Home Nursing for Utah

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and record review, it was determined the agency did not maintain an emergency plan that was based on and included a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: On August 28, 2025, surveyors completed a review of the agency’s emergency preparedness documentation. There was no documented evidence of a facility-based and community-based risk assessment. On August 28, 2025, at 12:45 PM, surveyors interviewed the agency’s Director of Nursing (DON). The DON stated they had not done a facility-based and community-based risk assessment.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the agency did not develop and maintain an emergency preparedness communication plan that complied with Federal, State, and local laws. Findings include: On August 28, 2025, surveyors completed a review of the agency’s emergency preparedness documentation. There was no documented evidence of an emergency preparedness communication plan. On August 28, 2025, at 12:45 PM, surveyors interviewed the agency’s Director of Nursing (DON). The DON stated they did not have a communication plan.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on interview and record review, the agency did not ensure the quality assessment and performance improvement (QAPI) program included documented evidence of data collection or tracking. Findings include: On August 25, 2025, surveyors requested the agency’s QAPI program and documentation. The chief executive officer (CEO) provided the agency’s QAPI performance improvement plan that included four performance improvement projects (PIPs); however, there was no documented evidence of data collection or tracking of the PIPs. On August 26, 2025, the agency’s CEO was interviewed. The CEO stated they did not have any documentation of data collection or tracking.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, it was determined that the agency had not conducted home health aide supervisory visits at least every 14 days as required for 4 of 4 sampled patients who were receiving skilled visits. (Patient identifiers: 1, 3, 8, and 9.) Findings include: On September 4, 2025, surveyors completed a review of the medical records for Patients 1, 3, 8, and 9. There was no documented evidence that supervisory visits were completed every 14 days. On August 28, 2025, at 12:45 PM, surveyors interviewed the agency’s Director of Nursing (DON). The DON stated supervisory visits were only done every 60 days and that she was not aware they needed to be done every 14 days for patients receiving skilled care.”