Carter Healthcare

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: As part of the annual internal review, an agency must test the response phase of its emergency preparedness and response plan in a planned drill, if not tested during an actual emergency response. Except for a freestanding hospice inpatient unit, a planned drill can be limited to the agency’s procedures for communicating with staff. Based on interview and record review the agency failed to test the response phase of its emergency preparedness and response plan by conducting a planned drill as part of its annual review of the plan for 2 (2022 and 2023) of 3 years in that the agency performed fire drills but no other type of drill was conducted. This failure could place clients, employees, and the agency at risk of not being prepared to respond to any disaster. Findings included: Review of document titled “Emergency Preparedness Response Questionnaire Details Report,” dated 10/31/2024, revealed that agency staff enacted a drill responding to the scenario of a tornado. Review of document “Quarterly Office Drill Detail Report,” dated 10/28/2024, revealed a drill type listed as “fire drill.” Review of document “Quarterly Office Drill Detail Report,” dated 10/28/2024, revealed a drill type listed as “natural disaster.” The document contains no other details that defined “natural disaster” or what actions were taken during the drill. Review of document “Quarterly Office Drill Detail Report,” dated 6/16/2023, revealed a drill type listed as “fire drill.” Review of document “Quarterly Office Drill Detail Report,” dated 6/16/2023, revealed a drill type listed as “natural disaster.” The document contains no other details that defined “natural disaster” or what actions were taken during the drill. Review of document “Quarterly Office Drill Detail Report,” dated 6/16/2023, revealed a drill type listed as “fire drill.” Review of document “Quarterly Office Drill Detail Report,” dated 6/16/2023, revealed a drill type listed as “natural disaster.” The document contains no other details that defined “natural disaster” or what actions were taken during the drill. Review of document “Quarterly Office Drill Detail Report,” dated 12/121/2022, revealed a drill type listed as “fire drill.” Review of document “Quarterly Office Drill Detail Report,” dated 12/21/2022, revealed a drill type listed as “natural disaster.” The document contains no other details that defined “natural disaster,” or what actions were taken during the drill. Review of policy titled “Emergency Management Plan,” dated 04/2023, revealed that the agency “will activate the emergency management plan annually. The organization will conduct one exercise per year to test the plan. One year, the annual exercise will consist of an operations-based (full-scale, community based or functional, facility-based exercise when community is not possible). The other year, the annual exercise will consist of either operations-based exercise or discussion-based exercise.” In an interview with the SN on 2/19/2025 at 10:05 AM, the Surveyor showed SN one complete drill that was completed on 10/31/2024. The Surveyor showed SN that the other sheets provided listed “Fire drill,” or “Natural disaster,” with dates, but no information about what occurred was listed. SN reported that she would have to ask AA, who was the only one at the company during that time. The surveyor asked if SN could find in their emergency preparedness policy a section where it discussed how many full-scale drills they would have and how often. SN looked through emergency preparedness plan and responded that she could not find a spot where it was mentioned. In an interview with AA on 2/19/2025 at 10:15 AM, the Surveyor showed AA that the sheets provided listed “Fire drill,” or “Natural disaster,” with dates, but no information about what occurred was listed. Surveyor asked AA what occurred during those drills. AA reported that all meetings that included “Natural Disaster” occurred in the case conference room and that staff agreed that in the event of a natural disaster they would meet in the conference room. Surveyor asked AA was any other information regarding contacting patients, ensuring continued care, or safety measures was discussed. AA responded “no, we just designated the conference room as a place to meet in the event of a natural disaster.” In an interview with the Alternate Administrator on 2/19/2025 at 2:09 PM, the surveyor asked Alternate Administrator about drills conducted in 2022, 2023, and 2024. The Alternate Administrator recognized that the documentation provided did not have details about what they did for drills in 2022 or 2023. The Alternate Administrator was unable to say why drills documented in 2022, 2023, and the remainder of 2024 did not contain details about how the drill was conducted, who was involved, or what component of the emergency preparedness plan they enacted. The Alternate Administrator stated that he was not employed at the time with the agency and therefore he could not say if those drills did occur. d. The surveyor asked how this impacted client care. The Alternate Administrator responded that they needed to practice in the event of a real emergency to be prepared to care for their patients.