Med-Staff Home Health

“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 ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 57 patients and all employees. A review of administrative records showed no documentation of a community-based risk assessment, completed within the past two years, which addressed the agency, its patient population, or its employees. On 08/29/24 at 1:30 pm., Staff A stated the agency had no emergency preparedness community-based risk assessment completed within the past two years.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services were followed as ordered for one (Patient #5) of seven patients. Patient #5 A review of the plan of care dated 05/21/24 to 07/19/24 showed skilled nurse frequency of one visit per week for one week and two visits per week for eight weeks. A review of the clinical record showed the following: A skilled nurse missed visit dated 05/17/24 documented the reason for the missed visit as declined first visit of the week for the week of 05/26/24 to 06/01/24 (one incomplete visit) with no documented attempts to reschedule the visit to meet the physician ordered frequency. A skilled nurse missed visit dated 06/24/24 documented the reason for the missed visits as reports not available and a skilled nurse visit dated 06/26/24 documented the reason for the missed visit as no electricity for the week of 06/23/24 to 06/29/24 (two of two incomplete visits) with no documented attempts to reschedule the visits to meet the physician ordered frequency. A skilled nurse missed visit dated 07/19/24 documented the reason for the missed visit as not available for the week of 07/14/24 to 07/19/24 (one incomplete visit) with no documented attempts to reschedule the visit to meet the physician ordered frequency. On 08/29/24 at 2:00 pm., Staff A stated the skilled nurse made no documented attempts to reschedule the missed visits to meet the physician ordered frequency for Patient #5.”

“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 an individualized plan of care included patient-specific interventions and goals for the primary diagnosis for one (Patient #4) of seven patients. Patient #4 A review of the plan of care dated 05/13/24 to 07/11/24 showed a primary diagnosis of chronic obstructive pulmonary disease and documented no patient specific interventions or goals for the management of the primary disease process. On 08/29/24 at 1:45 pm., Staff A stated the plan of care for Patient #4 documented no patient specific interventions or goals for the management of the primary diagnosis.”