Memorial Hospital Home Care

“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 record review and interview, the hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for three patients and all employees. A review of administrative records showed no community-based risk assessment which addressed the agency and it’s patient population. On 02/24/25 at 2:15 pm, Staff A stated there was no documentation of an all-hazards risk assessment.”

“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 record review and interview, the agency failed to ensure emergency drills were completed for all employees and three current patients. A review of Emergency Preparedness and administrative records showed no Emergency Preparedness Tabletop Exercise or disaster drill completed for calendar years 2023 or 2024. On 02/24/25 at 2:15 pm, Staff A stated the agency was unable to provide a documented disaster drill or tabletop exercise for 2023 or 2024.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of notification of the potential for discharge for cause was provided to the patient for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no notification to the patient of need for discharge for cause. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not provided information in regard to the potential for discharge for cause prior to the date of discharge.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of efforts to resolve the patient’s behavior for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not informed of or provided the opportunity to correct unacceptable behaviors.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it provided contact information to other agencies to provide care for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no issues which warranted a discharge for cause and did not provide contact information for other agencies to provide care. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. On 02/24/25 at 1:52 pm., Staff A stated Patient #10 was not provided contact information for other agencies to provide care.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the duration of skilled nurse visits was included on the plan of care for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. On 02/24/25 at 2:10 pm., Staff A stated the plan of care for Patient #10 did not include the duration of the visits to be provided.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were obtained and documented in the clinical record for one (Patient #10) of 13 patients. A review of the plan of care dated 01/21/25 to 03/21/25 showed a primary diagnosis of dehiscence of amputation stump with a skilled nurse frequency of 1-2 times per week. A review of the clinical record showed the following: Skilled nurse assessments dated 01/27/25, 01/28/25, 01/30/25/ 01/31/25, 02/02/25, 02/03/25 and 02/04/25 documented no behaviors or attempts to resolve unacceptable behaviors and no documentation of reason for potential discharge was provided to the patient. A communication note dated 02/05/25 at 3:37 pm., documented the patient was informed she would have to be discharged due to having no physician at this time. No orders were received for the discharge of the patient. On 02/24/25 at 2:00 pm., Staff A stated the clinical record for Patient #10 did not have any orders to discharge the patient.”