Elara Caring Xxiii

“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 agency failed to develop a community-based risk assessment (All Hazards Risk Assessment) for their own service area for all employees and patients. Findings: A review of emergency preparedness records showed the location on the risk assessment was not located in the agency’s service area. On 10/10/24 at11:00 am, Staff B stated they must not have changed the agency name on the template.”

“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 record review and interview, the agency failed to ensure the Emergency Preparedness Plan was updated for the surveyed agency every two years. Findings: A review of the Emergency Preparedness Plan showed it was last updated on 7/14/24 for a different Agency. On 10/10/24 at 11:00 am, Staff B stated the agency had failed to change the name on the template.”

“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 Plan of Care included a pain level rating for one (Patient #3) of 17 patients. Findings: Patient #3 A review of the Plan of Care dated 6/12/24 - 8/10/24 showed that the physician should be notified when a patients pain level was above a 10. A Skilled nurse assessment dated 6/12/24 documented a pain level of 10 with no physician notification. A Skilled nurse assessment dated 6/20/24 documented a pain level of 9-10 with no physician notification. On 10/10/24 at 11:20 am, Staff B stated the physician was not notified of severe pain rating.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nurse frequencies were followed as ordered for one (Patient #16) of 17 patients. Findings: Pt #16 A review of the Plan of Care dated 09/17/24 - 11/15/24 showed a Skilled nurse frequency of twice a week for nine weeks. A review of visit notes showed one visit completed the week of 9/17/24 - 9-21/24,one visit completed the week of 9/22/24 - 9/28/24 (one of two completed visits). Documentation showed no patient/caregiver refusal, no change in orders and no attempts to reschedule the visits. On 10/10/24 at 11:10 am Staff B stated the ordered SN frequency was not followed for Pt #16.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide a current Plan of Care to the Assisted Living Facilities for three (Patients #6,9, and 10) of three patients residing in Assisted Living Facilities. Findings: Patient #6 A review of the assisted living center clinical record showed no Plan of Care. Patient #9 A review of the assisted living center clinical record showed no Plan of Care. Patient #10 A review of the assisted living center clinical record showed no Plan of Care. On 10/09/24 at 08:15 am ALF Staff #1 stated there was no plan of care for Patient #6. On 10/10/21 @ 1100 Staff B stated they I thought the plan of cares had been provided to the Assisted Living Facilities. On 10/10/24 at 3:29 pm ALF Staff #2 stated there was no Plan of Care for Patients #9 and 10.”