Every finding on record at Bridges Home Health, Inc.

42 CFR Part 484 Home Health Care The facility must meet all local, Federal and state emergency preparedness requirements as outlined in the Medicare and Medicaid programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. Deficiencies were noted at the time the survey was conducted on December 9-December 12, 2024.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview, review of facility policies and procedures and review of patient medical records, it has been determined the Administrator failed to ensure that patient individualized emergency plans were developed, included as part of the patient assessment, and documented in the patient's medical record. Failure to assist patients with developing individualized emergency plans as part of a comprehensive patient assessment as part of a facility's emergency management strategy can result in patients and facilities not being prepared at the time of an emergency event, leading to an increased likelihood of injury or death. Findings include: Facility policy titled, "...Emergency Operations Plan and Policies...." reviewed May 5, 2023 revealed: "...Mitigation activities...will be undertaken in an effort to lessen the severity and impact of a potential emergency. Such activities include...The plans for patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment...Developing an individual emergency preparedness plan for each patient as part of the comprehensive assessment...Individual patient preparation: prioritizing patients who might require care/service during emergency and advanced planning for extra supplies, equipment, medications, food and home evacuation...." The policy notes there are "...Related Documents...." including "...Individual Patient Emergency Preparedness Plan...." which was attached to the policy. At the bottom of the Individual Patient Emergency Preparedness Plan is indicated: "...*Copy to patient and original on medical record...." Bridges Home Health Emergency Preparedness Plan and All-Hazard Emergency Preparedness Policy, reviewed January 8, 2024 revealed: "...*On admission, the admitting nurse will assign each patient a priority code...Education of Patients Prior to an Emergency...The procedure for educating patients and patient caregivers about the home health's comprehensive emergency management plan are found in the emergency management policy. This instruction will be documented by the Admission Nurse in the initial and comprehensive assessment section of the electronic health record...." A review of 10 patient medical records was conducted. Although priority codes were found to be assigned to each patient, no individual emergency preparedness plans could be found. In an interview conducted with Employee #1 on December 11, 2024, Employee #1 confirmed that individualized emergency preparedness plans should be completed according to facility policies and procedures. Employee #1 stated that the hard copy of the completed individualized emergency preparedness plan should be left with the patient and scanned into the facility's Google drive; also, the individualized emergency preparedness plan contents should be entered into the gray drop box in the comprehensive assessment. In an interview conducted with Employee #1 on D

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the Administrator failed to ensure the facility had a strategy and ability to provide emergency preparedness officials needed information about patients to facilitate emergency evacuation and transportation. Failure to develop and maintain a strategy to inform emergency preparedness officials of needed information in the event of emergency evacuation can result in patients not having their need for evacuation or transportation met in an emergency, resulting in injury or death. Findings include: Facility policy titled, "...Emergency Operations Plan and Policies...." reviewed May 5, 2023 revealed: "...The agency will maintain at all times a current list of patients who might need evacuation....On an ongoing basis, staff will evaluate/assess such factors as transportation, evacuation and patient's medical and/or psychiatric condition and home environment...." Bridges Home Health Emergency Preparedness Plan and All-Hazard Emergency Preparedness Policy, reviewed January 8, 2024 revealed: "...Every nurse will maintain a current list of patients that includes address and phone number...Emergency Supervisor Tasks...Each month (or at changes to the list), members of the Leadership Team will get an updated copy of the emergency list and keep it at home for reference if an emergency occurs after hours, or if the Agency office is damaged or destroyed...." A patient census report printed on 12/09/2024 at 1:21 p.m. was found in the Emergency Preparedness binder. In an interview conducted with Employee #1 on December 11, 2024, Employee #1 stated that both electronic and paper copies of patient contact lists should be maintained according to facility policies and procedures and the paper lists are printed on payroll days. Additionally, Employee #1 stated the patient contact lists were maintained on two USB drives in the event of a power failure. Employee #1 was asked if a USB drive could be reviewed; however, Employee #1 stated that Employee #1 was in possession of one of these USB drives and Employee #1 was currently not in the country. Employee #1 did not know where the other USB drive was. Employee #2 searched the office for the USB drive but it could not be found. Employee #2 called Employee #3 who was last in possession of the USB drive and has not been in the office since October 2024. Employee #3 confirmed the USB drive was in the office; however, it could not be accessed by anyone because it was locked in a filing cabinet designated for the personal use of Employee #3 and only Employee #3 had a key to the filing cabinet.