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 6 assessments processed for the time-period reviewed of 2/11/2024 to 2/11/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 2/11/2024 to 2/11/2025 was reviewed. Review of the HHA Error Summary Report for the time period of 2/11/2024 to 2/19/2025 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 3 assessments and the percentage of assessments with this error was 0.92% of assessments completed by the Agency. An interview was completed with the Alternate Administrator on 2/19/2025 at 2:35 PM. The HHA Error Summary Report for the time of 2/11/2024 to 2/11/2025 was reviewed with the Administrator. The Surveyor asked about the process for submitting OASIS assessments. When the patient was admitted, the nurse completed the assessment and had 24 hours to submit their assessment before it goes to an offsite review. Once offsite, they have 24 hours to review. This then goes to the SN who had 24 hours to submit the assessment to OASIS. The surveyor asked why 3 of the assessments were submitted late. The Alternate Administrator responded that it was normally with the nurse that completed the assessment that it falls behind. The Surveyor asked what was being done to prevent OASIS assessments from being late. The Alternate Administrator stated he reviewed a billing report that showed which ones still need documentation. The Alternate Administrator stated he started tracking which nurses are repeatedly late for completing their assessments so that corrective action and education can be provided. The Surveyor asked how this impacts client care. Alternate Administrator reported that it is important that documentation be timely so that it can be accurate and that it also affects quality scores. The Surveyor requested a copy of the agency’s policy for submitting OASIS reports. The Alternate Administrator responded that he would ask the SN to find the policy. In an interview with the SN on 2/19/25 at 2:51 PM, the SN presented a policy titled “Initial and Comprehensive Assessment.” SN stated that this policy included steps of what to include in OASIS assessments, but that it did not have time frames for submission. The Surveyor asked SN if there was another policy that did include timeframes and SN responded “No.” Review of the Agency’s policy titled “Initial and Comprehensive Assessment,” dated 11/2021, revealed that a comprehensive assessment will be completed within five days of the patient’s start of care. The policy did not include information regarding submitting documentation of the comprehensive patient assessment.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to properly dispose of medical waste while providing home health services in 1 out of 3 clients (Client 5) observed during home visits. RN A was observed disposing of a vacutainer needle and tubing containing client’s blood that was used for a blood draw Client 5’s personal trash bin. Failure of the agency to ensure correct disposal of medical waste, including blood contaminated needles and tubing, puts the client, client’s family, and anyone handling the waste, at risk of contamination, injury, and infection. Findings include: Observation of RN A performing a blood draw for labs on Client 5 in the home of Client 5. RN A used a vacutainer blood collection set. A vacutainer includes a needle that enters patient’s vein (includes a safety that can be activated after removal), which is attached to tubing that ends in a capped needle where lab tubed can be directly attached for a seamless transfer of blood in multiple tubes while needle stays in patient’s vein). RN A was observed removing the vacutainer needle, engaging the safety, and placing the entire vacutainer blood collection set in a plastic bag she had set aside for waste. Upon exiting the Client’s home, RN A gathered that plastic bag in her hands, and asked the Client 5’s family member (FM) if she could place the bag in the trash bin in Client 5’s room. FM consented, and RN A placed the trash bag, including the sharps, in Client 5’s trash bin. In a phone interview with RN A on 2/18/25 at 4:05 PM, Surveyor asked RN A if she was aware of what the agency’s policy on used sharp disposal was. RN A stated she was not sure if they had a policy or what it included. Surveyor asked how RN A typically disposed of her sharps. RN A said that if the client had a sharp container in the home, she would dispose of the sharps there. She stated they used to carry sharp containers in their cars but were instructed to stop this due to the risk it could pose in a car accident. RN A stated that diabetic patients usually had a sharps container at home, but since this client was a one-off lab draw on a patient who did not often require needles, nurses have to do their best to keep the patients safe with the resources available to them. She elaborated how she engaged the vacutainer’s safety and bundled it up in a separate bag before disposing