharps debridement. Those are the two dressings I use for wounds. We don’t get specific orders from the doctor for any wound care unless they (patients) are already being seen by the wound care specialists.” During an interview on 4/22/25 at 9:26 a.m., staff member E stated she reviewed all Cerner messages from the physician to staff member A for patient #1 and found no wound care orders received from 2/13/25 through 3/3/25, until the order to send the patient to the hospital. During an interview on 4/22/25 at 1:54 p.m., staff member I stated, “... based on the picture on 2/27/25 and the nursing notes, including the odor, they should have been seeing the patient daily, the wound needed daily care, and the patient did not have a caregiver in the home. The nurse should have sent the patient in to see the doctor much sooner. I would have likely been able to get a handle on the wound had it not been allowed to decline so much; it was a Stage IV by the time he was taken to the hospital. The wound had become gangrene with a strong odor. Once he went to the hospital, and cleaned up, I was able to get a handle on the wound and the wound did show improvement. It was healing.” Staff member I stated he had not been made aware of the wound until the patient was brought to the hospital, and all visits should have included pictures of the wound but did not. Pictures were only found to be included on visits dated 2/24/25 and 3/4/25 (at the hospital) During an interview on 4/22/25 at 3:44 p.m., staff member E stated the agency did not have a policy related to physician orders. Staff member E stated no measurements of patient #1’s wound were in the EHR for 2/24/25 through discharge to hospital on 3/4/25. Review of an agency-provided document, “Outlook email Re: Complaint-P2025-020,” dated 3/27/25, reflected: “- ...The wound photo from 2/24/25 shows an infected and likely necrotic wound. It looks like a wound that could have been referred for evaluation by a healthcare provider, assessment for infection, and consideration for sharp or surgical debridement.” - Discharge note: 3/4/25 (charted 3/11/25)- Patient was admitted to the hospital for wound care. Review of the agency’s policy, “Clinical Documentation,” dated 12/21/21, reflected: “- ... 2. Clinical Notes for all disciplines will be completed and turned in within 24 hours of when the visit is performed.” Review of the agency’s policy, “Wound Documentation,” dated 12/21/21, reflected: “ - ... The nurse shall photograph or draw the wound and document the above data weekly. If the wound is changing very frequently, this can be done as needed to accurately document any changes in the wound status. A request was made on 4/21/25 at 3:02 p.m., for a policy or for the facility’s professional reference for wound care and one was not provided or available. Per staff member E, a wound dressing selection guide for supplies was the only procedural process available.”

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on interview and record review the agency failed to be in substantial compliance of the condition to establish a comprehensive emergency preparedness program with all of the required elements in writing. Findings include: 1. Create and maintain an emergency preparedness plan, review, and update with all of the required components (E0004); 2. Complete an emergency preparedness risk assessment specific to the agency’s needs (E0006); 3. Address the patient population, persons at risk, the services the agency could provide in an emergency, and continuity of agency operations in an emergency (E0007); 4. Include a process for collaborating with emergency preparedness officials to maintain an integrated response in an emergency (E0009); 5. Develop, implement, and review policies specific to the agency’s risk assessment and emergency preparedness needs (E0013); 6. Ensure each patients emergency preparedness needs were captured on their comprehensive assessment and implemented into their clinical record (E0017); 7. Develop and implement policies and procedures to communicate with authorities for homebound patients’ needs in the event of an emergency (E0019); 8. Develop policies and procedures to follow up with staff and patients in an emergency and notify officials of staff and patients the agency was unable to contact (E0021); 9. Develop and implement emergency preparedness policies and procedures to secure and maintain medical documentation, to preserve patient information, protect confidentiality, and maintain availability in an emergency (E0023); 10. Develop and implement policies and procedures for the use of volunteers and other staffing strategies in the event of an emergency (E0024); 11. Establish an agency emergency preparedness communication plan for staff and patient (E0029); 12. Develop and maintain an emergency preparedness plan including the name and contacts of staff, patients, services under contract, patient’s physicians, volunteers, and other agencies (E0030); 13. Maintain a communication plan with the contact information for local authorities and other sources of assistance in an emergency (E0031); 14. Develop an emergency preparedness communication plan with primary and alternate means of communication with staff and emergency officials (E0032); 15. Develop a communication plan including the way patient information would be shared to other providers in an emergency when the main access to records was inaccessible (E0033); 16. Develop and maintain a way of providing the agency’s information on its needs and ability to provide assistance to the authorities in an emergency (E0034); 17. Implement, document, review, and update an agency staff training and testing program for emergency preparedness based on the risk assessment and required program components (E0036); 18. Provide an emergency preparedness training based on their established emergency plan, risk assessment, policy and procedures, and communication plan (E0037); 19. Conduct and document the required annual agency staff emergency preparedness testing exercises staff (E0039); and 20. Implement and document required agency specific risk assessment, policies, and emergency preparedness components into an integrated health system emergency preparedness program (E0042).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on observation, interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Infection Prevention and Control. Findings include: The agency failed to ensure staff followed acceptable standards of practice for maintaining a clean field, performing hand hygiene, and donning gloves when preparing medications in the home setting (See 682); The agency failed to ensure a process was developed to observe and evaluate services from all disciplines to identify sources of causative factors of infection specific to care and services provided in the home setting (See G684); and The agency failed to ensure staff received annual infection control education consistent with accepted standards of practice for infection prevention and treatment to be implemented in the home setting (See G686).”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Skilled Professional Services. Findings include: The agency failed to ensure the development of an updated Plan of Care for SLP therapy visits to include treatment orders, interventions, and goals (See G708); The agency failed to ensure all SLP therapy visits were provided as ordered by the physician (See G710); The agency failed to ensure staff prepared and completed documentation of clinical records for SLP therapy visits (See G716); and The agency failed to ensure skilled professional staff participated in annual in-service trainings (See G722).”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Home Health Aide Services. Findings include: The agency failed to ensure a Home Health Aide (HHA) had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs (See G754); and The agency failed to ensure a Home Health Aide (HHA) received annual 12 hours of in-service training (See G774).”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Organization and Administration of Services; findings include: The agency failed to ensure an authorized pre-designated individual, who is responsible for fulfilling the role of the administrator in his/her absence was authorized in writing, in advance, and approved by the governing board (See G954); and The agency failed to hire direct home health nursing staff instead of utilizing supplemental contracted agency nursing staff when there was not an unexpected staffing shortage identified by the agency for home health nursing services (See G984).”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the agency failed to create and maintain an emergency preparedness plan, review, and update with all of the required components. Findings include: During an interview on 1/31/24 at 1:00 p.m., staff members N and O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program for the health system location. Review of the policies under the [Health System] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or plans.”