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, review of facility policies and procedures, review of facility documentation and review of facility personnel files, it has been determined the Administrator has failed to create, implement and document a training program for emergency preparedness and has failed to create, implement and document a testing program for emergency preparedness. Failure to create, implement and document training and testing programs for emergency preparedness can result in a staff that is unfamiliar with the emergency preparedness plan and a plan that does not meet the needs of the facility. Findings include: Facility policy titled, "...Emergency Operations Plan (EOP) Training Program...." reviewed May 5, 2023 revealed: "...The Agency has developed and maintains an emergency preparedness program that is based on the EOP, risk assessment, policies and procedures and the communication plan...Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies that occurred in the last two years and during review of the emergency operations plan every two years...Additional training is required when the EOP is significantly updated...Maintain documentation of the training...." Facility policy titled, "...Testing Program for Emergency Operations Plan (EOP)...." reviewed May 5, 2023 revealed: "...The Agency will conduct one exercise to test the EOP at least biennially...Exercises will incorporate likely disaster scenarios that allow the Agency to assess its handling of communications, resources and assets, staff and patients...Exercises must sufficiently stress Agency's plan to identify weaknesses. Exercises must activate and test...Patient acuity assignment and tracking procedures...Key care processes consistent with planned response activities: management of medications, medical equipment and supplies, instructions for self-evacuation, medical record documentation and coordination of information with alternative care site...." Bridges Home Health Emergency Preparedness Plan and All-Hazard Emergency Preparedness Policy, reviewed January 8, 2024 revealed: "...Agency staff members will participate in an annual drill to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster...." A curriculum was requested for Emergency Preparedness training but a curriculum could not be provided. In an interview conducted with Employee #1 on December 11, 2024, Employee #1 stated, "The Plan is the curriculum." Documentation of Fire/Evacuation Drills was found in requested personnel files as well as in the Emergency Preparedness binders; however, no description of the exercises were provided.

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), §485.542(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, REHs at §485.542, "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 interview, review of facility policies and procedures and review of facility personnel files, it has been determined the Administrator failed to ensure each personnel member has been trained at hire and at least every two (2) years in emergency preparedness policies and procedures. Failure to ensure staff are trained both at hire and at least biennially on facility emergency preparedness policies and procedures can result in staff being unprepared in an emergency event, leading to increased likelihood of staff and patient injury or death. Findings include: Facility policy titled, "...Emergency Operations Plan (EOP) Training Program...." reviewed May 5, 2023 revealed: "...The Agency will do the following...Provide initial training in emergency preparedness policies and procedures to all new and existing staff...Provide emergency preparedness training at least every two years...Maintain documentation of the training...Demonstrate staff knowledge of emergency procedures...." A staff list was requested and provided which indicated the facility has twenty-two (22) staff, seventeen (17) currently in active service. Ten (10) personnel files were requested for review. Of the ten files requested, six (6) were provided. Of these six files, only two (2) had documentation of Emergency Preparedness training. In an interview conducted with Employee #1 on December 11, 2024, Employee #1 verified that documentation of Emergency Preparedness training provided initially and at least biennially should be found, if not in the personnel files, then in the Emergency Preparedness binder. A review of the Emergency Preparedness binder revealed the presence of employee training in emergency preparedness for six (6) current employees Employee #2: Date of Hire (DOH) 09/26/2022: 06/30/2023 Biennial 06/03/2024 Biennial Employee #3: DOH 11/21/2023 06/03/2024 Biennial Employee #4 (inactive) DOH 05/20/2023 06/03/2024 Biennial Employee #5 DOH 03/22/2023 06/30/2023 Biennial 06/03/2024 Biennial Employee #6 DOH 9/01/2022 6/1/2023 Biennial Employee #7 DOH 9/9/2023 6/1/2023 Biennial Employee #8 Date of Hire: 04/22/2023 6/1/2023 Initial

