Every finding on record at Clark Fork Healthcare LLC

An Emergency Preparedness Recertification Survey was completed on 1/29/25. The agency was found to be in compliance with the regulatory requirements and with the standards of 42 Code of Federal Regulations (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Condition of Participation for Home Health Agencies.

A recertification survey was completed on 1/29/25. Condition Level and Standard Level deficiencies were cited. Glossary OT Occupational Therapist PT Physical Therapist RN Registered Nurse

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 interviews and record review, the agency failed to ensure patients' plan of care was detailed and individualized, reflecting current advance directives, for 2 (#s 2 and 3) of 7 sampled patients. Findings include: 1.Review of patient #3's plan of care, dated 1/21/25, reflected patient #3 was a Do Not Resuscitate. Review of patient #3's Five Wishes Advance Directive reflected patient #3 was a Full Code. During an interview on 1/28/25 at 11:01 a.m., staff member B stated the plan of care and the advance directives should match. 2. Review of patient #2's plan of care, dated 12/20/24, reflected patient #2 had a durable power of attorney for advance directives. During an interview on 1/29/25, at 5:45 p.m., staff member B stated the agency did not have the durable power of attorney or advance directive for patient #2. Review of the agency's policy, Advance Directives, dated May 2022, reflected: -"8. All clinicians/technicians providing care/service for the patient will: -A. Review the Advance Directive and report any discrepancies between the Directive and current treatment/service plan to the attending physician, Program Director, and the Patient."

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to ensure clinical staff completed competency in-service trainings. Findings include: 1. 1. Review of staff member F's personnel file reflected staff member F did not complete competency in-service training. 2. Review of staff member C's personnel file reflected staff member C did not complete competency in-service training. 3. Review of staff member G's personnel file reflected staff member G did not complete competency in-service training. 4. Review of staff member H's personnel file reflected staff member H did not complete competency in-service training. Staff member H did not have an annual performance evaluation. 5. Review of staff member I's personnel file reflected staff member I did not complete competency in-service training. Staff member I did not have an annual performance evaluation. During an interview on 1/29/25 at 10:10 a.m., with staff members A and B, staff member A stated the above staff did not complete the in-service competency trainings. Staff member A stated she could not locate any annual performance evaluations for staff members H and I. Staff member B stated if a staff member missed the competency training scheduled, there was not an opportunity for staff to make-up the trainings.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Organization and Administration of Services. Findings include: The agency failed to ensure the parent HHA provided direct support and administrative control of its branches for day-to-day management (see G974).

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide supervision and administrative control of it's branches daily operations. Findings include: During an interview on 1/27/25 at 3:20 p.m., staff member B stated each branch functioned independently. Staff member B stated each branch has their own administrator, director of clinical services and staff. Staff member B stated they do not know each other's staff members, patients, or processes. Staff member B stated each branch had its own QAPI and infection control program. Staff member B stated the branches all shared their QAPI data quarterly with the corporate support team. Staff member B stated the only overlap between branches was management to cover each other for vacations or other time off periods. Staff member B stated staff member A did not go to other branches as their manager. During an interview on 1/27/25 at 1:50 p.m., staff members A and B stated the Missoula location was a branch of their home health office in Bozeman. The Missoula location had it's own administrator and clinical manager who were the backups for Bozeman. Staff members A and B were the backups for the Missoula location. Staff member A stated their office in Bozeman covered Gallatin County and the Missoula office covered Missoula County and part of Bitterroot County. During an interview on 1/27/25 at – Toshua interview During an interview on 1/28/25 at 9:23 a.m., staff member A stated their office in Bozeman and the Missoula office location would have weekly calls on operations, but only met in person for a quarterly rotation between four locations. Staff member A stated the Missoula location managed their own referrals, admissions, QAPI, and daily operations. Staff member A and B did not have involvement in the daily management of the Missoula location. Staff member A stated the two locations did not share staff. Review of the agency’s completed form 1572 showed there was a branch and listed the Missoula location as Branch #1. Review of the agency’s website showed the Bozeman location did not provide services contiguous with the Missoula location. There were at least two counties separating the respective operating locations.

Based on the regulatory requirements and standards of 42 Code of Federal (CFR) 484.22 Emergency Preparedness (EP) Final Rule Requirement for Conditions of Participation for Home Health Agencies, effective 11/15/17, a recertification survey was performed on 2/16/22. No Deficiencies were cited.