of it in the patient’s trash. In a face-to-face interview with SN on 2/19/25 at 10:42 AM, Surveyor shared observations of contaminated sharps being disposed of in client’s trash and asked SN what their policy was. SN stated they should be properly disposed in a sharps container. SN stated they should be properly disposed of in sharps container. Surveyor asked if nurses were provided sharps containers. SN stated they were not, and that there was no sharps container in their office for safe needle disposal. Surveyor asked how the RN would dispose of their sharps if they collected them in a personal sharps container. SN stated “I don’t know”. SN stated the RN should have placed sharp in a “safe place” and “thrown in the trash” but admitted that “even that would be unsafe”. Surveyor asked SN what impact incorrect sharps disposal could have on patient care. SN said it could put client and client’s family in danger. In a face-to-face interview with Alternate Administrator at 2:23 PM on 2/19/25, Surveyor shared observations of contaminated sharps being disposed of in client’s trash. Alternate administrator stated that is not how it should be done. Alternate administrator was not sure of details of their policy, but stated the sharp should not be disposed of in clients’ trash. Surveyor showed Alternate Administrator the agency policy on hazardous waste handling. Alternate Administrator called in Supervising Nurse and asked if the nurses had sharps containers or if there was one in the office. Supervising Nurse reported that there was not. Alternate Administrator said he was just learning about this issue that needed to be addressed. When asked how unsafe sharp disposal could affect client care, Alternate Administrator stated that is presented a danger of infection or contamination, or that anyone handling the waste could get stuck by the sharp. Review of the agency’s policy and procedure manual revealed a policy updated on 2/6/2025 titled “Hazardous Waste Handling” that reads in part, “Needles and syringes will be placed in a hard plastic or metal container with a screw-on cap or tightly secured lid…Encapsulation is used to safely dispose of sharps and used vacutainer waste that is generated while providing agency services. This this method, sharps and vials are collected in puncture-resistant and leak-proof containers.” Review of the agency’s policy and procedure manual revealed a policy updated on 2/6/2025 titled “Hazardous Waste Handling” that reads in part, “Personnel will be provided training on the basics of transmission of pathogens to patients and staff, bloodborne diseases, the use of standard precautions, infectious waste management, and other infection control procedures when their work activities…may results in an exposure to blood…” and “Agency maintains and enforces policies addressing infection control including the prevention and spread of infectious and communicable disease”.”

“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 interview, the agency failed to conduct an initial assessment visit within 48 hours of referral in 2 out of 7 clients (Client 6 and Client 7). The agency also had a written policy that established a time frame of 48 hours to conduct the initial assessment visit after receiving a referral. For 2 of the client records reviewed, the agency did not enforce that policy or provide documentation of why the initial assessments did not occur within 48 hours. Failure of the agency to conduct initial assessment visits within 48 hours of referral results in a delay of care and needed services for clients who rely on the agency services for vital healthcare needs. Findings include: Record review of Client 6’s medical record revealed a referral date of 7/11/24 and a Start of Care date of 7/17/24. Record review of Client 7’s medical record revealed a referral date of 10/17/24 and a Start of Care date of 10/24/24. In an interview with the Supervising nurse and the Alternate Administrator on 2/19/25 at 2:45 PM, surveyor asked if they could provide documentation supporting a reason for the delay in initial assessment for the above two clients. Supervising Nurse went to check electronic medical record, but she was unable to find supporting documentation or reason for delay in care. Alternate Administrator stated that it was their policy to start care the same day or withing 24 hours of receiving referral. He stated the only acceptable reason would be if the client refused care and physician was contacted that the patient refused. He said that no client should be delayed. If for any reason care was delayed, he stated it should be documented in the client’s record. Alternate administrator said this affects client’s care because it prevents clients from getting the timely care and services that they need. Review of the agency’s policy and procedure manual revealed a policy revised Sept. 2017 titled “Initial and Comprehensive Assessment” which states, “the initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the healthcare professional, or at the patient/family request with the approval of the healthcare professional”.”