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, review of facility policies and procedures, and review of facility documentation, it has been determined the Administrator failed to ensure that a full-scale drill was conducted at least every two years followed by either a subsequent full-scale drill the following year, or else a community-based drill, functional drill, mock disaster drill, tabletop drill or real-life emergency that required activation of the facility emergency preparedness plan. Failure to adequately test and document the testing of the emergency preparedness plan can result in the facility having a plan that is not actionable or practicable in a real-life disaster event, leading to increased likelihood of staff and patient injury or death. Findings include: Facility policy titled, "...Testing Program for Emergency Operations Plan (EOP)...." reviewed May 5, 2023 revealed: "...The Agency will conduct one exercise to test the EOP at least biennially. The Agency will do the following...Participate in a full-scale exercise (if available) that is community-based or when a community-based exercise is not accessible, an individual, facility-based functional exercise...A full-scale exercise is a multi-agency...exercise...A facility-based functional exercise may include...Mock disaster drill or workshop...A tabletop exercise that includes a group discussion led by a facilitator...Analyze the Agency's response to and maintain documentation of all drills, tabletop exercises and emergency events...Evaluation will include the identification of deficiencies and opportunities for improvement..." Bridges Home Health Emergency Preparedness Plan and All-Hazard Emergency Preparedness Policy, reviewed January 8, 2024 revealed: "...Agency staff members will participate in an annual drill to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster...." "...Bridges In-Service Sign-In Sheet Fire Drill/Evacuation Drill...." was found dated June 1, 2023 and June 3, 2024. The In-Service sign-in sheet dated June 1, 2023 was signed by five (5) employees. Curriculum or a description of the drill completed was requested but could not be provided. "...Emergency Operations Plan Evaluation/Analysis...." was attached to the sign-in sheet. The description of the drill was "tabletop" and "Fire Drill and Evacuation Drill." No further detail was provided. No recommendations were made. The In-service for June 1, 2024 did not have any attachments. No curriculum or description of the drill completed could be provided other than the description at the top of the sign-in sheet of "Fire Drill/Evacuation Drill." Documentation of drills completed in 2022 could not be found in the Emergency Preparedness binder.

The following deficiencies were cited during the unannounced onsite Medicare Recertification survey conducted December 9, 2024 through December 12, 2024. The facility is not in compliance with 42 CFR Part 484 subparts A, B, and C requirements for a Home Health Agency. Three (3) home visits were conducted during the survey. Appendix Z, Emergency Preparedness was surveyed at the time of the Medicare Recertification, deficiencies were cited.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: The home health agency must ensure patients receive written notice of the patient's rights and responsibilities as well as the transfer and discharge policies of the HHA . This STANDARD is NOT MET as evidenced by: Based on review of facility documentation, and interview, the Department has determined the home health agency failed to ensure patients receive written notice of the patient's rights and responsibilities in seven (7) of eleven (11) patient charts reviewed. Failure to provide patients with copies of their rights and responsibilities can result in patients not fully understanding their healthcare rights and the expectations placed on them during treatment. This also has the potential to result in violation of HIPAA regulations, legal action from the patient, and a lack of informed consent. Based on review of facility documentation, and interview, the Department has determined the home health agency failed to ensure patients receive written notice of the discharge policy of the Agency in ten (11) of eleven (11) patient charts reviewed. Failure to provide patients with copies of their rights and responsibilities can result in patients not fully understanding their healthcare rights and the expectations. This also has the potential to result in and a lack of discharge preparedness and legal action from the patient. Findings include: Facility policy entitled, "...Patient Bill of Rights and Responsibilities" revealed, "...The Agency will provide each patient with a written notice of the patient's rights in advance of furnishing care to the patient during the initial evaluation visit before the initiation of treatment. The Agency will provide verbal notice of patient's rights and responsibilities in individual's primary or preferred language and in a manner that the individual understands...The Agency will document that a verbal discussion of rights took place and that the patient and/or representative was able to confirm his/her understanding of rights...Agency will provide patient with a written copy of the patient rights information, unless the patient requests that the document be provided electronically...Agency maintains documentation in the patient's medical record demonstrating compliance with informing patient about rights. The patient's or legal representative's signature confirming that he/she received a copy of rights/responsibilities must be obtained. A review of EMR records for patients #1,2,3,4,5,6,7,8,9,10, and 11 did not reflect documentation to support patients provided written copy of patient rights and responsibilities per agency policies and procedures. A review of EMR records for patients #1,5,8,10, and 11 did not reflect documentation to support discussion of patient rights and responsibilities completed per agency policies and procedures. Facility policy entitled, "...Patient Bill of Rights and