Elara Caring

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on record review and staff interview, it has been determined that the home care agency failed to ensure that refusals of care are investigated, and the patient is educated when services are refused, or the patient elects to be discharged from services for 1 of 1 discharge record reviewed, Patient ID #3. Findings are as follows: Review of the record revealed the patient was admitted to services with a start of care date of 5/26/2024, with diagnoses including but not limited to, orthopedic aftercare following surgical amputation and acquired absence of right toe, end stage renal disease, and type 2 diabetes mellitus. Review of the plan of care revealed orders for skilled nursing care for wound care management 2 times a week for 2 weeks, 1 time a week for 3 weeks, then 1 time every 2 weeks for 4 weeks. Review of a document titled, “Client Coordination Note Report”, dated 6/26/2024, indicates the patient refused services. Review of an additional late entry note dated 7/2/2024, revealed the patient had cancelled her scheduled skilled nursing visit on 6/27/2024. Further record review failed to reveal evidence that the home care agency discussed with the patient the reason for his/her cancellation of services. Nor was their evidence that the home care agency provided education to the patient regarding the potential adverse outcomes that could occur due to his/her cancellations. The patients care plan lacked evidence that it was revised following the cancellations. Review of a note, dated 7/5/2024, authored by the Director of Nursing Services, revealed the patient had cancelled multiple visits. According to the patient, she/he was told by the physician that s/he no longer needed skilled nursing services any longer. During a surveyor interview on 7/15/2024 at 4:50 PM with the Director of Nursing Services, she acknowledged that she did not speak with the physician and the patient was discharged from services. Additionally, she was unable to provide evidence that the home care agency contacted the patient after the missed appointments, provided education regarding potential adverse outcomes of refusing care, or of any attempted interventions to encourage him/her to participate in the plan of care.”

“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 staff interview, it has been determined that the home care agency failed to effectively coordinate the patient’s care and assure communication with the physician involved in the plan of care for 1 of 2 active clients reviewed, Patient ID #1. Findings are as follows: Review of the record revealed the patient was admitted to services with a start of care date of 6/4/2024, with diagnoses including but not limited to, fracture of the right patella, laceration to right lower leg, and hypertension. Review of the plan of care revealed orders for skilled nursing care for wound care and medication management 2 times a week for 1 week, 3 times a week for 1 week, 2 times a week for 3 weeks, then 1 time a week for 4 weeks. Review of an admission note, dated 6/4/2024, revealed that the patient currently does not have a primary care provider and the orthopedic physician will be signing orders for care. Additionally, the patient’s right lower leg wound was closed with sutures, had a small amount of bloody drainage, and s/he had completed a 10-day course of Keflex (medication used to treat a wide variety of bacterial infections) to treat his/her cellulitis. A message was left with the physician to discuss the plan of care. Review of a note, authored by Licensed Practical Nurse (LPN), Staff A and dated 6/10/2024, revealed the patient’s blood pressure was 164/68 and the patient ran out of his/her Amlodipine (used to treat high blood pressure) medication therefore s/he did not take it. Further review revealed LPN, Staff A placed a call to the physician. Review of a note, authored by Registered Nurse (RN) Staff B and dated 6/13/2024, revealed that the patient ran out of the Amlodipine medication provided to him/her when discharged from a skilled nursing facility. Staff B recommended that the patient go to urgent care with the nursing facility discharge papers and empty blister packs to request a medication refill until his/her new primary care provider appointment in July. Further review revealed his/her blood pressure was 140/68. Additional review failed to reveal evidence of notification to the physician. Review of a note, authored by LPN, Staff A and dated 6/17/2024, revealed the patient’s blood pressure was 146/70 and the sutures to his/her wound were still in place. Review of a note, authored by RN, Staff B and dated 6/21/2024, revealed the patient continues to not have his/her Amlodipine. Additionally, he indicated that the middle of the