Transitions Home Health of Central Wisconsin

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, this agency failed to ensure there is a comprehensive Emergency Preparedness Program, in 1 of 1 Emergency Programs reviewed. Findings include: This agency failed to establish an Emergency Preparedness program that is reviewed and updated every two years. See tag E-0004. This agency failed to ensure the Emergency Preparedness policy and procedures are reviewed and updated every two years. See tag E-0013. This agency failed to ensure the communication plan is reviewed every two years. See tag E-0029. This agency failed to ensure training and testing of the emergency preparedness program is documented and reviewed every two years. See tag E-0036. This agency failed to conduct One full-scale community-based exercise every two years. See tag E-0039. The cumulative effect of these systemic problems resulted in the clinic’s inability to effectively develop or implement an emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, emergency preparedness training and testing program that includes one full-scale community-based exercise and is reviewed and updated every 2 years.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, this agency failed to develop, implement, evaluate, and maintain an effective ongoing home health agency wide data driven QAPI (Quality Assessment and Performance Improvement) program in 1 of 1 QAPI programs reviewed. Findings include: This agency failed to implement and maintain an agency wide QAPI program as follows: 1)This agency failed to ensure a QAPI program that showed measurable improvements in quality indicators. See tag G642. 2)This agency failed to ensure a QAPI program that utilized quality indicator data, such as OASIS (Outcome and Assessment Information Set) in the design of its program. See tag G644. 3) This agency failed to ensure a QAPI program that included performance improvement activities. See tag G646. 4) This agency failed to ensure a QAPI program that included a focus on high risk, high volume, or problem-prone areas. See tag G648. 5) This agency failed to ensure a QAPI program that included incidence, prevalence, and severity of problems. See tag G650. 6) This agency failed to ensure a QAPI program performance improvement measured success and tracked performance to ensure sustainability. See tag G656. 7) This agency failed to ensure a QAPI program conducted performance improvement projects. See tag G658. 8) This agency failed to ensure a QAPI program had continued oversight by the Governing Body. See tag G660. The cumulative effect of this systematic problem resulted in the agency’s inability to ensure an effective ongoing home health agency wide QAPI program.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review this agency failed to document the Emergency Plan risk assessment is reviewed and updated every two years in 1 of 1 Emergency Preparedness Programs reviewed. Findings Include: A review of policy and procedure titled “Emergency Operations Plan and Policies” not dated, revealed in part under “Procedure 1. The agency complies with all applicable federal, state and local emergency preparedness requirements. 3. The emergency preparedness program includes but is not limited to, the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials. Efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. 4. The agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. local health department, law enforcement and office of emergency management. 23. Agency will participate in a healthcare coalition as it may provide assistance in planning and addressing community needs.” Interview with Administrator A on 02/13/2024 at 12:08 PM. Administrator A was asked if this agency had an emergency preparedness plan all hazards risk assessment that was reviewed and updated every two years, Administrator A stated, “What I provided is what I have, unfortunately I will have some work to do.””

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and record review this agency failed to ensure the Emergency Preparedness Policy and Procedures were reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed. Findings Include: A review of policy and procedure titled “Emergency Operations Plan and Policies” not dated, revealed in part under “Procedure 1. The agency complies with all applicable federal, state and local emergency preparedness requirements. 3. The emergency preparedness program includes but is not limited to, the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials. Efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. 4. The agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. local health department, law enforcement and office of emergency management. 23. Agency will participate in a healthcare coalition as it may provide assistance in planning and addressing community needs.” Interview with Administrator A on 02/13/2024 at 12:08 PM. Administrator A was asked if this agency had emergency preparedness plan policies and procedures that were reviewed and updated every two years, Administrator A stated, “What I provided is what I have, unfortunately I will have some work to do.””

