Lvn Health Care

“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 interview and record review, the facility failed to implement unplanned drills as well as annual testing in accordance with their emergency preparedness training and testing program for 2 of 3 years reviewed (2023 and 2024). This failure could limit the ability of the facility staff to react without proper knowledge and actions prior to, and during, emergency situations. This could place active patients and employees at risk of harm in the event of an emergency or disaster. Findings included: Review of emergency preparedness binder for “2022” revealed a fire drill was conducted on 01/31/22. Further review of emergency preparedness binder for “2023” and “2024” did not reflect any emergency drills or implementations of the agency’s emergency plan. Forms titled “Disaster/Drill After Action Review Critique” was left blank and incomplete by the agency for years 2023 and 2024. In an interview on 03/06/25 10:00 a.m. with the Alt Adm/DC and HR, surveyor presented the above findings and Alt Adm/DC confirmed that he was responsible for the emergency preparedness plan and was the designated disaster coordinator. Surveyor asked if the agency tested the response phase during an actual emergency in years 2023 and 2024. Alt Adm/DC confirmed that the agency did not test the response phase during an actual emergency for years 2023 and 2024. Surveyor further asked, why this was important. Alt Adm/DC stated, “So, we can be prepared for any disasters, and staff will know what they are supposed to do in the event of a disaster.” Surveyor asked why did the agency not test the response phase during an actual emergency for 2023 and 2024. Adm/Alt DC stated “We didn’t think we needed to have drills, since we haven’t had patients since 2023. Alt Adm/DC stated, “It was overlooked since we didn’t have no patients.” Surveyor further asked, how cannot conducting annual drills affect agency staff and clients. Alt Adm/DC stated, “It can endanger our staff and any active clients.” HR stated, “By not doing annual drills we wouldn’t know what procedures needed to be done and it can endanger our staff and clients.” Review of Agency policy titled “Emergency Preparedness Policy and Plan”, with a date of 12/16/21 revealed in part: “Policy…Agency will maintain documentation of compliance with the required elements, required forms and agency policies in the Emergency Preparedness and Response Plan Manual…The agency will conduct one exercise to test the emergency plan at least annually…Documentation of Agency compliance will be maintained and available for review at any time for a period no less than three (3) years.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information upon exit on 03/06/25 at 2:00 p.m. No additional documents provided by agency.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Assessment Performance Improvement (QAPI) program in 2 of 3 years reviewed (2023 and 2024). The agency did not provide evidence that revealed the agency measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance to assess processes of care, HHA (Home Health Agency) services, and operations. This failure could place the agency’s Licensed & Certified patients at risk of receiving inadequate care and services which could result in negative patient care outcomes in the event that substandard care was not identified and corrected by the agency during ongoing QAPI evaluations. The findings included: Review of the QAPI mannual with no date failed to reveal that the QAPI Committee discussed an analysis of a representative sample of services furnished to patients contained in both active and closed records; a review of negative patient care outcomes; complaints and incidents of misconduct by unlicensed staff; infection control activities; effectiveness and safety of all services provided, including: the competency of the agency’s staff; the promptness of service delivery; and the appropriateness of the agency’s responses to patient complaints and incidents; a determination that services have been performed as outlined in the individualized service plan, and an analysis of patient complaint, satisfaction survey data, and total operation of the agency. In an interview on 03/06/25 10:00 a.m. with the Adm and Alt Adm surveyor presented the above findings and Alt Adm confirmed he is responsible for the QAPI and its contents. Alt Adm further confirmed the QAPI did not complete all the elements required or evaluate the total operation of the agency for 2023 and 2024. Surveyor asked why he did not include all required elements or evaluate the total operation of the agency in their QAPI for 2023 and 2024. Adm stated, “We didn’t think we needed to because we have no census.” Alt Adm stated, “We didn’t know since we don’t have a census at this time.” Surveyor asked how cannot having all the elements included in your QAPI or evaluating the total operation affect patient care. Adm stated, “We would lack in