Every finding on record at Anderson Hospital

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 4/30/2025. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 4/30/2025. The Agency was not in compliance with 42 CFR 484, Standards for Home Health Agencies, for this survey. Abbreviations: Employee = E Patient = Pt Start of Care = SOC Plan of Care = POC Number = #

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 document review and staff interview, it was determined that 3 of 13 (Pt #1, Pt #4, and Pt #11) patients' records reviewed, the Agency failed to ensure the initial assessment was conducted within 48 hours of referral. Findings include: 1. Pt #1 SOC: 4/3/2025 Diagnosis: Hypertensive heart and chronic kidney disease. On 4/28/2025 at approximately 11:00 AM the clinical record of Pt #1 was reviewed. Pt #1 was referred to the Home Health Agency (HHA) on 3/25/2025. The initial assessment was conducted 4/3/2025, 8 days after the referral. There was no physician order changing the start of care date. 2. Pt #4 SOC: 4/15/2025 Diagnosis: Streptococcal arthritis right knee, status post incision and drain. On 4/29/2025 at approximately 2:30 PM, the clinical record of Pt #4 was reviewed. Pt #4 was referred to the HHA on 4/8/2025. The initial assessment was conducted on 4/15/2025, 7 days after the referral. There was no physician order changing the start of care date. 3. Pt #11 SOC: 3/12/2025 Diagnosis: Interstitial pulmonary disease. On 4/30/2025 at approximately 10:30 AM, the clinical record of Pt #11 was reviewed. Pt #11 was referred to the HHA on 2/28/2025. The initial assessment was conducted on 3/12/2025, 12 days after the referral. There was no physician order changing the start of care date. 4. On 4/28/2025 at approximately 3:30 PM, an interview with the Clinical Manager (E #2) was conducted. E #2 reviewed the records of Pt #1, Pt #4, and Pt #11. E #2 verbally confirmed the initial assessments were conducted more that 48 hours after the referral. E #2 stated, “Yes, they are past the 48-hour requirement.” 5. On 4/30/2025 at approximately 11:30 AM, an interview with the Director (E #1) was conducted. While discussing the referral policy, E #1 stated, “We left the 48-hour referral requirement out of our policy because it’s a home health wide rule for patients to be seen within 48 hours. When providers call us, we will tell them that we may not be able to see the patient for 7 to 10 days. The providers are ok with that, but we need to improve our documentation if the patient is going to have a delayed start of care.”

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 5/18/22. The Agency was not in compliance with the 42 CFR 484.102 Establishment of the Emergency Program, as evidenced by: Abbreviations: E employee EPP Emergency Preparedness Plan HHA Home Health Agency

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), §485.625(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 a request for documents, document review and staff interview, it was determined the home health agency (HHA) failed to develop and implement policies and procedures based on the home health's specific emergency plan, hazard risk assessment and communication plan. This failure has the potential to affect all home health staff (currently 22) and patients (currently 85). Findings include: 1. A request for the HHA's emergency preparedness policies and procedures was made to the clinical manager (E#1) on 5/16/22 at approximately 11:00 AM. Policies for the communication plan, volunteers and staffing and hazard risk assessment were provided. 2. A review of additional policies and procedures was completed on 5/16 and 5/17/22. The policies were those addressing the hospital system procedures and did not specify the involvement of the home health. No additional policies or procedures were provided. 3. In an interview with E#1 on 5/17/22 at 2:30 PM, E#1 reported the person in charge of the emergency plan at the hospital is responsible to assist the HHA in areas related emergency situations. E#1 confirmed there are no other policies she is aware of to provide.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a request for training documents, document review and staff interview, it was determined the HHA failed to ensure all staff were included in emergency preparedness training exercises and demonstrated related competencies. This failure has the potential to affect all staff (22) and patients (86). Findings include: 1. A request for documentation of staff involvement in training exercises related to the emergency preparedness plan was made to E#1 on 5/16/22 at approximately 11:00 AM. No documentation was provided to show any staff had been involved in a actual or simulated emergency situation. A request for documentation to indicate staff competencies related to emergency preparedness training was also made. There was no documentation of competencies related to staff understanding of their roles in emergency situation(s). 2. A review of the only documentation provided was for COVID training. The review was completed on 5/17/22 at 2:00 PM. The documentation included an agenda and highlights but failed to show who was trained or ensure understanding and competency. 3. An interview was conducted with E#1 at the time of the document review. E#1 pointed out the training materials for COVID and an agenda but reported there was no list of staff in attendance and no evidence of competency. E#1 confirmed there was no other documentation of staff being involved in training exercises or active training other than the electronic learning materials. E#1 confirmed these are completed by staff on their own and no competencies are included.