incision is soft, and the wound continues to have bloody drainage. Further review failed to reveal evidence of notification to the physician. Review of a note, authored by LPN, Staff A and dated 6/25/2024, revealed the patient’s blood pressure was 146/76 and the sutures to his/her wound were still in place. Review of a note, authored by LPN, Staff A and dated 6/28/2024, revealed the patient’s blood pressure was 170/70. Review of a note, authored by LPN, Staff A and dated 7/2/2024, revealed the patient’s blood pressure was 146/70. Review of a note, authored by LPN, Staff A and dated 7/5/2024, revealed the patient’s blood pressure was 172/80 and the sutures were still in place. Review of a document titled, “Client Coordination Note Report”, dated 7/7/2024, revealed the patient contacted the agency and stated that the wound is leaking out of the bandage. Review of a note, authored by RN, Staff B and dated 7/8/2024, revealed the patient contacted the agency and reported increased drainage to the incision and redness above the wound. Further review revealed, “…SIGNING DOCTOR FOR ORDERS IS AN ORTHOPEDIC DOCTOR WHO WILL NOT SIGN ANYTHING OTHER THAN THE ORDERS FOR THE VISITNG NURSE. EDUCATED PATIENT CAREGIVER TO GO TO URGENT CARE…” Review of the community reported complaint, submitted to the Rhode Island Department of Health on 7/8/2024, revealed the sutures to the patient’s leg were placed in May of 2024 but were never removed. Further review revealed black eschar (hardened, dry, black or brown dead tissue) was noted that required removal in order to remove the sutures. Furthermore, the sutures were deeply embedded in the skin due to prolonged time and two remain because they are embedded under the skin and could not be reached. Additionally, the anterior right leg has 2+ pitting edema, is red with pustules and honey colored drainage that was cultured for infection, s/he was treated for cellulitis and his/her blood pressure was 209/66. During a surveyor interview on 7/15/2024 at 4:50 PM with the Director of Clinical Outcomes and Risk and the Director of Nursing Services, they were unable to provide evidence of any additional attempts by the agency to contact the physician to report concerns with the patient. Additionally, the DNS indicated that she was unaware that the patient’s blood pressure was elevated, s/he did not have his/her blood pressure medication, the patient’s wound was not healing properly or that the physician would not sign anything other than orders for the visiting nurse.”

“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 staff interview, it has been determined that the home care agency failed to provide services that were ordered by the physician, as indicated in the plan of care, for 1 of 2 active patients reviewed, Patient ID #2. Findings are as follows: Review of the record revealed the patient was admitted to services with a start of care date of 5/31/2024, with diagnoses including but not limited to, fracture of the right femur, type 2 diabetes mellitus, Alzheimer’s disease, and dementia. Review of the plan of care revealed physician orders relative to skilled nursing care for teaching diabetic management, including blood sugar monitoring and use of the glucometer (an instrument for measuring the concentration of glucose in the blood). Review of a note authored by Licensed Practical Nurse (LPN) Staff A, dated 6/17/2024, revealed that she was unable to check the patient’s blood sugar because the lancets (small devices used to take blood samples) do not fit the device. Further review of this note revealed the patient’s Registered Nurse Case Manager, Staff B was notified; however, the patient’s physician was not made aware. Review of an additional note authored by LPN, Staff A, dated 6/24/2024, revealed that she was still unable to check the patient’s blood sugar. Further review of this note revealed the patient’s representative was notified; however, his/her physician was not made aware. Further review of the notes, authored by LPN, Staff A, revealed that on 7/2/2024 she was still unable to check the patient’s blood sugar and left a voicemail for his/her physician requesting a new glucometer kit. During a surveyor interview on 7/15/2024 at 4:50 PM with the Director of Clinical Outcomes, and the Director of Nursing Services, they were unable to provide evidence that the physician’s orders were followed. Additionally, they could not explain why Staff A failed to notify the physician that she was unable to obtain the patient’s blood sugar on 6/17/2024, 6/24/2024, and 7/2/2024, but did not notify the physician until 7/2/2024.