“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 record review, the agency failed to complete an emergency preparedness risk assessment specific to the agency’s needs. Findings include: During an interview on 1/31/24 at 1:00 p.m., staff members Nand O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program with one risk assessment for the health system location. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and record review, the agency failed to address the patient population, persons at risk, the services the agency could provide in an emergency, and continuity of agency operations in an emergency. Findings include: During an interview on 1/31/24 at 2:18 p.m., staff member P stated the agency was part of the health system emergency preparedness program. Staff member P stated the emergency program for the health system consisted of one risk assessment and plan for patient needs, and communication policies in the event of an emergency. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment for their population and agency needs.”

“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 record review, the agency failed to include a process for collaborating with emergency preparedness officials to maintain an integrated response in an emergency. Findings include: During an interview on 1/31/24 at 1:15 p.m., staff member N stated during training exercises and in an emergency, a representative for the health system would be sent to the command center to work with the emergency officials. The agency would be part of the health system represented but the agency was not always affected or included specifically. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness elements specific to the agency. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, Emergency Operations Plan/Home Health Policy, showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop, implement, and review policies specific to the agency’s risk assessment and emergency preparedness needs. Findings include: During an interview on 1/31/24 at 1:13 p.m., staff member N stated he was unaware of any separate policies for the agency’s emergency preparedness plan but would look through the health system policies. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, Emergency Operations Plan/Home Health Policy, showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patients emergency preparedness needs were captured on their comprehensive assessment and implemented into their clinical record. Findings include: During an interview on 1/29/24 at 2:40 p.m., staff member A stated the clinical records did not have the emergency priority but she could run a report for current patients’ priority level needs. During an interview on 2/1/24 at 1:30 p.m., staff member A stated there was a computer system malfunction and the required emergency preparedness patient triage and communication plan was not flowing over onto the plan of care for patients. She stated there was no emergency preparedness triage plan identified for requested sampled patients. Review of patient clinical records for patient #’s 1, 2, 3, 4, 5, 6, and 7, showed no documentation of emergency preparedness needs or priority level. A document request was submitted to the agency on 1/31/24 at 10:00 a.m., for the emergency preparedness triage/disaster plan for patient #s 1, 2, 3, 4, 5, 6, and 7. This documentation was not provided by the end of survey.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement policies and procedures to communicate with authorities for homebound patients needs in the event of an emergency. Findings include: During an interview on 1/29/24 at 2:50 p.m., staff member A stated the patient charts would not show a triage level of need for emergencies, but a report could be ran. Some charts, such as hospice patients, had a form sent to local law enforcement when admitted notifying of hospice election and address. Review of agency patient admission packets for home health and hospice showed only hospice patients had the admission form sent to local law enforcement, however, it did not provide information on care needs in the event of an emergency or homebound/evacuation status. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any emergency preparedness policies for a communication plan with authorities for homebound patients needs.”