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on interview and record review this agency failed to ensure the Emergency Preparedness communication plan is reviewed and updated every two years in 1 of 1 Emergency Preparedness Plan reviewed. Findings Include: A review of policy and procedure titled “Emergency Operations Plan and Policies” not dated, revealed in part under “Procedure 1. The agency complies with all applicable federal, state and local emergency preparedness requirements. 3. The emergency preparedness program includes but is not limited to, the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials. Efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. 4. The agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. local health department, law enforcement and office of emergency management. 23. Agency will participate in a healthcare coalition as it may provide assistance in planning and addressing community needs.” Interview with Administrator A on 02/13/2024 at 12:08 PM. Administrator A was asked if this agency had an emergency preparedness plan communication plan that was reviewed and updated every two years, Administrator A stated, “What I provided is what I have, unfortunately I will have some work to do.””

“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: Based on interview and record review this agency failed to ensure the Emergency Preparedness training and testing is reviewed and documented every two years in 1 of 1 Emergency Preparedness Plan reviewed. Findings Include: A review of policy and procedure titled “Emergency Operations Plan and Policies” not dated, revealed in part under “Procedure 1. The agency complies with all applicable federal, state and local emergency preparedness requirements. 3. The emergency preparedness program includes but is not limited to, the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials. Efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. 4. The agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. local health department, law enforcement and office of emergency management. 23. Agency will participate in a healthcare coalition as it may provide assistance in planning and addressing community needs.” Interview with Administrator A on 02/13/2024 at 12:08 PM. Administrator A was asked if this agency had a documented training and testing program for the emergency preparedness plan that was reviewed and updated every two years, Administrator A stated, “What I provided is what I have, unfortunately I will have some work to do.””

“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 this agency failed to conduct one full-scale community-based exercise every two years in 1 of 1 Emergency Preparedness Plan reviewed. Findings Include: A review of policy and procedure titled “Emergency Operations Plan and Policies” not dated, revealed in part under “Procedure 1. The agency complies with all applicable federal, state and local emergency preparedness requirements. 3. The emergency preparedness program includes but is not limited to, the following elements: The agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials. Efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. 4. The agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond and recover from high priority emergencies that impact the community, e.g. local health department, law enforcement and office of emergency management. 23. Agency will participate in a healthcare coalition as it may provide assistance in planning and addressing community needs.” A review of this agency’s emergency preparedness plan not dated revealed; a tabletop drill for a bomb-threat was conducted 08/17/2023. No other testing or drills were documented. Interview with Administrator A on 02/13/2024 at 12:08 PM. Administrator A was asked if this agency conducted any other additional full-scale or functional exercises for emergency preparedness in the last two years, Administrator A stated, “What I provided is what I have, unfortunately I will have some work to do.””

“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, this agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program that showed measurable improvements in quality indicators in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 1. The agency program will 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 agency must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, services, and operations.” Record review of QAPI binder contents revealed no documentation that the agency gathered or reviewed quality indicator data to show measurable improvement as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacking evidence of the QAPI committee’s analysis and review of indicators to show improvement or decline of data tracking. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency-wide specific QAPI program in relation to tracking quality indicators and showing the tracking of improvement and analysis of the data, Administrator A replied, “It’s a broad layout. I have no more detail.””

“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 record review and interview, this agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program that utilized quality indicator data, such as OASIS (Outcome and Assessment Information Set) in the design of its program in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 3. The agency must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program.” Record review of QAPI binder contents revealed no documentation that the agency collected and reviewed QASIS quality indicator as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI committee’s review of OASIS outcome data as part of their data analysis and tracking. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program in relation to OASIS data tracking, Administrator A replied, “It’s a broad layout. I have no more detail. The clinical manager does OASIS audits and reviews.” When discussed that the QAPI binder does not contain OASIS data as part of the quality indicator data collection, Administrator A replied, “We don’t have current reports in Brightree (software system utilized by the agency) for OASIS but we are looking at software for analytics to pull that information. We don’t review that data now as it’s old.””

“Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA’s performance improvement activities must-- This Standard is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program included performance improvement activities in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 6. The agency’s performance improvement activities will: Focus on high risk, high volume, and problem-prone areas; Consider incidence, prevalence, and severity of problems in those areas; lead to an immediate corrective action of any identified problem. 7. Performance improvement activities must track adverse patient events, analyze their causes and implement preventative actions.” Record review of QAPI binder contents revealed no documentation that the agency tracked performance improvement activities as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI committee’s review of tracking performance improvement activities. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program and no evidence in the QAPI binder in relation to tracking performance improvement activities, Administrator A replied, “It’s a broad layout. I have no more detail.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program conducted performance improvement projects in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 7. Performance improvement activities must track adverse patient events, analyze their causes and implement preventative actions.” Record review of QAPI binder contents revealed no documentation that the agency conducted performance improvement projects as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI performance improvement projects. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program that directed by the Governing Body, provides direction of setting priorities to implement Performance Improvement Projects, Administrator A replied, “I want to say that we do, but not 100%. I will look through my notes to see.” During an interview on 02/13/2024 at 12:50 PM, Administrator A stated, “I don’t have anything specific in terms of a project part. We do education and review data but that is it.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program that had continued oversight by the Governing Body in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Responsibility/Accountability: 1. The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented, and maintained. 2. Administrative responsibility for the QAPI plan is delegated to the Administrator/Director of Clinical Services, who, in turn, assigns certain QAPI activities to other staff members. Additional requirements: 1. The agency will prepare an annual, comprehensive report that describes the QAPI activities, findings, and corrective actions that relate to care/services provided.” Record review of QAPI binder revealed no documentation that the Governing Body provided oversight on the implementation, maintenance, and evaluation of the overall QAPI program. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about documented evidence that the agency has a quality program directed by the Governing Body provides direction of setting priorities for data collection for the agency wide QAPI program, Administrator A replied, “I want to say that we do, but not 100%. I will look through my notes to see.” During an interview with Administrator A on 02/13/2024 at 12:50 PM, when asked about the overall Governing Body have an overall oversight and direction for the QAPI program and evidence of this, Administrator A replied, “I don’t have anything more. We definitely have misses. “”