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to include all professional services as required, relative to speech-language pathology and medical social services. Findings are as follows: A review of the agency’s Admission Home Health Booklet, under section 1, the services provided by the home care agency are listed as follows: ...Skilled Nursing, Physical therapy, Occupational therapy, and Speech- therapy. Additionally, it also lists Medical social services and home health aides. A staff list was provided, and job descriptions were reviewed, it was determined that the agency did not have a speech language therapist or a social worker available, or under contract if needed by the clients. During an interview with the Administrator, Staff L, she informed the surveyor that they do not have a Speech Language Therapist or a Social Worker on staff, or under contract. When questioned as to how long they had been without these services, she acknowledged the services have not been provided since the company was acquired by Elara in July 2023. The Administrator was unable to provide evidence that social services or speech therapy is available should the physician order these services.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to ensure individual emergency plans for each client are included as part of the comprehensive assessment, are in writing, and a copy of the individualized emergency plan is in the client’s file as well as a copy is given to the client and or their caregiver for 5 of 5 clients who had surveyor home visits, ID#’s 1, 2, 3, 7 and 8. Findings are as follows: 1. Review of the home record for Client ID #1, during a surveyor home visit on 2/19/2024, revealed the client was admitted with a start of care date of 11/12/2023. Review of the Agency admission folder revealed a “Patient Emergency Preparedness Plan” form that was blank and had not been completed. 2. Review of the home record for Client ID #2, during a surveyor home visit on 2/20/2024, revealed the client was admitted with a start of care date of 2/7/2024. Review of the Agency admission folder revealed a “Patient Emergency Preparedness Plan” form that was blank and had not been completed. 3. Review of the home record for Client ID #3, during a surveyor home visit on 2/20/2024, revealed the client was admitted with a start of care date of 12/9/2023. Review of the Agency admission folder revealed a “Patient Emergency Preparedness Plan” form that was blank and had not been completed. 4. Review of the home record for Client ID #7, during a surveyor home visit on 2/20/2024, revealed the client was admitted with a start of care date of 1/24/2024. Review of the Agency admission folder revealed a “Patient Emergency Preparedness Plan” form that was blank and had not been completed. 5. Review of the home record for Client ID #8, during a surveyor home visit on 2/21/2024, revealed the client was admitted with a start of care date of 12/9/2023. Review of the Agency admission folder revealed a “Patient Emergency Preparedness Plan” form that was blank and had not been completed. During surveyor interview with the Administrator, Staff M on 2/21/2024 at approximately 2:45 PM, she stated that the staff complete the emergency preparedness plan as part of the assessment in the electronic medical record and provided evidence of the assessments to the surveyor. However, she was unable to produce evidence that a copy of the plan is reviewed with the client and or their caregiver and the form in the admission packet is completed and signed by the client or caregiver and the agency staff and a copy left in the home as required by regulation.”

“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 record review and staff interview, it was determined that the agency failed to provide Initial training in emergency preparedness policies and procedures to all new and existing staff, and individuals providing services under arrangement, as well as volunteers, consistent with their expected roles. Findings are as follows: During a review of the Emergency Preparedness Plan, on 2/22/2024 at 3:30 PM, with the Administrator, Staff M, she was unable to provide evidence that all new and existing staff have knowledge of the emergency procedures and that they had received the initial training in emergency preparedness policies and procedures.”

“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 staff interview, it has been determined that the agency failed to conduct exercises to test the emergency plan annually, participate in a full-scale exercise that is community-based, or conduct a facility-based functional exercise. Findings are as follows: During review of the agencies Emergency Preparedness Plan on 2/22/2024 at 3:30 PM, which was provided to the surveyor by the Administrator Staff M, she acknowledged that the agency had not participated in a full-scale community-based exercise to test their emergency plan and had not conducted facility-based exercises as required.”