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on a request for documents, document review and staff interview, it was determined the health system, which includes the home health as a part of their facilities, failed to demonstrate the home health agency (HHA) was included in the emergency preparedness plan (EPP) as separate related to patient population and unique circumstances, and failed to involve the HHA in development of specific EPP policies, and in training and testing. This failure has the potential to affect all staff (22) and all patients (currently 85). Findings include: 1. A request for the HHA's emergency preparedness plan (EPP) was made to the clinical manger (E#1) on 5/16/22 at approximately 11:00 AM. 2. A review of the documents provided by E#1 and E#2 (chief nursing officer of Anderson Hospital) on 5/17/22 at 1:30 PM were completed. The EPP failed to include any verbiage related to the home health patients, staff or unique circumstances. Policies reviewed were also detailed for the hospital but did not include the HHA. The training and testing also failed to include the HHA staff was trained in their specific policies or included in the testing, either tabletop or active. 3. An interview was conducted with E#1 on 5/17/22 at 4:00 PM. E#1 agreed there were no other documents to be provided which included the HHA as an integrated part of the hospital system's EPP.

A recertification survey was conducted on 5/18/22. The Agency was not in compliance with the Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E employee OT occupational therapy Pt patient PT physical therapy RN registered nurse # number

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, document review and staff interview, it was determined in 1 of 5 (Pt #4) home visits observed, the Agency failed to ensure medication discrepancies were reported to physician per policy. This failure has the potential to affect all patients receiving home health services-current census 85. Findings include: 1. On 5/17/22 at 11:00 AM, a home visit was conducted with occupational therapy (OT) with Pt #4. During the medication review, Pt #4 stated, "the zofran (anti-nausea) was making me sick to my stomach and I vomited after taking it." Pt #4's daughter stated, "the pharmacist recommended dramamine (anti-nausea medication), so we started giving it." The OT also noted a bottle of D2 and D3 vitamins in the medication collection. The OT verbalized the nurse was coming later and she would notify her of discrepancies. 2. The clinical record of Pt #4 was reviewed on 5/17/22. Pt #4 was admitted for services on 5/4/22 with diagnosis of displaced intertrochanter fracture left femur. Pt #4 was receiving skilled nurse, OT and physical therapy (PT) services. 3. On 5/18/22 at 11:00 AM, the OT visit note 5/17/22 at 10:57 AM of Pt #4 was reviewed. Documentation under "Assess Medication Reconciliation Note: Reviewed current medication with patient and instructed on proper dosage and administration. Patient voiced understanding of instruction." There was no documentation to indicate the OT notified the registered nurse (RN) or the physician of medication changes. On 5/18/22 at 1:28 PM, the RN visit note was reviewed. Documentation under "Assess Medication Reconciliation Note: Medication list reconciled with meds found in home. Dramamine updated per therapy. Patient admits to also taking previously prescribed 50 mg of Tramadol q 6 hours PRN for pain. To be added to med list". There was no documentation to indicate the RN reconciled the Vitamin D2 or D3 medication. There was no documentation to indicate the physician was notified of these discrepancies. 4. On 5/18/22 at 11:00 AM, the policy dated, 10/25/20, titled, "Medication Management, Home Health" was reviewed. The policy under "Guidelines/Procedures: M. The reconciled medication list and any discrepancies identified are communicated to the physician (s) managing the care at time points listed above or any other time during the course of care deemed necessary. If clarification of medication order is needed from the ordering or managing physician it can be accomplished by phone or fax". 5. On 5/18/22 at 11:15 AM, an interview was conducted with the clinical manager (E#1). E#1 reviewed the OT and RN notes for Pt #4 and confirmed that the medication discrepancies were not reported to the physician. E#1 also confirmed the documentation was lacked communication between the OT and RN of medication discrepancies.