Responsibilities" revealed, "...Procedure 9. Agency will inform patient and/or representative during the initial evaluation visit of responsibilities and transfer and discharge criteria per Agency policy...Patients have the right: (to) the following information during the initial evaluation visit, in advance of furnishing care to the patient : Written notice of the patient's rights and responsibilities and Agency's transfer and discharge policies...." A review of EMR records for patients #1,2,3,4,5,6,7,8,9,10, and eleven did not reflect documentation to support patients provided a copy of the agency's discharge policy. In an interview with the administrator conducted on December 12, 2024, acknowledged copies of patient rights and responsibilities as well discharge policies should be provided to all patients and/or representatives and verbal discussions regarding patients rights/responsibilities and documented in patient medical record per policy.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: The Agency is responsible to advise patients of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Home Health Agencies. This STANDARD is NOT MET as evidenced by: Based on interview, review of facility policies and procedures and review of admission packet, the Department has determined the home health agency failed to ensure patients receive the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local Home Health Agencies. This deficient practice can result in delayed patient care resulting in negative patient experience and has the potential to adversely impact patient outcomes. Findings include: Review of agency policy, " Patient Bill of Rights and Responsibilities", revealed, "...Patients have the right: To be advised of telephone number and hours of operation of the state's Home health Agency hotline, that receives complaints or questions about local home care agencies. The hours are 24 hours a day seven(7) days a week and the phone number is _____(sic). The hotline...." Review of Agency's Start of Care admission packet reflects. "...COMPLAINTS OR QUESTIONS ABOUT HOME HEALTH AGENCIES MAY BE DIRECTED TO: STATE DEPARTMENT OF LICENSURE HEALTH FACILITIES DIVISION, Phoenix Main Office,150 N.18th Ave, Suite 400. Phoenix, AZ 85007, Phone: (602)364-2536, Fax: (602)364-4808...." During interview conducted with the administrator acknowledged the Agency's start of care admission packet should be updated to reflect Arizona's toll free home health hotline or hours of operation.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: The Agency is responsible to advise patients of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This STANDARD is NOT MET as evidenced by: Based on interview, review of facility policies and procedures and review of admission packet, the Department has determined the home health agency failed to ensure patients receive contact information for a Center of Independent Living entity the serves the agency's patient population. This deficient practice can result in delayed patient care resulting in negative patient experience and has the potential to negatively impact patient outcomes. Findings include: Review of agency policy, " Patient Bill of Rights and Responsibilities", revealed, "...Patients have the right to: Be advised of the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides Review of the Agency's " Bridges Home Heath, Inc. Start of Care Admission Packet" revealed, document "OTHER ESSENTIAL CONTACT INFORMATION AND RESOURCES" revealed, "...Center for Independent Living" Web: https://mycil.org/ Tel: (800)344-7211 (toll free) Email jross@mycil.org. Review of the website address https://mycil.org/ reveals the organization provides "... MyCIL provides independent living resources to 10 counties in northeastern Pennsylvania including Bradford, Columbia, Lackawanna, Luzerne, Pike, Monroe, Sullivan, Susquehanna, Wayne, Wyoming...." During interview conducted on December 12, 2024 with the administrator, they acknowledged the start of care patient admission packet should be updated to reflect contact information for a Center of Independent Living entity the serves the agency's patient population.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: The Agency is responsible to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is NOT MET as evidenced by: Based on interview, and documentation review the Department has determined the home health agency failed to ensure all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This deficient practice has the potential to negatively impact patient care. Findings include: Review of agency policy, "Transfer/Referral Criteria Planning" revealed, "...A written Transfer Summary concerning the Agency's involvement with the patient, e.g., patient condition at transfer, lab data, patient outcomes in meeting goals in the plan of care, instructions/referrals provided to the patient, current reconciled medication list (with an explanation how to obtain clarification) advanced directives, any continuing symptom management needs e.g., pain, nausea, or dyspnea and reasons for transfer or referral will be completed. Review of the medical records for patient #10 on December 12, 2024 in Data Soft Logic (DSL) EMR, revealed transfer summary and other documentation as required by the Home Health Agency's policy, "Transfer/Referral Criteria Planning" not in patient medical record. During interview conducted with the administrator designee, it was acknowledged that transfer summary was not in Agency EMR.