“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 staff interview, it has been determined that the agency failed to ensure that services are written in an individual plan of care which is established, reviewed and signed by a doctor for 1 of 13 clients reviewed, ID #3. Findings are as follows: Record review for Client ID #3 revealed a start of care (SOC) dated 12/9/2023 and an initial certification dated 12/9/2023 through 2/6/2024, that was not signed by the physician. Additionally, a recertification dated 2/7/2024 through 4/6/2024, had been signed by the nurse on 2/2/2024, and was not signed by the physician as required. During a surveyor interview with Staff M, on 2/20/2024 at approximately 2:00 PM, she acknowledged that the above plans of care were not signed by the physician and was unable to produce evidence that the physician had reviewed and signed the plan of care as required.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on record review and staff and client interviews, the agency failed to provide the client and caregiver with a copy of written instructions outlining the plan of care to ensure that clients and families understand what services to expect from the HHA, the purpose of each service and when to expect the services, for 5 of 5 clients who were observed during surveyor home visits, ID#’s 1, 2, 3, 7 and 8. Findings are as follows: 1. Review of the home record for Client ID #1, who was admitted with a start of care date of 11/12/2023, failed to reveal any written instructions, plan of care, or schedule detailing what services are that are being provided by the agency, or a schedule as to when the staff will come to the client’s home. During surveyor interview with the client at the time of the home visit on 2/19/2024, when asked if s/he had a schedule of when the staff was due to visit or a written plan of care, s/he replied that “they call when they are going to visit”. 2. Review of the home record for client ID #2, who was admitted with a start of care date of 2/7/2024, failed to reveal any written instructions, plan of care, or schedule detailing what services are that are being provided by the agency, or a schedule as to when the staff will come to the client’s home. 3. Review of the home record for Client ID #3, who was admitted with a start of care date 12/9/2023 failed to reveal any written instructions, plan of care, or schedule detailing what services are being provided by the agency, or a schedule as to when the staff will come to the client’s home. 4. Review of the home record for Client ID #7, who was admitted with a start of care date 1/24/2024, failed to reveal written instructions, plan of care, or schedule detailing what services are provided by the agency, or a schedule as to when the staff will come to the client’s home. 5. Review of the home record for Client ID #8, who was admitted with a start of care date 1/19/2024, failed to reveal written instructions, plan of care, or schedule detailing what services are provided by the agency, or a schedule as to when the staff will come to the client’s home. During surveyor interview with the Administrator on 2/21/2024 at approximately 2:45 PM, she stated that the staff all have the plan of care in their electronic tablet that they use for the visit. Previously, they left a copy of the plan of care in the client’s home prior to the implementation of the new electronic medical record. She stated that the agency mails a copy of the plan of care to the client’s however, none of the client’s visited during the survey had a copy of the plan of care.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and staff interview the agency failed to ensure that a Registered Nurse or Rehabilitation Skilled Professional conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of the referral for 1 of 9 records reviewed, ID #14. Review of the record for Client ID #14’s, during a complaint investigation, revealed the client was referred for home care on 1/22/2024, following discharge from an acute care facility. The client did not have an RN assessment visit until 1/27/2024, 5 days after the initial referral was made. During a surveyor telephone interview with the complainant, Case Manager at the acute care hospital, on 2/20/2024 at approximately 12:00 PM, s/he stated that the home care agency had accepted the patient and agreed to provide services within 24-48 hours of the clients discharge on 1/22/2024. During surveyor interview with the Administrator, Staff M, on 2/22/2024 at approximately 10:45 AM, she was unable to explain why the client was not assessed within 48 hours of referral, as required. During surveyor interview with the Administrator Staff M, on 2/22/2024 at approximately 10:45 AM, she was unable to explain why the clients were not assessed within 48 hours of referral as required.