Windber Home Health Agency

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of agency emergency preparedness training program, personnel files (PF) and interview with staff (EMP), the facility failed to provide initial training in emergency preparedness (EP) policies and procedures to agency staff and staff under arrangement, consistent with their expected roles in emergency preparedness training for five (5) of ten (10) PFs reviewed (PF 1, 2, 4, 9, & 10) and ongoing training every 2 years for three (3) of six (6) PFs reviewed with employment greater than 2 years (PF 6, 9, & 10). Findings included: Review of personnel files conducted March 20, 2024, at approximately 9:45am revealed: PF1, agency staff with a date of hire 9/4/23. Evidence of emergency preparedness training dated 11/29/23. PF2, agency staff with a date of hire 9/5/23. Evidence of emergency preparedness training dated 11/28/23. PF4, agency staff with a date of hire 1/2/23. Evidence of emergency preparedness training dated 2/11/24. PF6, agency staff with a date of hire 1/2/03. No evidence of emergency preparedness training every 2 years. PF9, contracted staff with a date of hire 12/3/21. No evidence of emergency preparedness training initially or every 2 years. PF10, contracted staff with a date of hire 12/3/21. No evidence of emergency preparedness training initially or every 2 years. Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on review of clinical records (CR), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure wounds were assessed and managed for five (5) of seventeen (17) CR reviewed (CR 3, 4, 5, 7, & 17). Findings included: Review of agency policy on 3/19/24 at approximately 2:30pm revealed: “...Wound care Documentation...PROCEDURE...Continued/Ongoing Treatment...At each visit the patient’s skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. Include a full set of vital signs including temperature...Wound measurements are documented in the EMR to show progress to healing...” Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed: CR3, start of care (SOC) 4/10/23, dates reviewed 4/10/23-4/26/23. Initial comprehensive assessment included documentation of wound to right third toe. Plan of care (POC) included corelating wound care orders. No wound assessment or measurements documented the week of 4/16/23. CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. Initial comprehensive assessment included documentation of 4 wounds. Wounds #1 and #2 located on sacrococcygeal spine, #3 on left anterior thigh, and #4 to left dorsal foot. No wound measurements documented on wounds #1-#4 week of 12/10/23 or week of 12/17/23. CR5, SOC 10/22/23, dates reviewed 10/22/23-11/12/23. Documentation of wound #1 to left foot on 10/26/23. No measurements documented week of 10/29/23 or week of 11/5/23. Documentation of wound #2 to buttock on10/31/23. No measurements documented week of 11/5/23. CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. Initial comprehensive assessment included documentation of surgical wound. No measurements documented week of 3/3/24, week of 3/10/24, or week of 3/17/24. CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. Initial comprehensive assessment included documentation of venous stasis ulcer to bilateral lower legs. No measurements documented week of 2/18/24, week of 2/25/24, or week of 3/17/24. Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.”

“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 review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to ensure the plan of treatment included supplies, and equipment required for seven (7) of seventeen (17) CR reviewed (CR 1, 2, 8, 10, 12, 13, & 15). Findings included: Review of agency policy on 3/19/24 at approximately 2:30pm revealed: “...Plan of Care (CM-485) Development and Coordination...PROCEDURE...The plan of care will address the following information: ...Types of services, supplies, ad equipment required. Include all DME the patient currently has in home. Include any DME the patient needs in the home. Include any medical supplies that the patient is using in the home...” Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed: CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included orders for “compression stockings to be worn on surgical leg...” and “maintain shoulder immobilizer to affected arm.” Compression stockings and shoulder immobilizer not included on POC supplies or DME. CR2, SOC 5/12/23, dates reviewed 5/12/23-5/30/23. POC included order “to instruct patient and caregiver on the use of incentive spirometer...” Incentive spirometer not included on POC supplies or DME. CR8, SOC 2/10/24, dates reviewed 2/10/24-3/20/24. Medication list included insulin administered based on blood glucose results. POC failed to include insulin needles. CR10, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included order “to instruct patient and caregiver on the use of incentive spirometer...” Incentive spirometer not included on POC supplies or DME. CR12, SOC 3/18/24, dates reviewed 3/18/24-3/26/24. At HV2 conducted 3/21/24 at 10:15am surveyor observed a gel cushion and patient also reported using a wheelchair. Gel cushion and wheelchair not included on POC supplies or DME. CR13, SOC 2/28/24, dates reviewed 2/28/24-3/26/24. POC included order “to instruct patient and caregiver on the use of incentive spirometer...” Incentive spirometer not included on POC supplies or DME. CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. At HV5 conducted 3/22/24 at 9:30am patient verbalized to surveyor that they [the patient] uses a c-pap at night. C-pap not included on POC supplies or DME. Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator. Repeat deficiency, previously cited: 3/18/21.”