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: The home health agency must must conduct performance improvement projects. The Agency 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 review of facility documentation present and interview, the Department has determined the agency failed to conduct performance improvement projects and document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This deficient practice has the potential to result in an increase preventable errors, compromised patient care and decreased patient satisfaction. Findings include: Review of agency policy, "Quality Assessment and Performance Improvement (QAPI) Plan and Program" revealed, Policy The Agency will establish and ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program...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....Performance improvement activities must track adverse patient events, analyze their causes and implement preventative outcomes. 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...." Review of QAPI documentation presented revealed no identified performance improvement projects. During interview conducted on December 11, 2024 with the administrator designee, a request was made to provide documentation to support performance improvement project activities. Not received.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: The home health agency must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is NOT MET as evidenced by: Based on interview, review of facility policies and procedures and observation, the Department has determined the home health agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. During one (1) of three (3) home visits it was observed, personnel failed to complete proper hand hygiene. This deficient practice can result in increased risk of pathogen transmission to both patients and healthcare workers, potentially leading to unnecessary infections, complications, and negatively impacting outcomes. Findings include: Review of Agency policy "Hand Hygiene Policy and Compliance Program" revealed"...Indications for staff performing hand hygiene are: Before and after direct patient care, Before and after each procedure,...Before and after collecting specimen...2. All employees are responsible for implementing hand hygiene procedure in an ongoing attempt to prevent and/or contain infection processes and communicable disease...." Review of Agency policy "Specific Procedures for Employee and Patient Infection Control training" revealed, "...1. All employee who come in contact with blood, body fluids, tissue, solids or any moist body part or substance of any patient will use the following specific procedures in compliance with Standard Precautions procedures:...Wash hands before and after wearing gloves...." During a home visit, it was observed the nurse failed to complete hand hygiene prior to donning and after doffing gloves.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: The home health agency must ensure a clinical record for each patient is maintained containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This STANDARD is NOT MET as evidenced by: Based on review of facility documentation, and interview, the Department has determined the home health agency failed to ensure a clinical record for each patient is maintained containing past and current information for every patient accepted by the HHA and receiving home health services. A failure to maintain complete medical records can lead to medication errors, incorrect treatment plans, and delays in care, ultimately impacting patient quality of care and safety. Findings include: Review of agency policy, "Timely Submission of Patient Documentation" revealed, "...The Agency will ensure timely and proper submission of patient documentation. Purpose To comply with state/federal laws and regulations related to timely submission of all patient documentation. Review of agency policy, "Initial Assessments/Comprehensive Assessments" revealed, "...For Medicare patients, Agency must verify patients eligibility for home health benefit, including homebound status...Initial Assessment and Time Frame:..A RN,PT, or SLP must conduct the initial assessment visit within 48 hours of the referral...The initial assessment visit is conducted to determine the immediate care and support needs of the patient...RN must complete the comprehensive assessment and determine eligibility for home health benefit (for Medicare patients), including homebound status...." Review of patients medical records on December 11, 2024 revealed: Patient #1 - SOC 12-5-2024 Review of EMR record reflects Patient OASIS full assessment dated December 5, 2024 start time 0900 not completed. "...Psychosocial...." section of assessment, marked patient has "...inadequate sleep...."...Bowel Elimination Section....", "...No Problem...." box not marked. Problem not listed in available comment box. "...laxative/enema use...." box checked affirming use. marked "...PRN....". Review of patient medical record in Data Soft Logic (DSL) EMR reflects Oasis E Full assessment not signed or dated by personnel completing assessment. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Skilled Nursing Note for visit on December 5th, 2024 had not be completed. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Patient Care Plan not signed or dated by any discipline. Patient #2 - SOC 11-16-2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects History and Physical (H&P) not in patient EMR record. Review of patient medical record in Data Soft Logic (DSL) EMR document titled OASIS E Full assessment completed on 11/07/2024 reflects: Section assessment "...Living Arrangements...." "...Primary Caregiver...." box checked. No primary caregiver information entered - "...Name....", "...Phone number....", "...Relationship...." entered. Section assessment "...Endocrine/Hematology...." "...No Problem...." box checked. Assessment reflects, "...Section I - Active Diagnosis....", "...Primary Diagnosis...Type 2 Diabetes Mellitus...." Assessment revealed Diabetic Foot exam not completed. Section "...Diabetic Foot Exam...." revealed "...Frequency of diabetic foot exam - n/a...." Patient is a type 2 diabetic with one below the knee amputation per Musculoskeletal section of assessment. Section "...Patient/Caregiver Education...." revealed box was checked "...N/A...." for "...Patient/caregiver/family knowledgeable and able to verbalize and/or demonstrate independence with...Diabetic foot exam/care...." Review of "...Section N-Medications.... " revealed box was not marked for patient taking hypoglycemic (including insulin). "...Section I-Active Diagnoses...." revealed diagnosis. "...LONG TERM (CURRENT) USE OF ORAL HYPOGLYCEMIC DRUGS...." Box not checked for patient taking antiplatelet medication. "....Section I-Active Diagnoses...." revealed diagnosis. "...LONG TERM (CURRENT) USE OF ASPIRIN". "...Summary Checklist...." reflects "...Medication Status...Medication Regimen completed/reviewed no change...." Review of patient medical record in Data Soft Logic (DSL) EMR reflects Case Conference notes not signed or dated by any discipline. Patient #3 - SOC 11-13-2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects Oasis E Full assessment revealed "Assessment Summary" section including "...Reason for Admission...." and "...Homebound Reason..." incomplete. Oasis E Full assessment not signed or dated by personnel completing assessment. Review of record patient medical in Data Soft Logic (DSL) EMR reflects Patient Care Plan dated11/13/2024 not signed or dated by physician or registered nurse. Patient #4 - SOC 8-19-24 Review of patient medical record in Data Soft Logic (DSL) EMR reflects Oasis E Full assessment not completed, signed, or dated by personnel completing assessment. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Patient Care Plan not signed or dated by any discipline. Patient #5 - SOC Review of patient medical record in Data Soft Logic (DSL) EMR reflects Patient Care Plan not signed or dated by any discipline. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Home Health Aide note dated 12/5/2024 incomplete. Patient #6 - SOC 8-6-2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects LPN note from 11/28/2024 not complete "...In Progress...." Patient #7 - SOC 10-2-2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects nurse's note from 12/05/2024 not complete "...In Progress...." Review of patient medical record in Data Soft Logic (DSL) EMR reflects Care Plan not sign by Registered Nurse. Patient #8 - SOC 4-12-2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects Nursing Note for 12/4/2024 not complete "...In Progress...." Review of patient medical record in Data Soft Logic (DSL) EMR reflects RN supervisory notes for 10/30/2024 not complete "...In Progress...." Review of patient medical record in Data Soft Logic (DSL) EMR reflects RN supervisory notes for 9/02/2024 not complete "...In Progress...." Patient #9 - SOC 7-27- 2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects History and Physical (H&P) not in patient EMR record. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Case Conference notes from 7/24/2024 not completed. Patient #10 - SOC 8-27- 2024 Review of patient medical record in Data Soft Logic (DSL) EMR reflects History and Physical (H&P) not in patient EMR record. Review of patient Plan of Care with start of care date of 8/27/2024 revealed no physician signature. Patient #11 - SOC 1-20-24 Review of patient medical record in Data Soft Logic (DSL) EMR reflects Supervisory note dated 5/15/2024 not completed. Review of patient medical record in Data Soft Logic (DSL) EMR reflects Supervisory note dated 4/172024 not completed. Review of patient medical record in Data Soft Logic (DSL) EMR reflects supervisory note for 4/2/2024 not completed. Review of patient medical record in Data Soft Logic (DSL) EMR reflects nursing progress note for 3/26/2024 not completed. In interview conducted on December 11, 2024, administer designee acknowledged documentation should be completed in a timely manner.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: The home health agency must ensure the clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. The hospice must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164. This STANDARD is NOT MET as evidenced by: Based on interview, review of facility policies and procedures and review of medical records, the Department has determined the home health agency failed to ensure the patient has the right to confidential clinical records means safeguarding the content, including paper records and/or electronically stored information from unauthorized disclosure without the specific informed consent of the patient or legal representative. This deficient practice can result in privacy violations, potential security breaches, and unauthorized access to patient data. Findings include: Review of facility policy, "Patient Bill of Rights and Responsibilities" revealed, "...Patients have the right:...Have(sic) a confidential patient record...." On December 12th, 2024 it was observed confidential patient document was not properly secured in a file cabinet in the open general office area proximate to the business entry to ensure contents protected against unauthorized access to confidential patient information. During interview, the administrator acknowledged the file cabinet was not properly secured to ensure unauthorized access. The administrator stated, "I was not aware. We will work on correcting. "

42 CFR 484.50-484.105. Subpart A, B, C Home Health Care The facility must meet all applicable Federal, State and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. This is a Medicare Recertification survey. No deficiencies were found during the Emergency Preparedness Appendix Z (E Tags) survey that was conducted on 02/5/21 through 02/09/21.