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and staff interview it has been determined the agency failed to ensure the patient’s clinical record identified all medications that the patient is taking (both prescription and non-prescription) as well as the time of medication administration and route for 5 of 5 clients who received a surveyor home visit, ID#’s 1, 2, 3, 7 and 8, and 1 of 1 client who’s record was reviewed who was admitted from a long term care facility, ID # 6. Findings are as follows: 1. Review of the medications during a home visit with the nurse, Staff A, on 2/19/2024 at approximately 2:00 PM, revealed that Client ID #1 with a start of care dated 11/13/2023, record review revealed the following list of medications that the client is currently taking, including but not limited to the following: Cephalexin 500 mg capsule, once daily by mouth Ciprofloxacin 500 mg tablet, once daily by mouth Cyanocobalamin (vitamin B 12) 1,000 mcg tablet, every other day. Fosamax 70 mg tablet, once a week. Metoprolol Succinate ER 50 Mg tablet, 3 tablets daily. Oxycodone 10 mg tablet, three times daily PRN (when necessary). Rifampin 300 mg capsule, one daily. Senna laxative 8.6 mg tablet, 1 tablet as needed PRN. During surveyor interview on 2/19/2024 at approximately 2:40 PM, with Client ID #1, the following medication discrepancies were noted, the client was no longer taking the Cephalexin or the Ciprofloxacin which were discontinued approximately 2 weeks prior. The Cyanocobalamin, Fosamax, and the Senna had also previously been discontinued. The Metoprolol Succinate ER 50mg had also been changed to 75mg twice a day, the Rifampin 300 mg had been increased to twice a day, and the Oxycodone has been changed to every 6 hours as needed. Additionally, the client stated that s/he had been taking Losartan Potassium 25 mg daily, which had also been discontinued and s/he was now taking Levofloxacin 500 mg daily, and Hydrochlorothiazide 25 mg one tablet daily. Both medications were filled by the pharmacy on 2/2/2024, 2 weeks prior to the surveyor’s home visit. During an interview with Nurse, Staff A, at the end of the home visit on 2/19/2024, she stated she was unaware of all the medication changes noted above and could not explain the discrepancy in the client’s current medication list. During an interview with the Administrator, on 2/21/2024 at approximately 11:00 AM, she stated that the medications should be reviewed and that the nurse should have been aware of the medication changes. 2. Review of the medications during a home visit with the Nurse, Staff B, on 2/20/2024 at approximately 10:30 AM, revealed that Client ID #2’s record had the following list of medications that the client is currently taking, including but not limited to the following: Celebrex 100 mg, 1 capsule twice daily. Diclofenac 3% topical gel, apply 1 inch twice daily and as needed for pain. Ecotrin 325 mg, take 1 tablet twice daily for six weeks. Lisinopril 10 mg, 1 tablet daily. Ondansetron hydrochloride 4 mg, 1 tablet every eight hours as needed for nausea/vomiting. Oxycodone 5 mg, 1 tablet every six hours as needed for severe pain. Pantoprazole delayed release 40 mg, 1 tablet daily for six weeks. Rosuvastatin 5 mg, 1 tablet at bedtime. Sennosides 8.6-Docusate sodium 50 mg, 1 tablet twice daily as needed for constipation. Sertraline 100 mg, 1 tablet daily. During surveyor interview on 2/20/2024 at approximately 11:30 AM with Client ID #2, the following medication discrepancies were noted, the client indicated that s/he is no longer taking Celebrex, Ecotrin, Ondansetron, and had stopped taking the Oxycodone last week. Furthermore, the client stated s/he is now taking Acetaminophen 625 mg tablet once daily, and 1000 mg of Acetaminophen twice daily, as well as aspirin 325 mg tablets twice daily. Additionally, the client indicated that s/he is taking Famotidine one 20 mg tablet at night, Sertraline had been discontinued, and s/he was also taking Escitalopram oxalate, one 20 mg tablet daily. During an interview with Licensed Practical Nurse, Staff B, at the end of the home visit, it was indicated that she was unaware of all of the medication changes noted above and was unable to explain the discrepancy with the client’s current medication list. 3. Review of the medications during a home visit with the Nurse, Staff C, on 2/20/2024 at approximately 12:30 PM, revealed that Client ID #3’s record had the following list of medications that the client is currently taking, including but not limited to the following: Hydrochlorothiazide 25 mg, one tablet once a day. Lisinopril 40 mg, one tablet once a day. Tylenol extra strength 500 mg tablets, take 1-2 tablets three times a day when needed. During surveyor interview with the client on 