giving patients 100% and it can have a negative impact on our patients.” Alt Adm stated, “We can miss something with our patients, and it can make them vulnerable if we don’t improve.” Record review of the Agency’s policy manual contained a policy titled, “Quality Assessment Performance Improvement Plan QAPI”, with a date of 03/04/15, quoted in part, “Policy: Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated or revised at least once within the calendar year…Performance improvement priorities identified by leaders will be identified through the collection of data for analysis of Agency services…The measures must include the following…1. Analysis of representative sample of services furnished to patients contained in both active and discharged charts; 2. Negative patient care outcomes; 3. Complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff; 4. Infection control activities; 5. Medication administration and errors; 6. Effectiveness and safety of all services provided, including the competency of the agency’s clinical staff, the promptness of service delivery and the appropriateness of the agency’s responses to patient complaints and incidents; 7. A determination that services have been performed as outlined in the individualized service plan, care plan or plan of care; 8. An analysis of patient complaints and satisfaction survey data; and 9.An annual evaluation of the total operation, including services provided under contract or arrangement…” Record review of the Agency’s policy manual contained a policy titled, “QAPI.7”, with a date of 06/30/07, quoted in part, “Purpose: To outline the process for performing an annual agency evaluation and assess Agency’s program for appropriateness, adequacy, effectiveness, and efficiency. Policy Agency leaders…will participate in an annual evaluation of the organization’s performance in relation to its written organizational plan, mission, vision, and philosophy. Findings will be utilized to correct identified problems…” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information upon exit on 03/06/25 at 2:00 p.m. No additional documents provided by agency.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policies to provide Bloodborne pathogen training as required by the Occupational Safety and Health Administration (OSHA), 29 CFR 1910.1030 and Appendix A relating to Bloodborne pathogens for 1 of 5 personnel record review (Adm) whose personnel records were reviewed for 2024. This deficient practice could place staff and agency’s current patients at risk for exposure to communicable and/or infectious diseases. The findings include: Record review of agency’s policy “Infection Control Program”, dated, quoted 05/31/16 in part, “Policy…Agency’s infection control program will be based on the following criteria…CDC guidelines…current federal/state/local laws and regulations…Education of Employee…Upon hire and annually thereafter, all Agency employees will be educated regarding the policies and procedures related to…Bloodborne/Airborne/HIV Pathogen Program…” Review of OSHA 29 CFR 1910.1030 dated 11/03/23 contains the following in part: “The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employer shall institute a training program and ensure employee participation in the program. Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training”. 1. Review of the Administrator’s personnel record revealed an employment application that was completed by the administrator on 06/01/23. Personnel record further revealed a job description for the position of “Administrator” signed by Adm, 06/04/24. Review of the Adm’s personnel record included an agency form titled “Bloodborne pathogens Quiz” that revealed an initial Bloodborne pathogen training for Adm dated 06/01/23. The Adm personnel record further revealed form “In-service record for year 2023” which documented “Bloodborne Pathogen Program” with a date of 06/2023. Further review of the Alt Adm’s personnel record failed to reveal it contained evidence on annual Bloodborne Pathogen trainings were conducted for year 2024. In an interview on 03/06/25 10:00 a.m. with the Adm, Alt Adm, and HR. The surveyor presented the above findings and HR confirmed that she was responsible for Bloodborne pathogen trainings. Adm confirmed that Bloodborne Pathogen trainings were to be done upon hire and yearly. Adm further confirmed that there are no Bloodborne pathogens trainings for Adm for year 2024. Surveyor asked why bloodborne pathogen trainings for the Adm were not conducted for 2024. Adm stated, “I don’t have an answer.” Alt Adm stated, “It was overlooked, and HR never got to it.” HR stated, “Honest answer I haven’t gotten around to checking the personnel records.” Adm confirmed by not doing annual bloodborne pathogen trainings, it could create a risk for infection to the staff and patients. The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information upon exit on 03/06/25 at 2:00 p.m. No additional documents provided by agency.”