“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 record review, the agency failed to develop policies and procedures to follow up with staff and patients in an emergency and notify officials of staff and patients the agency was unable to contact. Findings include: During an interview on 1/29/24 at 3:00 p.m., staff member A stated agency staff were spread out through the county and there were dead zones for cell phone reception. Some staff had trouble with internet connection as well. During an interview on 1/31/24 at 1:20 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they didn’t have text or email capabilities. Staff member N stated there were also backup radios in an emergency but did not know if agency staff had access to them. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan or backup communication process.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures to secure and maintain medical documentation, to preserve patient information, protect confidentiality, and maintain availability in an emergency. Findings include: During an interview on 1/29/24 at 2:50 p.m., staff member A stated patient charts were electronic and paper charts. In an emergency agency staff would still be able to access and distribute paper and electronic patient records to share information with emergency officials if needed. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness medical documentation policies specific to the agency needs. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, Emergency Operations Plan/Home Health Policy, showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement policies and procedures for the use of volunteers and other staffing strategies in the event of an emergency. Findings include: During an interview on 1/31/24 at 3:15 p.m., staff member P stated depending on when an emergency took place and who was the initial response, they would call the on-call manager of the health system. The on-call manager would work though the organizational chart for different departments involvement and staffing in an emergency through the health system emergency plan. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness staff and volunteer policies specific to the agency needs.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to establish an agency emergency preparedness communication plan for staff and patients. Findings include: During an interview on 1/31/24 at 1:20 p.m., staff member N stated there was an emergency communication plan for leadership. Each department leader was responsible for contacting their staff and patients in the event of an emergency. Staff member N stated he did not know of a specific communication plan for the agency with the required people listed. During an interview on 1/31/24 at 3:00 p.m., staff member P stated in the event of an emergency the organizational chart for the whole health system would be utilized. There was no specific plan for the agency for communication. Review of the [Health System] Emergency Operations Plan, last reviewed 1/5/23, did not show the required communication plan with staff, patients, and volunteers listed for the agency.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and maintain an emergency preparedness plan including the name and contacts of staff, patients, services under contract, patient’s physicians, volunteers, and other agencies. Findings include: During an interview on 1/31/24 at 1:20 p.m., staff member N stated there was an emergency communication plan for leadership. Each department leader was responsible for contacting their staff and patients in the event of an emergency. Staff member N stated he did not know of a specific communication plan for the agency with the required people listed. Review of the [Health System] Emergency Operations Plan, last reviewed 1/5/23, did not show the required names and contact information for agency staff, patients, contracted services, patient physicians, other agencies, and volunteers.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to maintain a communication plan with the contact information for local authorities and other sources of assistance in an emergency. Findings include: During an interview on 1/31/24 at 1:22 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they did not have text or email capabilities. The determination of who was contacted and when was by the health system leadership for the entire system, not specially each department such as the agency. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan with the required names and contacts.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop an emergency preparedness communication plan with primary and alternate means of communication with staff and emergency officials. Findings include: During an interview on 1/29/24 at 3:00 p.m., staff member A stated agency staff were spread out through the county and there were dead zones for cell phone reception. Some staff had trouble with internet connection as well. During an interview on 1/31/24 at 1:20 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they didn’t have text or email capabilities. Staff member N stated there were also backup radios in an emergency but did not know if agency staff had access to them. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan or alternate means of communication.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop a communication plan including the way patient information would be shared to other providers in an emergency when the main access to records was inaccessible. Findings include: During an interview on 1/29/24 at 2:50 p.m., staff member A stated patient charts were electronic and paper charts. In an emergency agency staff would still be able to access and distribute paper and electronic patient records to share information with emergency officials if needed. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan for providing patient information in the event of an emergency or if original electronic or paper charts were inaccessible.”

“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 develop and maintain a way of providing the agency’s information on its needs and ability to provide assistance to the authorities in an emergency. Findings include: During an interview on 1/31/24 at 1:00 pm., staff members Nand O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program with one risk assessment for the health system location. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment to show the needs and abilities of the agency in an emergency.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to implement, document, review, and update an agency staff training and testing program for emergency preparedness based on the risk assessment and required program components. Findings include: During an interview on 1/31/24 at 1:25 p.m., staff members N and O stated, the health system had an actual flood emergency for the county in 2022. Staff members N and O stated the health system had conducted other tabletop and full-scale exercises but there were none specific to the agency or showing agency participation. Staff members N and O stated ongoing training with tests for emergency preparedness were included in the health system online training program and new hire orientation in person. Human Resources and the department managers would have access to agency staff records for completion. A request was made on 1/29/24 at 2:30 pm., at the agency entrance conference, and another on 1/31/24 at 1:00 p.m., during the emergency preparedness meeting, for training and testing records including tabletop exercises for agency staff and none were provided by the end of the survey.”

“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 interview and record review, the home health agency failed to provide an emergency preparedness training based on their established emergency plan, risk assessment, policy and procedures, and communication plan every two years for 2 (staff members D and G) of 7 sampled staff members. Findings include: During an interview on 1/31/24 at 11:40 a.m., staff member N stated he provided an initial on-boarding emergency preparedness training to new staff at the beginning of their employment. He stated he did not provide a biannual emergency preparedness training for staff based on their established emergency plan, risk assessment, policy and procedures, and communication plan, because staff completed the annual computer-based trainings for emergency preparedness. He stated he was not certain what that specific training included. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated the annual computer-based emergency preparedness training provided to staff included FEMA (Federal Emergency Management Agency) and incident command. She stated the computer-based training was not specific to the agency’s EP plan. Review of the agency personnel files on 2/1/24 at 8:40 showed staff members D and G were not provided a biannual EP training based on the agency’s EP 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 record review, the agency failed to conduct and document the required annual agency staff emergency preparedness testing exercises staff. Findings include: During an interview on 1/31/24 at 1:25 p.m., staff members N and O stated, the health system had an actual flood emergency for the county in 2022. Staff members N and O stated the health system had conducted other tabletop and full-scale exercises but there were none specific to the agency or showing agency participation. Staff members N and O stated ongoing training with tests for emergency preparedness were included in the health system online training program and new hire orientation in person. Human Resources and the department managers would have access to agency staff records for completion. A request was made on 1/29/24 at 2:30 pm., at the agency entrance conference, and another on 1/31/24 at 1:00 p.m., during the emergency preparedness meeting, for testing records including tabletop exercises for agency staff and none were provided by the end of the survey.”

“Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.542(f), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system’s coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to implement and document required agency specific risk assessment, policies, and emergency preparedness components into an integrated health system emergency preparedness program. Findings include: During an interview on 1/31/24 at 1:00 p.m., staff member N stated the emergency preparedness program was all in one for the health system location. There were no specific emergency plan elements for the agency. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness elements specific to the agency.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to accurately code the SOC OASIS to reflect clinically significant medication issues identified during the drug regimen review as part of the comprehensive assessment for 3 (#s 1, 3, and 4) of 7 sampled patients. Findings include: A review of the agencies policy and procedures, titled OASIS Accuracy, with a revision date of 12/21/21, showed: - “Purpose: The encoded OASIS data shall accurately reflect the patient’s status at the time of the assessment…” 1. Review of patient #1’s skilled nursing SOC OASIS, dated 11/15/23, showed (M2001) the drug regimen review did not reflect any potentially significant medication issues were identified during the review. - Review of patient #1’s DRR for clinically significant medication interactions showed: - Severe Interaction for: aspirin and apixaban. This severe interaction was not accurately coded on the patient’s SOC OASIS. 2. Review of patient #3’s skilled nursing SOC OASIS, dated 1/3/24, showed (M2001) the drug regimen review did not reflect any potential significant medication issues were identified during the review. Review of patient #3’s DRR for clinically significant medication interactions showed: - Severe interaction for: ranolazine. This severe interaction was not accurately coded on the patient’s SOC OASIS. 3. Review of patient #4’s skilled nursing SOC OASIS, dated 11/16/23, showed (M2001) the drug regimen review did not reflect any potential significant medication issues were identified during the review. Review of patient #4’s DRR for clinically significant medication interactions showed, severe interactions for: - Acetaminophen and leflunomide, - Aspirin and leflunomide, - Aspirin and apixaban. These severe interactions were not accurately coded on the patient’s SOC OASIS: During an interview on 2/1/24 at 1:30 p.m., staff member A stated it was the expectation that staff run a drug interaction report in the patient’s EMR to check for any adverse and significant drug interactions. If a severe drug interaction is identified on the review, staff were expected to notify the physician of any severe interactions. Staff member A stated the information should be entered on the SOC OASIS for any drug interactions noted during the comprehensive assessment.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure staff followed acceptable standards of practice for maintaining a clean field, performing hand hygiene, and donning gloves, when preparing medications in the home setting for 1 (#1) of 7 sampled patients. This deficient practice had the potential to affect all patients receiving home medication preparation services. Findings include: A review of the agency’s policy and procedure titled, Hand Washing, with a revision date of 11/2/20, showed: - “Policy: It is the policy of [Facility Name] that all employees utilize appropriate hand washing and hand antisepsis techniques to reduce and prevent the risk of infection transmission. All employees require strict adherence to the policy. - Intent: Hand washing is the single most important means for preventing the spread of infections and prevent the spread of potential pathogenesis microorganisms and infections to patients and employees of BBC… - Education: A. All staff members will complete and sign hand hygiene competency upon hire and annually through HealthStream competency. B. Infection Prevention Department will utilize Glo-bug for training purposes.” During an observation on 1/30/24 at 11:10 a.m., after staff member F disinfected her hands, then gathered patient #1’s medication bottles from a tray in the patient’s living room, from a cupboard in the kitchen, and from the top of a curio cabinet in the kitchen. She then opened a kitchen drawer, removed patient #1’s weekly pill organizer, and placed it on top of a dirty counter. Staff member F opened the different pill compartment lids of the pill organizer and dumped pills into the palm of her hand. She then proceeded to place each pill into the designated compartment. When staff member F was done putting the pills into the pill organizer, she returned the remaining pills from the palm of her hand back into the corresponding pill bottle. Staff member F completed this process for three different medications. Staff member F failed to establish a clean field in which to prepare the medications. She failed to disinfect her hands after retrieving the pills bottles and prior to preparing the medications; and failed to don gloves while placing medications into the patient’s pill organizer. During an interview on 1/31/24 at 10:30 a.m., staff member M stated it was the expectation that staff create a clean field when preparing medications and should disinfect/wash their hands and don gloves prior to preparing patient medication in the home setting. Staff member M stated she completed annual hand hygiene competencies with all staff and just completed the most recent hand hygiene education. Review of the agency personnel files on 2/1/24 at 8:10 a.m., showed staff member F had not completed an annual infection control education and competency training including hand hygiene and medication preparation for 2023 (See 686). During an interview on 2/1/24 at 1:30 p.m., staff member A stated it was the expectation that staff prepare a clean field to prepare medications and to wash/disinfect their hands and don gloves prior to the preparation of medications. A request was made to have staff member F call the surveyor for an interview. Staff member A stated staff member F was not working that day, and she would have staff member A call the surveyor when she returned. A return call was not received by 2/5/24 at 5:30 p.m.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a process was developed to observe and evaluate services from all disciplines to identify sources of causative factors of infection specific to care and services provided in the home setting. This deficient practice has the potential to affect all patients receiving home health services. Findings include: During an observation on 1/30/24 at 11:10 a.m., staff member F prepared home medications without preparing a clean field, disinfecting her hands, or donning gloves prior to preparing medications for a patient (See G682 & G686). During an interview on 1/30/24 at 12:57 p.m., staff member A stated there was not oversight of nurses in the field and no observations of skills or competencies for any staff providing cares. During an interview on 1/31/24 at 10:25 a.m., staff member M stated any hand hygiene practices would be referred to staff member A for oversight. She stated there were not any specific annual infection control competencies for care providers. A document request was submitted to the agency on 2/31/24 at 10:30 a.m., to provide additional documentation for annual oversight of clinical staff and competency evaluations. No additional documentation was provided by the end of survey.”