“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, observation, and interview, agency staff failed to ensure patient medication orders were accurately recorded on the agency medication list as compared to what patients are taking in 2 of 3 home visits observed (Patients #3 and #6) in a total of 11 patient records reviewed. A home visit for Patient #6 was conducted at the patient’s residence on 02/13/2024 from 10:00 AM - 11:00 AM. During the home visit, observed RN (Registered Nurse) C discuss medications with Patient #6. The medication list contained the following medications: “Accu-check guide strips-stick; Inject 1 application intramuscularly. Lantiseptic – topical ointment; apply topically four times a day to protect skin. Zinc oxide topical 20% topical ointment; apply topically thin layer bid (twice daily) to pressure ulcer on buttocks.” During an interview with Patient #6 on 02/13/2024 at 10:50 AM, when asked about Accu-check, Lantiseptic and Zinc oxide and if these medications Patient #1 had been taking/using at this time, Patient #6 replied “I’m no longer using them.” During an interview with RN C on 02/13/2024 at 10:55 AM, when asked about the discrepancy of the agency’s plan of care medication list and the agency’s current medication list for Patient #6, C confirmed “Yes, the list is not current.” Findings were reviewed with Administrator A on 02/13/2024 at 2:30 PM for Patient #3 and #6. When asked what the expectation is for medication review and having an accurate medication profile, Administrator A replied, “The case manager should reconcile medications every visit.” Findings include: Review of agency policy and procedure titled “Medication Profile” (not dated) revealed “Procedure: 2. The admitting RN (Registered Nurse), PT (Physical Therapist) and SLP (Speech Language Pathologist) checks all medications a patient may be taking and documents on the medication profile. 4. The nurse or therapist will add all new/changed medications to the medication profile. Discontinued medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur. 5. When SN (Skilled Nursing) is ordered, the RN reviews the medications with the patient on an ongoing basis to ensure the understanding of medication use. 7. When therapy services only are ordered, any new/changed medications will be reflected on the CMS (Center for Medicare or Medicaid Services) POC (Plan of Care) orders and the medication profile updated at this time. Record review of Patient #3’s “Home Health Care Certification and POC” dated 12/13/2023 to 02/10/2024 revealed Patient #3 was admitted to this agency on 06/16/2023 with a primary diagnosis of Neurocognitive disorder with Lewy bodies and resided with Patient #3’s daughter. In December of 2023, Patient #3 moved to an ALF (Assisted Living Facility). Prior to home visit observation with OT (Occupational Therapist) B for Patient #3 on 02/12/2024 at 4:40 PM, OT B obtained a current medication list from the ALF staff. During a home visit observation with OT (Occupational Therapist) B for Patient #3 at the ALF in which the patient resides on 02/12/2024 from 4:40 PM to 5:15 PM, observed OT B ask Patient #3’s caregiver, Caregiver F, if there was any changes in medications. Caregiver F replied, “No.” Record review of Patient #3’s home health medication profile dated 02/12/2024 as compared to the ALF’s MAR (Medcation Administration Record) dated February 2024 revealed the following medication order discrepancies: -Home Health order revealed, “Acetaminophen 325mg (milligram) oral tablet. Take 2 tablets 4 to 6 hours as needed for mild pain. Start 06/12/2023.” ALF order revealed, “Acetaminophen 325mg oral 2 tablets by mouth once daily at bedtime. Start 01/18/2024.” There was a discrepancy in the frequency for this medication. -Home Health order revealed, “Carbidopa-Levodopa 25/100 mg. Take 1 tablet 3 times a day; 2 tablets in the morning, 1 tablet in the afternoon, and 1 tablet in the evening. Start 06/16/2023.” ALF order revealed, “Carbidopa-Levodopa 25/100 mg. Take 1 and 1/2 tablets once daily in morning, 1 tablet at 1 PM and 1 tablet at 6 PM. Take 1/2 tablet by mouth 3 times daily with scheduled dose as needed. Start 01/17/2024.” There was a discrepancy in the dose for this medication. -Home Health order revealed, “Fluticasone 50 mcg (micrograms) inhalation powder. Inhale 1 puff inhaled 2 times a day. Start 06/16/2023.” ALF orders revealed, “Fluticasone 50 mcg (micrograms). Instill 1 spray into each nostril once daily at bedtime. Start 12/20/2023.” There was a discrepancy in the frequency and route for this medication. -ALF orders revealed, “Magnesium 400mg take 1 tablet by mouth once daily. Preservision Softgel take 1 capsule by mouth once daily. Sertraline 50mg take 1 tablet by mouth once daily. Tab-A-Vite Advanced Multivitamin take 1 tablet by mouth twice weekly on Tuesday and Thursday. Vitamin B-12 1,000mcg take 1 tablet by mouth once daily. Acetaminophen 500mg tablet take 1 tablet by mouth every 6 hours as needed for pain or fever.” The home health medication profile for Patient #3 did not contain orders for Magnesium, Preservision, Sertraline, Tab-A-Vite Advanced Multivitamin, Vitamin B-12 and Acetaminophen 500mg. During an interview with OT B on 02/12/2024 at 5:15 PM at the end of the home visit, when asked about medication discrepancies comparing the ALF and home health agency list, OT B replied, “Yes, I saw that too.” When asked who is responsible for medication review, OT B replied, “If the nurse is involved in the case, it’s the nurse. If not, it should be me and I should review or the PT. We just had a meeting about this too.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, agency staff failed to develop Plans of Care (POC) that were individualized to meet the specific needs of the patients and/or develop goals that were measurable within a specified timeframe and/or individualized in 7 of 11 patients (Patients #1, #2, #5, #6, #8, #9, and #11) records reviewed. Review of document for Patient #6 titled “Home Health Certification and Plan of Care” dated 12/17/2023- 02/14/2024 revealed in part, “Patient #6’s start of care date: 04/21/2023 with a Primary Diagnosis of Chronic myelomonocytic leukemia. Goals: Patient/caregiver can describe measures to reduce/prevent fatigue; Target Date: 03/01/2023. Patient/caregiver will demonstrate understanding of appropriate use of medications for pain and symptom management. Target Date 03/01/2024. Patient/Caregiver will verbalize understanding and adhere to measure to maintain adequate nutrition/hydration. Target Date: 03/01/2024.” The Plan of Care goals were not measurable or individualized to meet the patient’s need. A home visit for Patient #6 was conducted at patient’s residence on 02/13/2024. During the home visit, observed RN C assess for Nausea, Patient #6’s current, worst, and acceptable level