2/20/2024 during the home visit, s/he informed the surveyor that she did not have any Lisinopril or Hydrochlorothiazide, as these medications needed to be refilled. An observation of the medication bottles during the home visit revealed that the medications were filled on 10/19/2023 and 10/2/2023 with a 90-day supply. Client ID #3 informed the surveyor that s/he ran out of the medications a few weeks ago. Additionally, the bottle of Tylenol contained Tylenol 650 mg tablets and not 500 mg tablets as ordered. During surveyor interview with the Nurse, Staff C, at the end of the home visit on 2/20/2024, he stated that he was unaware that the client had been taking the wrong strength of Tylenol, and also unaware that the client had run out of the Lisinopril and Hydrochlorothiazide until the medications were reviewed by the surveyor during the home visit. During an interview with the Administrator, on 2/21/2024 at approximately 11:00 AM, she stated that the medications should be reviewed and that the nurse should have been aware of the medication changes and could not explain the discrepancies. 4. Review of the medications during a home visit with the Nurse, Staff G on 2/21/2024 at approximately 12:30 PM revealed that Client ID #7, stated that s/he is currently taking Meclizine is 3 times a day when needed, and also uses Salonpas (patch for the skin, used for temporary relief of minor aches and pains) once or twice daily which is not reflected on the client’s current medication list, including but not limited to the following: During surveyor interview with the Administrator, Staff M, on 2/21/2023 at approximately 3:00 PM, she was unable to explain the discrepancies in the medication list or why the medications had not been reconciled and could not explain the discrepancies. 5. Review of the medications during a home visit with the Nurse, Staff F, on 2/21/2024 at approximately 11:30 PM, revealed that Client ID #8 had a list of medications the client is currently taking, including but not limited to the following: Prednisone 2.5 mg tablet every other day. Prednisone 5 mg tablet every other day. During interview with the client’s caretaker during the home visit, s/he informed the surveyor that the client had not been taking the Prednisone for quite a while. S/he also provided the surveyor with the following medications that were not listed on the client’s current medication list. Trospium 20 mg, one once a day (for bladder). Alendronate 35 mg, one time a week. Lisinopril 10 mg, one once a day. Metoprolol ER 25 mg, once a day. Vitamin D tablets 50,000u, once a week. During an interview with the Administrator, on 2/21/2024 at approximately 11:00 AM, she stated that the medications should be reviewed and that the nurse should have been aware of the medication changes.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on surveyor observation and record review it has been determined that the agency failed to provide education and training to the client’s caregiver relative to dressing changes for 1 of 1 client (ID# 3) who’s caregiver provides wound care. Findings are as follows: Record review for Client ID #3, revealed that the client was admitted to the agency for wound care on 12/9/2023. During a surveyor home visit with the Staff Nurse C on 2/20/2024, she was to provide treatment per orders for wound care to the left lower leg, as follows; cleanse wound with saline, apply triad to the peri-wound, cover with silver alginate, followed by Unna boot toes to knee, then absorbent Opti lock (Does not stick to the wound bed, protects the surrounding skin). During a home visit on 2/20/2024 with Staff Nurse C, the surveyor observed the dressing change. While the nurse was removing the soiled dressing, that had been completed on Saturday 2/17/2024 by the client’s family member, it was noted that the Opti lock dressing was incorrectly applied and taped directly to the client’s leg. According to staff C, the client is followed by a wound clinic weekly on Thursdays, is seen by the homecare agency Staff Nurse on Tuesdays, and the Client’s family member changes the wound dressing on Saturdays. Record review lacked documentation of the client’s family member being educated in the correct application of the dressing change which is completed by family on Saturday’s. The client’s family member who was present in the home at the time of the visit was informed by the nurse that the dressing was not correctly applied and that the Opti lock is not to be directly taped to the leg. The patient’s son stated that he was not aware that the Opti lock should not be taped directly to the leg. During surveyor interview with the Nurse Staff C, during the home visit he could not produce evidence that the client’s son had been educated regarding the client’s wound care.”