“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 observation, interview, and record review, the agency failed to ensure staff received annual infection control education consistent with accepted standards of practice for infection prevention and treatment to be implemented in the home setting for 7 (staff members D, E, F, G, I, J, and L) of 7 sampled staff members. This deficient practice had the potential to affect all patients receiving services. Findings include: A review of the agency policy and procedure titled, Orientation, Mandatory and Ongoing Staff Education and Competency Assessment Cycle, last revised 7/18/17, showed: - F. Mandatory Education: 1. All [Facility Name] employees will be required to complete ongoing education that includes, but is not limited to the following: …b. Infection control topics including, but not limited to: i. Hand hygiene ii. TB exposure control iii. Infectious waste management iv. Standard Precautions v. Isolation practices vi. Cleaning, disinfection, and sterilization…” During an observation on 1/30/24 at 11:10 a.m., staff member F prepared home medications without disinfecting her hands or donning gloves prior to preparing medications for a patient (See G682). 1. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated staff were expected to complete annual computer-based training on infection control and prevention. She stated the computer-based trainings were refresher courses on infection control practices but were not specific to such practices used in the home setting. She stated the annual hands-on infection control competency-based training was provided by staff member M. Review of the agency’s personnel files on 2/1/24 at 8:10 a.m., showed the following staff members had not completed an annual computer-based training on infection control practices: - Staff member D: no computer-based IFC training on file. - Staff member G: Last IFC training was completed on 6/29/22. - Staff member F: Last IFC training was completed on 9/14/22. - Staff member J: Last IFC training was completed on 5/3/22. 2. During an interview on 1/31/24 at 10:30 a.m., staff member M stated she provided the agency staff with infection control education and competency evaluations annually. She stated she had just provided a training regarding the use of PPE. Staff member M stated the education was not based on the infection control practices utilized by staff in the home setting. A review of the agency’s personnel files on 2/1/24 at 8:10 a.m., showed staff members D, E, F, G, I, J, and L, received education titled, PPE Acknowledgement, which outlined the following: - “I have received and understand education regarding PPE and donning and doffing. - I understand that it is my responsibility to properly disinfect and store my face shield/goggles/PAPR before and after use with Sani-Cloths. - If I leave the room of a designated Isolation Precaution Room, I will not wear any of my PPE I was wearing in the precaution room to prevent cross contamination. - I understand that I must wear PPE in all rooms that have been designated for isolation. - I will only wear the N-95 that I was fit tested for during orientation or annual fit testing. - Men understand that they will be clean shaven when wearing N-95 masks, no stubble or facial hair.” On 2/1/24 at 9:00 a.m., a request was submitted to provide additional infection control education training for all agency staff for accepted standards of practice for infection prevention and treatment to be implemented in the home setting for staff members D, E, F, G, I, J, and L. No additional information on was provided by the end of the survey.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Home Health Aide (HHA) received annual 12 hours of in-service training for 1 (staff member J) of 1 sampled HHA. This deficient practice had the potential to affect all patients receiving home health aide services. Findings include: During an interview and record review on 2/1/24 at 8:50 a.m., staff member Q stated the agency did not have documentation to show staff member J received 12 hours of in-service training within the last 12-months. Staff member Q stated it was the expectation the required annual in-service training be completed.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure staff received periodic training on the protection of patient clinical records in the home-setting for 2 (staff members D and F) of 7 sampled staff. Findings include: A review of the agency policy and procedure titled, Orientation, Mandatory and Ongoing Staff Education and Competency Assessment Cycle, last revised 7/18/17, showed: - Policy Statement: “[Facility] provides general organizational orientation, general clinical provider orientation, departmental orientation and initial and ongoing mandatory education to its employees, temporary agency staff and volunteers… - Mandatory Education: … c. Compliance topics including, but not limited to: …i. Confidentiality of Protected Health Information, Patient Privacy, and Information Security…” 1. Review of staff member D’s personnel file, on 2/1/24 at 8:10 a.m., showed she had not been provided any annual in-service training on the protection of patient clinical records in the home setting. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated the agency did not provide staff member D with annual in-service HealthStream trainings because she was an independent contractor. 2. Review of staff member F’s personnel file, on 2/1/24 at 8:10 a.m., showed she had not been provided any annual in-service training on the protection of patient clinical records in the home setting since 9/14/22. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated it was the expectation of the agency to ensure staff completed annual in-service HealthStream trainings annually.”