A recertification survey was completed on 2/16/22. Standard Level Deficiencies were cited Abbreviations: OASIS - Outcome and Assessment Information Set OT - Occupational Therapy POC - Plan of Care PT - Physical Therapy ROC - Resumption of Care SN - Skilled Nursing SOC - Start of Care

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the transmitted OASIS data was consistent with current status of the patient at the time the OASIS was completed for 3 (#s 3, 5 and 6) of 7 sampled patients. Findings include: 3. Patient # 3 had a SOC date of 12/22/21 with a primary diagnosis of Parkinson's Disease. Review of the Plan of Care, with a certification period of 12/22/21-2/19/22 showed patient #3 had a catheter under DME (durable medical equipment). Review of patient #3's SOC OASIS completed on 12/22/21, item number M1610, showed the patient was continent and did not have a catheter. Review of a nurse's note, dated 12/22/21, showed a SN visit was completed and the patient's suprapubic catheter was changed by the nurse. 1. Patient #5 had a SOC date of 1/26/22, with a primary diagnosis of Wound Care. During an observation and interview on 2/14/22 at 11:00 a.m., patient #5 was receiving wound care for a right lower leg wound. Patient #5 stated she was a diabetic and self-administered insulin twice a day. Review of patient #5's Medication Profile, for certification period 1/26/22 to 3/26/22, showed, “Humalog Mix 75/25 Kwikpen subcutaneous (75-25) 100 unit/ML 46 units inject 46 units subcutaneously BID before breakfast and dinner”. Review of patient #5's SOC OASIS, completed on 1/26/22, showed Management of Injectable Medications (M2030), was marked, "NA - No injectable medications prescribed". During an interview on 2/16/22 at 10:00 a.m., staff member B stated she thought the injectable section on the OASIS was meant for what services the nurse would be providing. Since the patient self-administered her own insulin, she selected the no injectables, because the nurse would not be administering the insulin for the patient. 2. Patient #6, had a SOC date of 1/14/22, with a primary diagnosis of COVID-19 Respiratory Exacerbation Aftercare. A review of patient #6’s physician order, dated 1/11/22, showed a referral was made to the home health agency, with a provider ordered SOC of 1/14/22. Review of patient #6’s SOC OASIS, with completion date of 1/14/22, showed, Date of Physician-ordered Start of Care (M0102) was marked, “NA-No specific SOC date ordered by physician”. A review of the agency's policy and procedure titled, Initial and Comprehensive Assessment, showed, "...The assessment will be patient-specific and comprehensive to include the patient's need for home care, rehabilitative care, social, and discharge planning needs. The assessment will also include the exact use of the current version of the Outcomes and Assessment Information Set (OASIS). This assessment will measure patient outcomes from data collected at the start of care..."

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 observation, interview, and record review, the agency failed to ensure the current frequency and duration of visits to be made was updated on the plan of care for 2 (#s 5 and 6); and failed to ensure the Orders for Treatments (interventions) and Goals and Outcomes were updated for provided occupational therapy services for 1 (#6) of 7 sampled patients. Findings include: 1. Patient #5 had a SOC date of 1/26/22, with a primary diagnosis of Wound Care. Review of patient #5’s physician ordered treatment frequency and duration, dated 1/27/22, showed, PT was ordered for two times a week for four weeks, and OT was ordered for two times a week for two weeks, then one time a week for two weeks. Review of patient #5’s POC (485), with a certification period of 1/26/22 to 3/26/22, did not show the updated visit frequency and duration for PT and OT as ordered by the physician. 2. Patient #6, had a SOC date of 1/14/22, with a primary diagnosis of COVID-19 Respiratory Exacerbation Aftercare. During an observation and interview on 2/15/22 at 9:30 a.m., staff member E provided occupational therapy for patient #6. Staff member E stated she currently provided occupational therapy twice a week for patient #6. Review of patient #6’s physician ordered treatment frequency and duration, dated 2/3/22, showed OT was ordered for two times a week for two weeks. Review of patient #6’s POC (485), with a certification period of 1/14/22 to 3/14/22, showed, OT was ordered for one time a week for one week for evaluation and treatment. The POC (485) was not updated with the current frequency and duration for OT services. Review of patient #6’s POC (485), with a certification period of 1/14/22 to 3/14/22, did not show the updated treatment options or goals and outcomes for the provided OT services. A review of the agency’s policy and procedure, titled, Continuity of Care, showed, “…5. The comprehensive assessment should determine: H. Plan of care, including type of services, frequency and duration. I. Any information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the organization”.