Every finding on record at Campbell County Hospital District

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 7/2/26. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 6/29/26 through 7/2/26.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the iQIES "HHA Error Summary by Agency" report, and staff interview, the agency failed to ensure timely OASIS assessment submission for 22 clients. The finding were: 1. Review of the iQIES "HHA Error Summary by Agency" report ran from 10/1/25 through 6/23/26, showed the agency had submitted 22 patient assessments which resulted in error code -3330. This indicated the assessment was submitted late. 2. Interview with the Home Health Manager on 7/1/26 at 9:30AM revealed the agency was unaware of the 22 late submissions, and was unable to produce the names of the 22 clients. She revealed the agency had changed computer systems and was having some issues getting the information submitted.

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 client medical record review, and staff interview, the agency failed to ensure a detailed, individualized plan of care for 7 of 7 sampled clients (#1, #2, #3, #4, #5, # 6, #7) reviewed. The findings were: 4. Review of the care plan dated 5/14/26, and last updated 5/12/26 showed client #1 had diagnoses that included pressure ulcer of sacral region, stage 2, dementia, down syndrome, epilepsy. Further review showed the client was a fall risk, and skin breakdown risk, Review of the safety measures failed to show seizure precautions, blood and body fluid precautions, fall precautions, and universal precautions. 5. Review of the care plan dated 5/29/26, and last updated 5/27/26 showed client #2 had diagnoses that included pressure ulcer of right buttock, stage 2, cellulitis of left lower limb, acquired absence of right leg below knee, dependence on renal dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease, and diabetic neuropathy. Further review showed the client was at risk for infections, used a blood glucose monitor, was at risk for falls, and skin breakdown. Review of the safety measures failed to show sharp precautions, blood and body fluid precautions, fall precautions, hypo/hyperglycemia precautions, and universal precautions. 6. Review of the care plan dated 5/23/26, and last updated 6/5/26 showed client #6 had diagnoses that included rectal abscess, rectal fistula, malignant neoplasm of rectum, brain, left lung, right lung, and right adrenal gland, generalized epilepsy, colostomy, and drug-induced polyneuropathy. Further review showed the client was at risk for falls, and had problems with deep wounds with moderate to heavy drainage, Review of the safety measures failed to show seizure precautions, blood and body fluid precautions, fall precautions, and universal precautions. 7. Review of the care plan dated 6/21/26, and last updated on 6/29/26 showed client #7 had diagnoses that included other specified sepsis, parainfluenza virus pneumonia, other toxic encephalopathy, chronic myelomonocytic leukemia, thrombocytopenia, history of falls, history of traumatic brain injury, and dependence on supplemental oxygen. Further review showed the client had problems of balance deficit, history of falls, and impaired swallowing. Review of the safety measures failed to show fall precautions, blood and body fluid precautions, and universal precautions. 8. Interview with the home health manager on 7/1/26 at 11 AM revealed the agency did not have a "Fall prevention strategy" policy to instruct or monitor patient / caregiver adherence. In addition, she confirmed there were no individualized fall safety care plans. Further, she revealed the agency did not have a policy for precautions on the plan of care. 1. Review of the care plan dated 1/6/26, and last updated on 1/22/26 showed client #3 was at risk for falls. Further review showed interventions included "...Instruct in home safety and fall prevention strategies - monitor patient / caregiver adherence to and mindfulness of fall prevention strategies..." 2. Review of the care plan dated 11/18/25, and last updated 11/26/25 showed client #4 was at risk for falls. Further review showed interventions included "...Instruct in home safety and fall prevention strategies - monitor patient / caregiver adherence to and mindfulness of fall prevention strategies..." 3. Review of the care plan dated 4/30/26, and last updated 5/11/26 showed client #5 was at risk for falls. Further review showed interventions included "...Instruct in home safety and fall prevention strategies - monitor patient / caregiver adherence to and mindfulness of fall prevention strategies..."