“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 record review and interview, the agency failed to complete a drug regimen review to include a drug interaction review for any significant drug interactions as part of the comprehensive admission assessment for 4 (#s 1, 2, 3, and 4); and failed to notify the provider of any clinically significant drug interactions found on the review for 3 (#s 1, 3, and 4) of 7 sampled patients. Findings include: A review of the agency’s policy and procedure titled, Drug Regimen Review, with a revision date of 12/21/21, showed: - “…Policy: The results of patient medication monitoring will be used to improve the patient’s medication regimen. The ongoing monitoring will occur in accordance with the established goals of therapy and used… - To evaluate all potential major contraindications or potential adverse interactions with other meds - will all be taken into consideration and reported as appropriate to the physician. [EMR] is used to complete the Drug Regimen Review…” 1. Patient #1 had a SOC date of 11/15/23, with a primary diagnosis of hemiparesis/hemiplegia status post CVA. Review of patient #1’s EMR did not show a drug interaction review was completed at the time of the initial comprehensive assessment, dated 11/15/23. Review of patient #1’s DRR for clinically significant medication interactions showed a severe interaction for: - “Aspirin and apixaban monitor closely: Concomitant use of apixaban with other agents that alter hemostasis such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), platelet aggregation inhibitors, other anticoagulants, thrombolytic agents, or drugs that cause thrombocytopenia may increase the risk of bleeding...” Review of patient #1’s EMR and a document request submitted to the agency on 1/31/24 at 1:30 p.m., failed to provide further documentation of notifying the physician of the severe drug interaction. 2. Patient #2 had a SOC date of 1/22/24, with a primary diagnosis of RSV pneumonia. Review of patient #2’s EMR did not show a drug interaction review was completed at the time of the initial comprehensive assessment, dated 1/22/24. A document request submitted for the DRR review completed for patient #2, was submitted to the agency on 1/31/23 at 2:30 p.m.; no additional documentation was provided by the end of the survey. 3. Patient #3 had a SOC date of 1/3/24, with a primary diagnosis of hypertensive chronic kidney disease. Review of patient #3’s EMR did not show a drug interaction review was completed at the time of the initial comprehensive assessment dated 1/3/24. Review of patient #3’s DRR for clinically significant medication interactions showed a severe interaction for: - “Ranolazine generally avoid: Grapefruit and grapefruit juice may significantly increase the plasma concentrations of orally administered ranolazine…” Review of patient #3’s EMR and a document request submitted to the agency on 1/31/24 at 1:30 p.m., failed to provide further documentation of notifying the physician of the severe drug interaction. 4. Patient #4 had a SOC date of 11/16/23, with a primary diagnosis of pneumonia. Review of patient #4’s EMR did not show a drug interaction review was completed at the time of the initial comprehensive assessment, dated 11/16/23. Review of patient #4’s DRR for clinically significant medication interactions showed severe interactions for: - “Acetaminophen and leflunomide: Monitor closely: The recent, concomitant, or subsequent use (without the recommended leflunomide washout period or procedure) of other agents known to induce hepatotoxicity may potentiate the risk of liver injury associated with leflunomide… - Aspirin and leflunomide monitor closely: recent, concomitant, or subsequent use (without the recommended leflunomide washout period or procedure) of other agents known to induce hepatotoxicity including NSAIDs and salicylates may potentiate the risk of liver injury associated with leflunomide… - Aspirin and apixaban monitor closely: Concomitant use of apixaban with other agents that alter hemostasis such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), platelet aggregation inhibitors, other anticoagulants, thrombolytic agents, or drugs that cause thrombocytopenia may increase the risk of bleeding…” Review of patient #4’s EMR and a document request submitted to the agency on 1/31/24 at 1:30 p.m., failed to provide further documentation of notifying the physician of the severe drug interaction. During an interview on 2/1/24 at 1:30 p.m., staff member A stated it was the expectation that staff complete a drug interaction review in the patients’ chart after all the medications have been reconciled. She stated any severe drug interaction noted on the report should be reported to the physician. Staff member A stated there were no drug interaction reports ran for patient #s 1, 2, 3, and 4.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the development of an updated Plan of Care for SLP therapy visits to include treatment orders, interventions, and goals, for 1 (#1) of 7 sampled patients. This deficient practice has the potential to affect all patients receiving skilled therapy services. Findings include: A review of the agency’s policy and procedures titled, Plan of Care, with a revision date of 12/21/21, showed: -“… Procedure: Care will be provided according to a written plan of care established and periodically reviewed by the physician. Medical orders shall authorize the frequency of visits for each service to the patient. Home Care shall notify the physician to any changes in plan of care, including if the specific discipline is providing fewer or more visits in a given period of time. If a change occurs in the plan of care the discipline that has altered the plan of care or overseeing the HHS will: - Notify the physician why the change occurred - Write a verbal order to reflect the change - Write a narrative note explaining why the alteration occurred. - It is expected that an alteration in the Plan of Care (i.e. change in visit frequency) will be addressed in a timely manner but no later than by Tuesday at 5 p.m. of the following week… - Verbal orders are transcribed on the physician order form, signed, and dated by the receiving person and routed to the physician for signature, within 72 hours. - Discipline specific orders may be received by PT, OT, ST and the Social Worker. - The plan of care developed in consultation with all Home Care staff shall cover all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items…” 1. Patient #1 had a SOC date of 11/15/23, with a primary diagnosis of hemiparesis/hemiplegia status post CVA. Review of patient #1’s Physician Orders, dated 11/15/23, showed Speech Therapy to evaluate and treat. Review of patient #1’s Speech Therapy Visit Note, dated 11/29/23, showed, “Narrative Note: Patient was seen for evaluation in the home. Her husband was present for last half of the evaluation. She reports changes to word finding and memory. She stated that her goals are to improve memory to allow her to remain in