of pain. Mental Health, Weakness, and Falls. The Plan of Care dated 12/17/2023-02/14/2024 did not contain goals or interventions for these assessments. Review of document for Patient #8 titled “Home Health Certification and Plan of Care” dated 08/15/2023-10/13/2023 revealed in part, “Patient #8’s start of care date: 08/15/2023 with a Primary Diagnosis of Multiple Myeloma. Goals: Patient’s cardiovascular status is stable; Target Date: 10/13/2023. Patient/caregiver able to identify sign/symptom to report to MD (medical doctor); action to take; Target Date: 10/13/2023. Patient will be pain free or verbalize and acceptable level with current pain management regimen; Target Date: 10/13/2023. Patient/caregiver will verbalize understanding of pain management regimen; Target Date: 10/13/2023.” The Plan of Care goals were not measurable or individualized to meet the patient’s need. Review of document for Patient #9 titled “Home Health Certification and Plan of Care” dated 09/25/2023-11/23/2023 revealed in part “Patient #9’s start of care date: 09/25/2023 with a Primary Diagnosis of Type 2 Diabetes with Foot Ulcer. Goals: Patient/caregiver monitors patient’s weight and weight changes and reports to clinician; Target Date: 11/27/2023. Patient maintains vital signs within baseline range; Target Date 11/27/2023. Patient/caregiver will verbalize understanding of falls/injury preventions and home safety measures; Target Date: 11/27/2023. Patient/caregiver will verbalize understanding and demonstrates proper foot care; Target Date: 11/27/2023. Patient free of any sign/symptom of infection; Target Date: 11/26/2023. The Plan of Care goals were not measurable or individualized to meet the patient’s need. Review of document for Patient #11 titled “Home Health Certification and Plan of Care” dated 01/02/2024-03/01/2024 revealed in part “Patient #11’s start of care date: 01/02/2024 with a Primary Diagnosis of Pneumonia, Hypertension, and kidney disease. Goals: Patient/caregiver understands and adheres to prescribed low sodium diet; Target Date: 03/19/2024. Patient’s symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow; Target Date: 03/19/2024. The Plan of Care goals were not measurable or individualized to meet the patient’s need. During an interview with Administrator A on 02/13/2024 at 2:32 PM, when asked about the expectation for patients having goals with vital sign parameters on the plan of care Administrator A stated, “we should not see any goal on the plan of care related to vital signs unless the MD specifically orders set parameters. We have had staff education on this.” Administrator A was asked the expectation of nursing assessments and if the nurse assesses a problem would we expect to see an intervention and goal for that assessment. Administrator A stated, “Yes.” During an interview with Administrator A on 02/13/2024 at 2:50 PM, when the above findings for Patients #1, #2, #5, #6, #8, #9, and #11 were reviewed, and when asked if the patient POCs were generic and if clinicians are able to edit care plans in the documentation system, Administrator A replied, “They do have the choice of picking and choosing what they want in the care plan. We educated previously. They are too broad of care plans.” Findings include: Review of agency policy and procedure titled “POC-CMS (Center for Medicare and Medicaid Services) and Physician Orders” (not dated) revealed “Procedure: 2. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care. 3. Patient-specific goals must be individualized to the patient based on the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input. Progress/non-progress toward achieving the goals is evaluated through measurable outcomes.” Record review of Patient #1’s “Home Health Certification and Plan of Care” dated 11/25/2023 - 01/23/2024 revealed in part, “Patient #1 start of care date: 09/26/2023 with a Primary Diagnosis of Essential (primary) hypertension. Order/Treatments: SN Interventions: SN (Skilled Nurse): Teach regarding compliance with hypertension treatment regime. SN Goals: Patient/caregiver will demonstrate compliance with treatment regimen; Target Date: 11/27/2023. Aide Interventions: Elimination, Home Management, Hygiene, Vital signs. Goals: Patient’s personal care needs will be met; Target Date: 11/27/2023” The SN POC goals and interventions were not measurable or individualized to meet the patient’s need related to hypertension. The Aide POC goals were not measurable and individualized to meet the patient’s needs, however record review of certification period 11/25/2023 - 01/23/2024 revealed no aide visits were made during that timeframe. Record findings for Patient #1 were reviewed during an interview with Administrator A on 02/13/2024 at 1:55 PM. When asked about the accuracy of Patient #1’s POC versus if aide visits were conducted during the certification period 11/25/2023 - 01/23/2024, Administrator A replied, “The Aide was discontinued. The Aide care plan should have been resolved and wasn’t.” Patient #1’s POC was not accurate and specific to the patient needs during that certification period. Record review of Patient #2’s “Home Health Certification and Plan of Care” dated 01/03/2024 - 03/02/2024 revealed in part, “Patient #2 start of care date: 09/05/2023 with a Primary Diagnosis of Chronic Obstructive Pulmonary Disease, unspecified. Order/Treatments: SN Interventions: Prepour/set-up medications until patient is independent with medication setup or other resources to assist with medication setup. SN Goals: Patient/caregiver will demonstrate medication compliance with use of pill reminder; Target Date: 03/03/2024.” Record review of Patient #2’s SN visit documentation dated 01/02/2024 revealed “60 Day Summary: Ongoing management setup/effectiveness and cardiopulmonary assessment and education.” Patient #2’s POC was not individualized to meet the patient’s needs and lacked goals that were measurable as related to identified cardiopulmonary needs. Record review of Patient #5’s “Home Health Certification and Plan of Care” dated 12/25/2023 - 02/22/2024 revealed in part, “Patient #5 start of care date: 10/31/2022 with a Primary Diagnosis of Pressure Ulcer of other site stage 3. Order/Treatments: SN Interventions: Assess for skin excoriations, breakdown, friction, shearing, or pressure areas. Assess skin integrity and overall skin condition. SN Goals: Patient/caregiver can describe/demonstrate measures to improve/maintain skin integrity. Patient/caregiver can describe interventions to prevent skin breakdown. Skin integrity will be maintained and problems managed as disease process will allow. Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. Target Date: 02/27/2024” The SN POC goals and interventions were not measurable or individualized to meet the patient’s specific needs related to Patient #5’s pressure wounds.”