“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 staff interview, it has been determined that the agency failed to conform with the physician orders for home health aide services, occupational therapy, physical therapy, and skilled nursing services, for 10 of 13 client records reviewed, Client ID #s 1, 2, 3, 4, 5, 7, 8, 11,12 and 13. Findings are as follows: 1. Review of the record for Client ID #1, revealed a SOC (start of care) date of 11/13/2023, and a current Certification dated 1/12/2024 through 3/11/2024. Orders for Skilled nursing (SN) state to provide this service 1 time a week for 1 week, 3 times a week for 8 weeks. A Review of the visits revealed that during the week of 1/21/2024 through 1/27/2024 the client had only 2 SN visits when 3 were ordered. 2. Review of the record for Client ID #2 revealed, a SOC date of 2/7/2024, a current certification dated 2/7/2024 through 4/6/2024, Orders for physical therapy services (PT) for visits 1 time a week for 1 week, 2 times a week for 4 weeks. Review of the visits for week two, 2/11/2024 through 2/17/2024, revealed only 1 PT visit when 2 were ordered. During an interview on 2/21/2024 at approximately 10:00 AM, the Administrator Staff M, acknowledged the physician should have been notified that the abovementioned appointment was missed. 3. Review of the record for Client ID #3, revealed a SOC (start of care) date 12/9/2023, and a Certification dated 12/9/2023 through 2/6/2024 and 2/7/2024 through 4/6/2024. Physician orders for skilled nursing (SN) service state to provide service 1 time per week for 1 week, then 1 time per week for 9 weeks. Review of the visits revealed that during the weeks of 12/24/2023, 12/31/2023, and 2/11/2024 the client failed to receive a SN visit. 4. Review of the record for Client ID #4 revealed, a SOC date 2/1/2024, and a current certification dated 2/1/2024 through 3/31/2024. Physician orders for Occupational Therapy services (OT) for 1 time per week for 1 week. Review of the visit calendar for 2/1/2024 through 2/20/2024, failed to reveal the OT visit was conducted. During an interview on 2/21/2024 at 12:30 PM, the Administrator, Staff M, was unable to explain why OT failed to visit the client. 5. Review of the record for Client ID #5 revealed his/her certification period was from 1/26/2024 through 3/25/2024, with a start of care date 11/27/2023. Physician orders for PT services, effective 2/4/2024, for 1 time per week for 1 week, then 2 times per week for 4 weeks. Review of the visits calendar for week two, 1/28/2024 through 2/3/2024, revealed only 1 PT visit when 2 were ordered. 6. Review of the record for Client ID #7, revealed a SOC date 1/24/2024, and a Certification dated 1/24/2024 through 3/23/2024. Orders for Skilled nursing (SN) state 1 visit per week for 1 week, then 2 times a week for 1 week, then 1 time a week for 7 weeks. Review of the visits revealed that during the week of 2/4/2024 the client failed to receive a SN visit. 7. Review of the record for Client ID #8 revealed a certification period from 1/19/2024 through 3/18/2024, with a start of care date 11/19/2023. Physician orders for PT services, effective 1/21/2024, for 2 times a week for 2 weeks then 1 time a week for 2 weeks. Review of the visits calendar for week five, 2/11/2024 through 2/17/2024, lacked evidence that a PT visit was completed as ordered. 8. Review of the record for Client ID #11 revealed a certification period from 10/20/2023 through 12/18/2023, with a start of care date of 10/20/2023. Physician orders for PT services, effective 10/22/2023, for 1 time a week for 1 week, and Home Health Aide (HHA) 2 times a week for 4 weeks then 1 time a week for 4 weeks. Review of the visits calendar, from 12/15/2023 through 1/14/2024, failed to reveal that the client had received any visits from PT or HHA as ordered. During an interview on 2/21/2024 the Administrator, Staff M, at approximately 12:30 PM, was unable to provide evidence that Client ID #11 received PT and HHA services as ordered by the physician. 