Ardent Home Health Care Agency Corp

“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 review of the facility’s Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies were based on an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current 43 patients receiving care provided by the agency as well as all agency staff. Findings include: Review of the facility’s EPP on 01/31/25 at 4:00 PM with the Administrator, revealed the EPP policies were not developed on an all hazards-based facility and/or community risk assessment. During an interview with the Administrator on 01/31/25 at 4:15 PM, he confirmed there was no hazard risk assessment in the EPP.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all 43 patients receiving services from the HHA who require evaluation and care. Findings include: The facility’s OASIS submission data for calendar year 2024 was reviewed and revealed two out of a total of 383 assessments were coded as being transmitted to IQIES more than 30 days late during that time period. This resulted in an error code of -3330 (late submission) for 0.32% of all assessments submitted in the 2024 calendar year. During an interview on 01/31/25 at 1:00 PM, the Administrator stated the staff member who was responsible for the data transmission was not available for interview, but stated had transmitted data when the staff member was not available. The Administrator was not able to say why the agency’s OASIS data was transmitted late.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of five sampled patients (Patient (P) 2) reviewed for medication reconciliation. This deficient practice had the potential to affect all 43 patients receiving services from the HHA. Findings include: Observation during a homecare visit performed by Certified Nursing Assistant (CNA)1 on 01/30/25 at 2:00 PM revealed that P2’s Medication List, found in P2’s electronic medical record (EMR), did not accurately reflect the medications being administered to the patient in his/her group home. Medications observed in P2’s home, and reflected as being given in the patient’s home Medication Administration Record (MAR) included Loperamide (an antidiarrheal medication) 4 milligrams (MG) with each loose stool not to exceed 16 MG in 24 hours, Pantoprazole (an acid reducing medication) 40 MG twice daily, Alprazolam (an antianxiety medication) 0.25 MG twice daily as needed, and Risperdal (an antipsychotic medication) 1 MG daily. Review of the HHA’s Patient Medication Profile, found in the EMR and dated 01/04/25 through 03/04/25, revealed orders that did not indicate the Loperamide, and indicated P2 was to receive Pantoprazole 40 MG once daily, Alprazolam 0.25 MG three times daily as needed, and Risperdal 1 MG twice daily. The medications administered in the home did not match the orders - in the HHA’s EMR. During an interview on 01/30/24 at 2:30 PM, P2’s group home caregiver confirmed P2’s current prescribed medications and confirmed P2 was being given the medications indicated on the group home MAR routinely per physician’s order. During an interview on 01/30/25 at 3:15 PM, the Director of Nursing (DON) confirmed P2 was receiving routine skilled nursing visits and indicated that medications were expected to be reconciled by the nurse at every visit. The DON indicated the expectation was that the medications being administered to residents in their homes would match the HHA’s medication order set.”