the home with her husband. Pt [patient] was seen for tx [treatment] in seated upright in seated in couch. She was able to follow all directions of the assessment with the SLP [Speech-Language Pathologist]. She was administered the Boston naming test short form with a score of nine out of 15, which indicates mild and moderate deficits in her word finding. Further on the state she was administered the Montreal cognitive assessment with a score of 17 out of 30. Missed points on the mocha Were in delayed recall, abstraction, language, visual, spatial, attention. Patient voiced understanding of results and recommendation for therapy. Home health speech pathology is being recommended to address deficits in cognition and in word finding. Patient will be seen for ongoing home health speech therapy sessions. She can send it to further treatment and therapy is set up for next week.” [sic] Review of patient #1’s Plan of Care, with a recertification period of 11/15/2023 through 1/13/2024, did not include the new order for SLP treatment orders, interventions, and goals, for the patient based on the SLP evaluation and recommendations for treatment as outlined on the visit from 11/29/23. 2. Patient #1 had a ROC date of 1/14/24, with a primary diagnosis hemiplegia status post CVA. During an interview on 2/1/24 at 1:30 p.m., staff member A stated she called and spoke with staff member W and about the clinical visits for patient #1. Staff member A stated staff member W had a visit with patient #1 on 1/19/24. Review of patient #1’s ROC Plan of Care, for 1/14/24 through 3/13/24, did not include treatment orders, interventions, or established goals for SLP therapy. During an interview on 2/1/24 at 1:30 p.m., staff member A stated it was the expectation that the patient’s Plan of Care be updated with any new orders for therapy services as indicated. On 2/1/24 at 1:30 p.m., a request was made to interview staff member W. Staff member A stated he was, “out in the field”, and she would have him call the requesting surveyor. There was no call from staff member W by 2/5/24 at 5:30 p.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure all SLP therapy visits were provided as ordered by the physician for 1 (#1) of 7 sampled patients. This deficient practice has the potential to affect all patients receiving skilled therapy services. Finding include: A review of the agency’s policy and procedures titled, Plan of Care, with a revision date of 12/21/21, showed: -“… Procedure: Care will be provided according to a written plan of care established and periodically reviewed by the physician. Medical orders shall authorize the frequency of visits for each service to the patient. Home Care shall notify the physician to any changes in plan of care, including if the specific discipline is providing fewer or more visits in a given period of time. If a change occurs in the plan of care the discipline that has altered the plan of care or overseeing the HHS [sic] will: - Notify the physician why the change occurred - Write a verbal order to reflect the change - Write a narrative note explaining why the alteration occurred. - It is expected that an alteration in the Plan of Care (i.e. change in visit frequency) will be addressed in a timely manner but no later than by Tuesday at 5 p.m. of the following week… - Verbal orders are transcribed on the physician order form, signed, and dated by the receiving person and routed to the physician for signature, within 72 hours. - Discipline specific orders may be received by PT, OT, ST and the Social Worker…” 1. Patient #1 had a SOC date of 11/15/23, with a primary diagnosis of hemiparesis/hemiplegia status post CVA. Review of patient #1’s Speech Therapy Visit Note, dated 11/29/23, showed, “Narrative Note: Patient was seen for evaluation in the home… Patient will be seen for ongoing home health speech therapy sessions. She can send it [sic] to further treatment and therapy is set up for next week.” [sic] Review of patient #1’s Physician Orders, dated 11/15/23 through 1/13/24, did not show updated physician orders for SLP therapy services based on the SLP evaluation on 11/29/23. 2. Patient #1 had a ROC date of 1/14/24, with a primary diagnosis hemiplegia status post CVA. During an interview on 2/1/24 at 1:30 p.m., staff member A stated she called and spoke with staff member W about the clinical visits for patient #1. Staff member A stated staff member W had a visit with patient #1, on 1/19/24. Review of patient #1’s Physician Orders, dated 1/14/24 through 2/1/24, did not show updated physician orders for SLP therapy services based on the continued SLP visits provided. During an interview on 2/1/24 at 1:30 p.m., staff member A stated it was the expectation all services provided will be ordered by the physician and updated in the plan of care. On 2/1/24 at 1:30 p.m., a request was made to interview staff member W. Staff member A stated he was, “out in the field”, and she would have him call the requesting surveyor. There was no call received from staff member W, by 2/5/24 at 5:30 p.m.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure staff prepared and completed documentation of clinical records for SLP therapy visits for 1 (#1) of 7 sampled patients. This deficient practice has the potential to affect all patients receiving skilled therapy services. Findings include: Patient #1 had a SOC date of 11/15/23, with a primary diagnosis of hemiparesis/hemiplegia status post CVA. Review of patient #1’s Physician Orders, dated 11/15/23, showed Speech Therapy to evaluate and treat. Review of patient #1’s Initial Speech Therapy Visit Note, dated 11/29/23, showed, “Narrative Note: Patient was seen for evaluation in the home… Patient voiced understanding of results and recommendation for therapy. Home health speech pathology is being recommended to address deficits in cognition and in word finding. Patient will be seen for ongoing home health speech therapy sessions. She can send it to further treatment and therapy is set up for next week.” A review of patient #1’s EMR, on 2/1/24 at 12:00 p.m., failed to show any additional clinical visit notes were provided as outlined in the Speech Therapy Initial visit on 11/29/23. During an interview on 2/1/24 at 1:30 p.m., staff member A stated she called and spoke with staff member W about the clinical visits for patient #1. Staff member A stated staff member B attempted to see the patient on two separate occasions which resulted in missed visits on 12/8/23 and 12/15/23, which were not documented. Staff member A stated staff member W did have another visit with patient #1, on 1/19/24, which was not documented in the patient’s clinical record. Staff member A stated it was the expectation that staff complete clinical notes within 24 to 48 hours after seeing a patient. She stated all clinical visits should be documented in the patient chart in a timely manner. A request for SLP visit notes was submitted to the facility on 1/31/24 at 2:00 p.m., no additional documentation was provided by the end of the survey.”