9. Review of the record for Client ID #12 revealed a certification period from 12/3/2023 through 1/31/2024, with a start of care date of 12/3/2023. A physician’s order dated 1/2/2024 orders services for an HHA 2 times per week for 5 weeks. Review of the visits calendar, 12/3/2023 through 1/13/2024, failed to reveal HHA visits were completed as ordered. 10. Review of the record for Client ID #13 revealed a certification period from 10/10/2023 through 12/8/2023, with a start of care date of 10/10/2023. Physician orders, effective 10/15/2023, for HHA services 3 times per week for one week, then 2 times per week for seven weeks, OT services 2 times per week for four weeks, PT, effective 10/22/2023, 1 time per week for 1 week, then 2 times per week for 4 weeks. Review of the visit calendar revealed a total of three HHA visits were missed during the weeks of 10/15/2023 and 11/5/2023. 3 OT visits were missed during the weeks of 10/29/2023 and 11/5/2023. 3 PT visits were missed during the weeks of 10/29/2023 and 11/5/2023. During a surveyor interview with the Administrator, Staff M on 2/21/2024 at approximately 3:45 PM, she was unable to produce evidence that the plan of care was followed relative to the following services for SN, PT, OT, and HHA services for the above clients.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to ensure that communication is facilitated with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care for 1 of 1 client reviewed with an inhaler medication and cardiology visit, Client ID #6. Review of the record for Client ID #6 revealed a start of care (SOC) date 1/23/2024 and certification period from 1/23/2024 through 3/22/2024. Further review of the record revealed the client had diagnoses including but not limited to, acute on chronic respiratory failure with hypoxia and hypercapnia, dependence on supplemental oxygen, chronic obstructive pulmonary disease, long-term use of inhaled steroids, hypertensive heart disease with heart failure, atrial fibrillation, old myocardial infarction, and presence of cardiac pacemaker. Review of plan of care revealed that s/he is currently taking Symbicort 80 micrograms (mcg)-4.5 mcg inhaler, take two puffs twice daily. Review of a note, dated 2/1/2024, revealed that the client reported shortness of breath and chest pressure with exertion. The nurse instructed him/her to keep taking the Symbicort inhaler, but the medication could not be located. The client indicated that the inhaler has given him/her a mouth sore, and according to the progress note the client stated s/he will not take it and has not been taking it. Further review of the note revealed that the client’s physician will be notified of his/her non-compliance with the medication. Review of a note, dated 2/12/2024, revealed stated that s/he was going to see his/her cardiologist that afternoon. Review of the record lacked evidence that the client’s physician was notified of the mouth sore or that s/he had stopped taking the inhaler. Additionally, the record lacked evidence of any communication with the cardiologist following the appointment or updates to the plan of care. During an interview with Staff M on 2/20/2024 at approximately 3:00 PM, she was unable to produce evidence that the physician was notified of the client’s mouth sore or that s/he had stopped using the inhaler. Furthermore, she was unable to produce evidence of any documentation from the cardiology appointment or that the client’s plan of care was updated to ensure that communication is facilitated with all physicians.”