The following standard level deficiencies were cited during the Medicare Re-certification survey conducted on 02/5/2021 through 02/09/2021. There were no deficiencies found during the Focused Infection Control survey.

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 review of policy and procedures, home visit observation, and staff interview, it was determined during 2 of 2 home visits that the home health agency skilled nurse failed to ensure medication reconciliation was completed, which poses the potential high risk of medication duplication, harmful drug reaction and adverse effects to the patient. Findings: Home health agency policy and procedure titled, "Medication Reconciliation" revealed: " ...Medication ordered while the patient is receiving care will be compared with the medication list/profile. The medication list/profile will be updated with each new or changed medication ...." During the home visit observation on 02/05/2021, the medication profile review revealed, that patient #2 had 3 out of 9 medications which were discontinued but still listed on their medication profile. In addition, there were 6 medications that the patient verbalized taking that were not listed on their medication profile list. Those medications are the following: Oxygen 2 Liter Pro Re Nata (PRN) Iron Vitamin C Magnesium Sulfate Vitamin E Folic acid During the home visit observation on 02/09/2021, the medication profile review revealed, that patient # 1 was taking the following medications prescribed on 12/18/2020, which were not listed on the patient's current medication profile dated 01/11/2021-03/11/2021: Citalopram Lotrimin 2% Zinc Sulfate 220 milligram (mg) Vitamin C 1,000mg Senna 8.6mg Trazodone HCl 50mg Nystatin 100,000 Employee # 5 verified during an interview conducted on 2/5/21 at 2pm, that the medication for patient # 2 had not been reconciled. Employee # 7 verified during an interview conducted on 2/9/21 at 10am, that he/she was not aware that patient # 1 was taking additional medications. Summary: The home health agency skilled nurse failed to document all current medications the patient is taking, which poses the potential high risk of medication duplication, harmful drug reaction and adverse effects to the patient.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on review of policy and procedures, home visit observation, staff interview, and records review, it was determined during 2 of 2 home visits that the home health agency failed to communicate and/or coordinate all physician orders with the care provided to the patient. Findings: Home health agency policy and procedure titled, "Medication Monitoring" revealed: " ...Findings, conclusion, and recommendations from medication monitoring are documented and communicated to the Physician and other relevant care providers as appropriate ...." During the home visit observation on 02/05/2021, the medication profile review revealed, that patient #2 had 3 out of 9 medications which were discontinued but still listed on their medication profile. In addition, there were 6 medications that the patient verbalized taking that were not listed on their medication profile list. During the home visit observation on 02/09/2021, the medication profile review revealed, that patient # 1 was taking medications prescribed on 12/18/2020, which were not listed on the patient's current medication profile dated 01/11/2021-03/11/2021. Employee # 5 verified during an interview conducted on 2/5/21 at 2pm, that the home health agency did not have a medication order for the 6 medications that patient #2 is currently taking. Employee # 7 verified during an interview conducted on 2/9/21 at 10am, that he/she is unaware that patient # 1 is taking new prescribed medications from a new physician. The group home provider informed Employee #7 on 2/9/21 at 1030am, that they are unaware that the home health agency was managing patient #1's care. Based on records review on 2/5/21-2/9/21 for patients # 1 and 2, no documentation of discontinued or added medication for episode period: January 2021 to March 2021. Summary: The home health agency failed to communicate and/or coordinate the plan of care with other providers involved, which poses the potential risk to the patient for adverse outcomes.