“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 record review and interview, the agency failed to ensure skilled professional staff participated in annual in-service trainings for 2 (staff members D and F) of 7 sampled staff members. Findings include: A review of the agency policy and procedure titled, Orientation, Mandatory and Ongoing Staff Education and Competency Assessment Cycle, last revised 7/18/17, showed: - Policy Statement: “[Facility] provides general organizational orientation, general clinical provider orientation, departmental orientation and initial and ongoing mandatory education to its employees, temporary agency staff and volunteers… - …[Facility] provides staff the appropriate orientation, education, and training to validate and develop competencies to meet the unique needs of patients served. - The competency assessment process will occur on an ongoing basis. Competencies will be identified on an annual basis through a collaborative process and assessed on a continuum throughout the employment of an individual. - Performance appraisals will be conducted in accordance with policy HR-026 Employee Performance Appraisal and Competency Review… - Practice: B. Verification of Individual Competencies: - Each employee will be responsible for completing his or her own competencies using verification methods they select from an approved list for each competency. - The Manager’s role is to validate at the end of the competency assessment period that the employee has successfully completed the competencies identified. The competency/departmental orientation checklist must be completed within 8 weeks from the date of hire or cross training assignment and turned into Human Resources for tracking. - The employee will be deemed competent with the completion of 100% of the indicated competencies for their job class. If successful completion is not achieved, an action plan will be initiated with the employee…” 1. Review of staff member D’s personnel file, on 2/1/24 at 8:10 a.m., showed she had not been provided any annual in-service training by the agency. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated the agency did not provide staff member D with annual in-service HealthStream trainings because she was an independent contractor. 2. Review of staff member F’s personnel file, on 2/1/24 at 8:10 a.m., showed she had not been provided any annual in-service training by the agency since 9/14/22. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated it was the expectation of the agency to ensure staff completed annual in-service HealthStream trainings annually.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Home Health Aide (HHA) had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs for 1 (staff member J) of 1 sampled HHA. This deficient practice had the potential to affect all patients utilizing home health aide services. Findings include: Review of the Montana State Home Health Aide Registry, dated 2/1/24, showed staff member J had an expired CNA Home Health Aide Endorsement, dated 5/31/23. During an interview on 2/1/24 at 8:50 a.m., staff member Q stated the agency did not have an updated CNA Home Health Aide endorsement for staff member J. Staff member Q stated it would be the expectation that all certifications for services provided would be maintained and not expired.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure an authorized pre-designated individual, who is responsible for fulfilling the role of the administrator in his/her absence was authorized in writing, in advance, and approved by the governing board. Findings include: A documentation request was submitted to the facility on 1/30/24 at 9:00 a.m., to provide a copy of the secondary appointed administrator in the absence of the administrator, in writing, and approved by the governing board. The agency did not provide this documentation by the end of the survey. During an interview on 1/31/24 at 3:00 p.m., staff member P stated the agency did not have anything in writing which had been approved by the governing board for the secondary appointed administrator in the absence of the administrator. Staff member P stated the agency currently utilized the organization tree to determine who would be available if/when the administrator was not available.”

“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 interview and record review, the agency failed to hire direct home health nursing staff instead of utilizing supplemental contracted agency nursing staff when there was not an unexpected staffing shortage identified by the agency for home health nursing services for 1 (staff member D) of 4 sampled registered nurses. This deficient practice had the potential to affect all patients receiving home health nursing services. Findings include: During an interview on 2/1/24 at 8:10 a.m., staff member Q stated staff member D was a direct home health nurse for the agency and she left the agency to join a contract nursing agency. Staff member Q stated staff member D was re-hired as a contracted agency nurse by the home health agency on 8/27/21. Staff member Q stated staff member D had been working for the home health agency since that date. Review of the agency’s Independent Contractor Agreement showed: “…12. Termination: this Agreement shall terminate as follows: a) By mutual written Agreement of the parties. b) Either party may terminate this Agreement upon 30 days written notice with or without cause: In witness whereof, the parties have executed this Agreement on the dates set forth below”. The agreement was signed by staff member D on 8/27/21 and by staff member Q on 8/30/21. Review of staff member D’s Independent Contractor Agreement Exhibit B Addendum, Location and Scheduled Services showed, “Schedule: Registered Nurse will provide intermittent fill-in coverage at the request of [Home Health Agency] and agree to monthly schedule with Manger of Home Care and Hospice. For specific dates of 12/5/21 through 6/4/22, RN will provide 32 hours per week of services for this specific 26-week schedule.” The agreement was signed by an “HR Generalist” and staff member D on 11/17/21. Review of staff member D’s Independent Contractor Agreement, Exhibit C Addendum, Compensation and Payment, was dated and signed by staff member Q on 12/16/22 and staff member D on 12/19/22. The Addendum C did not include extension of scheduled services to be provided by the contractor, and did not include dates for services to be provided. During an interview on 2/1/24 at 12:15 p.m., staff member V stated although the facility currently had a hardship for staffing and hiring nurses, they have not been actively recruiting for direct care nursing staff for the home health agency, and they did not currently have an open requisition to hire any direct care nursing staff. Staff member V stated she spoke with staff member A and noted the reason for maintaining staff member D as a contracted nurse since 8/2021, was to maintain competent nursing for the home health agency.”