Marshall County Home Health, Inc.

“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 record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar year 2023 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for calendar year 2023. On 07/24/24 at 11:00 a.m., Staff A stated the agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for calendar year 2023.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. An operating budget, capital expenditure plan and allocation of resources activities for calendar years 2022 and 2023; and 01/01/24 to 07/23/24 and; 3. Agency program evaluation for calendar years 2022 and 2023 and for 01/01/24 to 07/23/24 effecting all patients and staff. Findings: A review of administrative records showed no governing body oversite and responsibility for the agency’s operating budget, capital expenditure plan or agency’s program evaluation for calendar years 2022 and 2023; and for 01/01/24 to 07/23/24. On 07/24/24 at 11:55 a.m., Staff B stated documentation showed no administrative records which showed evidence of ongoing governing body oversite and responsibility for the agency’s operating budget, capital expenditure plan or the agency’s program evaluation for calendar years 2022 and 2023; and for 01/01/24 to 07/23/24.”

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an ABN was provided prior to being discharged from the agency for one (Patient #7) of eight patients. Findings: Patient #7 A review of the clinical record showed the patient was discharged from the agency on 01/29/24 for a change in payor source and showed no documentation of an advance notice of discharge prior to discharge from the agency. On 07/24/24 at 11:23 a.m., Staff C stated: 1. Patient #7 received no advance notice of discharge prior to discharge from agency services; 2. During a nursing visit on 02/08/24 the patient reported a change in insurance company (payor source); 3. A verbal order was obtained from the physician after the visit on 02/08/24 with a retroactive discharge date on the date of the last SN visit on 01/29/24.”

“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 individualized patient POCs included a skilled nursing pain goal for six (Patients #1, 3, 4, 5, 7 and #8) of eight patients. Findings: Patient #1 A review of the POC dated 06/04/24 to 08/02/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. Patient #3 A review of the POC dated 06/30/24 to 08/28/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. Patient #4 A review of the POC dated 06/21/24 to 08/19/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. Patient #5 A review of the POC dated 06/06/24 to 08/04/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. Patient #7 A review of the POC dated 01/22/24 to 03/21/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. Patient #8 A review of the POC dated 03/13/24 to 05/11/24 showed orders for SN to assess, instruct and monitor the patient’s pain. Documentation showed no skilled nursing goal related to the assessment, instruction, and monitoring of the patient’s pain. Documentation showed no physician notifications and no change in orders. On 07/24/24 at 11:10 a.m. to 11:30 a.m., Staff C stated the POCs for patients #1, 3, 4, 5, 7 and #8 did not include a skilled nursing goal related to management of the patients’ pain.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of eight patients. Findings: Patient #5 A review of a POC dated 06/06/24 to 08/04/24 showed a SN visit frequency of one time a week for nine weeks for SN to conduct assessment and monitoring of the patient’s weight. Documentation showed during SN visits on 06/21/24, 06/28/23, 07/05/24, 07/12/24 and on 07/17/24 the patient was unable to be weighed or had refused to be weighed. Documentation showed no follow up physician communications or coordination of care notes for continued patient being unable to be weighed or refused to be weighed during conducted SN visits and showed no changes in orders. On 07/24/24 at 11:17 a.m., Staff C stated the staff did not follow up with the physician for continued patient being unable to be weighed or refused to be weighed during conducted SN visits for patient #5.”

“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 record review and interview, the agency failed to ensure: SN notified the physician of exceeded weight reporting parameter for one (Patient #5) of eight patients and; SN notified the physician for exceeded pain reporting parameter for two (Patients #5 and #8) of eight patients. Findings: Patient #5 A review of the POC dated 06/06/24 to 08/04/24 showed orders for SN visit frequency one time a week for nine weeks for SN to assess, instruct and monitor the patient’s pain and report pain level greater than 5 to the physician and SN to conduct weight assessment each visit and report weight gain of 5 pounds or greater in a week. Documentation showed during SN visits conducted on 06/21/24, 06/28/23, 07/05/24, 07/12/24 and on 07/17/24 the patient was unable to be weighed or had refused to be weighed and on 06/21/24 the patient reported a pain level of 6 of 10. Documentation showed no physician notifications and no change in orders. On 07/24/24 at 11:17 a.m., Staff C stated the staff did not report to the physician for continued patient being unable to be weighed or refused to be weighed during conducted SN visits, and the SN did not report the patient’s reported pain level of 6 of 10 to the physician for patient #5. Patient #8 A review of the POC dated 03/13/24 to 05/11/24 showed orders for a SN visit frequency one time a week for eight weeks for SN to assess, instruct and monitor the patient’s pain and report pain level greater than 5 to the physician. Documentation showed during SN visit conducted on 04/18/24 the patient reported a pain level of 7 of 10. Documentation showed no physician notifications and no change in orders. On 07/24/24 at 11:23 a.m., Staff C stated the staff did not report to the physician the patient’s reported pain level of 7 of 10 to the physician for patient #8.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2022 and 2023. On 07/23/24 at 2:00 p.m., Staff B stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure completed transfer summaries were provided to the receiving service provider for three (Patients #6, 7 and #8) of eight patients. Findings: Patient #6 A review of the clinical record documented transfer from the agency on 04/18/24 to inpatient hospital services. Documentation showed no transfer summary was provided to the inpatient hospital service provider. At 11:20 a.m., Staff C stated the transfer summary was not provided to the receiving service provider for patient #6. Patient #7 A review of the clinical record documented discharge from the agency on 01/29/24. Documentation showed no discharge summary was provided to the physician provider. At 11:23 a.m., Staff C stated the discharge summary was not provided to the receiving service provider for patient #7. Patient #8 A review of the clinical record documented transfer from the agency on 04/18/24 to hospice services. Documentation showed no discharge summary was provided to the hospice service provider. At 11:28 a.m., Staff C stated the discharge summary was not provided to the receiving service provider for patient #8.”