“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 review of clinical records (CR), observation of home visits (HV), review of agency policies, and interview with the administrator, it was determined that the agency failed to provide services or treatments only as ordered by a physician for seven (7) of seventeen (17) CR reviewed (CR 1, 4, 6, 7, 15, 16, & 17). Findings included: Review of agency policy on 3/19/24 at approximately 2:30pm revealed: “...Plan of Care (CM-485) Development and Coordination...POLICY...The Home Health Certification and Plan of Care (CMS-485) will include: ...Nursing Orders and Clinical Orders: Nursing orders specify the schedule of visits... Clinical orders outline specific interventions and goals for the patient. These orders guide the care provided by clinicians., Ancillary Care Orders: ...Details the frequency and type of therapy needed...” Review of CF conducted March 25, 2024, between approximately 9:15am and 1:00pm and March 26, 2024, between approximately 11:00am and 12:30pm revealed: CR1, start of care (SOC) 7/15/23, dates reviewed 7/15/23-7/25/23. Plan of Care (POC) included skilled nurse (SN) frequency 2 times a week for 1 week and 1 time a week for 8 weeks starting 7/16/23. Only 1 SN visit conducted week of 7/16/23. CR4, SOC 12/9/23, dates reviewed 12/9/23-12/28/23. POC included SN frequency 1 time a week for one week, 2 times a week for 4 weeks, and 1 time a week for 5 weeks starting 12/9/23. 3 SN visits conducted week of 12/17/23. No order for additional visit conducted. CR6, SOC 3/5/24, dates reviewed 3/5/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a week for 5 weeks starting 3/5/24. Additional SN visit conducted without order 3/14/24. POC included home health aide (HHA) visit frequency 1 time a week for 1 week and 2 times a week for 8 weeks starting 3/5/24. No HHA visit conducted week of 3/5/24. POC included occupational therapy (OT) visit frequency 1 time a week for 1 week and 2 times a week for 2 weeks starting 3/6/24. Only 1 OT visit conducted week of 3/10/24. CR included an order dated 3/15/24 for bloodwork to be obtained on 3/18/24. No evidence that bloodwork was obtained per order. CR7, SOC 2/22/24, dates reviewed 2/22/24-3/26/24. POC included SN frequency 2 times a week for 4 weeks and 1 time a wee for 5 weeks starting 2/22/24. Only 1 SN visit conducted week of 3/6/24. CR15, SOC 2/17/24, dates reviewed 2/17/24-3/26/24. POC included diagnosis of type II diabetes, parameters for blood glucose results, and blood glucose monitoring supplies. No orders for frequency of blood glucose monitoring. CR16, SOC 2/16/24, dates reviewed 2/16/14-3/26/24. POC included orders for bloodwork to be obtained on Mondays. No evidence of bloodwork obtained Monday 3/11/24 or Monday 3/18/24. Documentation of bloodwork obtained with no corresponding orders on Saturday 3/9/24, and Wednesdays 3/13/24 and 3/20/24. CR17, SOC 2/15/24, dates reviewed 2/15/24-3/26/24. CR included documentation of bloodwork obtained 2/29/24. No corresponding order for bloodwork. Findings confirmed at exit conference on March 26, 2024, at approximately 2:00pm with the Administrator.”