“High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This Element is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program focused on high risk, high volume, or problem-prone areas in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 6. The agency’s performance improvement activities will: Focus on high risk, high volume, and problem-prone areas.” Record review of QAPI binder contents revealed no documentation that the agency focused on high risk, high volume, or problem prone areas as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI committee’s review that focused on high risk, high volume, or problem prone areas. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program and no evidence in the QAPI binder related to performance improvement, Administrator A replied, “It’s a broad layout. I have no more detail.””

“Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This Element is not met as evidenced by: Based on record review and interview, this agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program included incidence, prevalence, and severity of problems in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 6. The agency’s performance improvement activities will: Consider incidence, prevalence, and severity of problems in those areas.” Record review of QAPI binder contents revealed no documentation that the agency included incidence, prevalence, and severity as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI committee’s review that focused on incidence, prevalence and severity. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program and no evidence in the QAPI binder in relation to tracking performance improvement, Administrator A replied, “It’s a broad layout. I have no more detail.””

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on record review and interview, this agency failed to ensure a QAPI (Quality Assessment Performance Improvement) program measured success and tracked performance to ensure sustainability in 1 of 1 QAPI programs reviewed. Findings include: Record review of agency policy and procedure titled “QAPI Plan and Program” (not dated) revealed “Program Scope: 8. Agency must take actions aimed at performance improvement and, after implementing these actions, must measure its success and track performance to ensure that improvements are sustained.” Record review of QAPI binder contents revealed no documentation that the agency measured success and tracked performance to ensure sustainability as part of the QAPI program as listed per policy. Record review of QAPI meeting minutes dated 04/13/2023, 07/14/2023, 10/27/2023, and 01/19/2024 revealed “Discussion Points: Infection Control, Falls, Med Error, Rehospitalizations, 5 Star, and Grievances” and lacked evidence of the QAPI committee’s review that measured success and tracked performance to ensure sustainability. During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked about agency wide specific QAPI program and no evidence in the QAPI binder in relation to tracking performance improvement activities, Administrator A replied, “It’s a broad layout. I have no more detail.””

“Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA’s request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ascertain that the secondary location as different from the parent location in which patient care was provided out of, was identified as a branch, subunit or drop-site location in 1 of 1 Home Health agency’s reviewed. Findings include: Record review of this agency’s “Home Health Agency Annual Report-2023” dated 07/06/2023 revealed location of “Transitions Home Health of Central Wisconsin, 4949 Kirschling Court, Suite 2, Stevens Point, WI 54481” and no other identified locations or branch locations. During an interview with Administrator A on 02/12/2024 at 10:10 AM, when asked about any branch locations, Administrator A replied, “Yes, we have a branch in Spooner, WI. We’ve had it since October 2023.” When asked if it was ever reported to the State Agency that this agency had a branch, Administrator A replied, “No, but I would maybe have to check. I contacted the licensing department to add counties. We added Barron, Rusk, and Bayfield county. But I will check with Director of Operations D.” Record review of email correspondance with licensing department on 02/12/2024 at 10:39 AM revealed, “No record of a branch in Spooner for this home health agency. They did contact me to add Barron, Rusk, and Bayfield counties to their license on August 1, 2023.” During an interview with Administrator A on 02/12/2024 at 12:00 PM: When asked if it could be explained about the administrative oversight and operations of the Spooner location, Administrator A replied, “I am the Administrator of both Stevens Point and the Spooner area. I probably misspoke. It is not a branch, just an office location. I have a clinical manager, Clinical Manager E, out of this location.” When asked what kind of staffing works out of that office, Administrator A replied, “We are staffed for that location, and have nursing, therapy and an aide.” When asked about patient care, after hours, on-call, and call expectations, Administrator A replied, “When on-call, there is an RN (Registered Nurse) for all counties over the phone. There is an RN in the Spooner location specifically. All nurses triage phone call, then make a visit or advise the patient to go to the ER (Emergency Room). There is no expectation or specific policy on timeframes to conduct a visit.” When asked about the supervision and management of staff, Administrator A replied, “We do weekly Zoom calls to touch base on patients. We supervise them and do evaluations from the Stevens Point location. Record review of current employee list received 02/12/2024 revealed a section of employees for Central location and a section of employees for Spooner location. The Spooner employe list revealed the following: “1 Administrative full time, 1 Intake full time, 2 RNs full time, 1 Physical Therapist (PT) Assistant full time, 1 PT part time, 2 PTs as needed, 1 Occupational Therapist as needed, 1 Aide part time.” During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked what date by which Transitions Home Health started operating an office out of the Spooner location, Administrator A replied, “The Clinical Manager (Clinical Manager E) has used that office since day of hire which was 07/27/2021. Clinical Manager E was hired specifically for that area. It only serviced 1 county at that point. The Administrator would go back and forth. As the census increased, there was a need for administrative presence up there to direct them more.” During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked that if this location was not reported as a branch, was it ever considered to notify the State Agency of a new location for operation, Administrator A replied, “It wasn’t specified that we wanted to open a branch.” During an interview with Administrator A on 02/13/2024 at 12:15 PM, when asked what the current patient census is in the Spooner location, Administrator A replied, “Approximately 33 patients.” During an interview with Administrator A on 02/13/2024 at 12:15 PM, discussed the definitions of a “drop-site” location versus a “branch” location as indicated in the “State Operations Manual, Chapter 2- The Certification Process, dated 03/11/2022” pages 127 to 137. During the interview, reviewed that this agency’s operations out of the Spooner location would not meet the “drop-site” definition, and that this agency may or may not meet the definition of a “branch” location. Administrator A replied, “I agree.””