Every finding on record at Community Hospital, Inc.

The recertification survey, conducted from 5/16/2022 through 5/18/2022, identified the following standard deficient practices in relation to Appendix Z Establishment of Emergency Preparedness.

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 review of the agency's policies and procedures for their emergency preparedness plan and staff interview, the agency failed to ensure the development of a policy and procedure to inform State and local officials of homebound patients in need of evacuation due to an emergency situation. The agency reported a current census of 18 patients. Failure to have a policy and procedure in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's policy titled Agency Emergency Response Plan dated 03/2022 identified the policies failed to include a policy and procedure for how agency staff will inform State and local officials of homebound patients in need of evacuation due to an emergency situation. Agency staff provided no further information prior to the end of the survey.

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 agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to 2 of 4 hired staff consistent with their expected roles and 1 of 1 contracted staff members since the last survey of 5/28/2019 did receive emergency preparedness training during orientation. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to agency policy, titled Agency Emergency Response Plan, dated 03/2022, all staff will be trained upon hire on agency emergency response plans and procedures. Current completion of this training will be kept in the Emergency Plans Training and Testing log. Interview with the clinical director on 5/18/2022 at 9:45 AM reported she failed to complete the initial orientation for the agency emergency response plan. The clinical director had a date of hire of 10/26/21 and a document titled Emergency Preparedness Orientation dated 3/11/22. Staff B, RN, (registered nurse), had a date of hire of 9/7/21 and a document titled Emergency Preparedness Orientation dated 3/11/22. The agency failed to document contracted staff, Staff D, speech therapist, completed the agency's Emergency Preparedness Orientation. The above information was reviewed with the Clinical Director. The agency provided no further information prior to the end of the survey.

The recertification survey, conducted 5/16/2022 through 5/18/2022, found the agency operating out of compliance with the following standard level deficiencies: The agency identified a current census of 18 patients.

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 clinical record review, agency policy review and agency staff interview, the agency failed to identify medication discrepancies and all components when completing a drug regimen review with each comprehensive assessment within the allowed time frames for 2 of 11 sampled patients. (Patients #1 and #2). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: 2. Patient #1 had a start of care date of 5/11/22. The patient received skilled nurse, and home health aide services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 5/11/22 to 7/9/22 identified orders for hydrocodone/acetaminophen 5/325mg tablet every 4-6 hours as needed for pain and alprazolam 0.5 mg tablet every 6 hours as needed for anxiety. b. The patient medication sheet printed 5/16/22 identified orders for hydrocodone/acetaminophen 5/325mg tablet every 4-6 hours as needed for pain and alprazolam 0.5 mg tablet every 6 hours as needed for anxiety. b. During a home visit observation on 5/17/22 at 8:00 AM with Staff B, RN, the surveyor observed the following prescriptions in labeled pharmacy bottles; hydrocodone/acetaminophen 7.5/325mg tablet dated 6/17/2020 and alprazolam 0.25 mg tablet dated 2/22/21. The current medication orders did not match the medications present in the patient's home supply. According to the agency policy titled Complete Comprehensive assessment, dated 6/2021, the comprehensive assessment must include 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. During an interview on 5/18/22 at 8:20 AM the Clinical Manager stated the patient's current or start of care medication list is compared to the patient's medication supply. The drug regimen review is completed at start of care, resumption of care, recertification and significant change in condition. 1. Patient #2 had a start of care date of 9/11/20. a. The plan of care (POC), dated 3/5/22 to 5/3/22, included Tramadol and Acetaminophen, duplicate pain medications. b. The DRR, dated 9/11/22, 3/1/22 and 4/29/22, failed to identify the patient had orders for duplicate pain medications. The agency failed to provide a complete DRR.

HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, personnel file review and patient interview, the agency failed to ensure 1 of 2 sampled home health aides (Staff C), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 3 sampled patients (Patients #2) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently performing the task with a patient. Failure to ensure home health aides successfully complete a competency evaluation in any assigned extra skills which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: According to the agency policy titled Home Care Aide Coordination, dated 11/2019, the RN assigning tasks beyond the basic skills must ensure that the home care aide assigned has been competency assessed prior to completing the assignment. 1. Patient #2 had a start of care date of 9/11/20 and had orders for skilled nursing and home care aide services. Clinical record review revealed: a. The skilled nurse visit note, dated 3/15/22, identified the patient had knee high support stockings in place. b. Patient #2's clinical record included documentation that Staff C, Home Health Aide, independently provided home health aide services to the patient. c. During a home observation visit with Staff A, RN the surveyor observed the RN apply the patients support stockings. During the same visit the patient stated the home care aide applies the support stockings every visit. d. Staff C, Home Health Aide (HHA), had a hire date of 2/14/22. The aide's personnel file lacked documentation that an RN had evaluated the HHA and determined the aide was proficient in the tasks of application of Ted hose. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 1 of 3 sampled patients receiving home health aide services (Patients #6). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patient's would receive inappropriate or inconsistent home health aide services. Findings include: According to the agency policy titled Home Care Aide Coordination, dated 11/2019, when it is determined by the Registered Nurse (RN) Case Manager that home care aide services are needed for a patient, the frequency and duration of home care aide services along with a Home Care Aide goal must be documented on the Plan of Care. Special instructions must be present for assigned skills beyond basic skills. During an interview on 5/18/22 at 8:20 AM the Clinical Manager stated the Case Manager is expected to complete the home care aide care plan. 1. Patient #6 had a start of care date of 1/12/21 and discharge date of 2/9/21. Clinical record review revealed the following: The POC's, dated 1/12/21 to 3/12/21, included physician orders for home health aide visits 2 to 3 times a week. a. The skilled nurse comprehensive assessment, dated 1/12/21, identified the patient had Interdry and Clotrimazol topical to prevent skin breakdown under the breasts.. b. The home health aide assignment for the period of 1/12/21 through 3/12/21, included instruction to apply medicated cream to skin folds and excoriated areas as needed (prn). The assignment failed to include the name of the medicated cream. The nurse failed to provide aide assignment individualized to the patient's needs. The above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff completed and sent a transfer summary to the health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of the planned transfer for 1 of 2 sampled patients requiring transmission of a transfer summary (Patient #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up and care. Findings include: Patient #6 had a start of care date of 1/12/2021 and discharge date of 2/9/21 and received agency services from the Dubuque parent office. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/12/2021 to 3/12/21, included a physician order for skilled nursing, home care aide and physical therapy services. Review of the document titled Transfer Checklist, dated 12/1/21, identified the patient summary document and current medication list faxed to facility the patient transferred to and to keep fax confirmation and attach o summary and place in the chart. b. A skilled nursing visit note, dated 2/9/21, included documentation the patient transferred to a nursing home. e. The clinical record lacked documentation agency staff sent a transfer summary to the nursing home within 2 business of the planned transfer. On 5/18/22 at 11:38 AM, during an interview, the nursing home Director of Nursing reported the nursing home did not have documentation of a discharge summary from the home health agency. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure authentication of hand written entries made in each patient's clinical record included the employee's signature, title, date and time of the signature for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). The agency reported a current census of 18 patients at the time of the survey. Failure to maintain timely, accurate and appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. 4. Patient #2 had a start of care date of 9/11/20. The patient received skilled nurse, and home health aide services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 3/2/22 to 5/3/22 identified an electronic signature that included the nurses name, signature date and time but lacked a title. b, The skilled nurse comprehensive assessment, dated 4/29/22, identified and electronic signature that included the nurses name, signature, date and time but lacked a title. b. The skilled nurse visit notes, dated 3/15, 3/22, 3/29, 4/5, 4/12, 4/19, 5/3 and 5/10/22, identified an electronic signature that included nurses name, signature, date and time but lacked a title. c. The home care aide visit notes, dated 3/14, 3/17, 3/21, 3/24, 3/28, 3/31/22, 4/4, 4/7, 4/11, 4/14, 4/18, 4/21, 4/25, 4/29/22, 5/2, 5/5, 5/9 and 5/12/22, identified an electronic signature that included the aides name, signature, date and time but lacked a title. 5. Patient #4 had a start of care date of 1/26/22. The patient received skilled nurse, and physical therapy services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plans of Care dated 1/26/22 to 3/26/22 and 3/27/22 to 5/25/22 identified an electronic signature that included the nurses name, signature date and time but lacked a title. b, The skilled nurse comprehensive assessment, dated 3/22/22, identified an electronic signature that included the nurses name, signature, date and time but lacked a title. b. The skilled nurse visit notes, dated 3/24, 3/29/22, 4/2, 4/5, 4/7, 4/13, 4/22, 4/23, 4/28, 4/30/22, 5/3 and 5/12/22, identified and electronic signature that included the nurses name, signature, date and time but lacked a title. c. The physical therapy note, dated 3/24/22, identified the physical therapy aides hand written signature that included the name, signature, date and time but lacked a title. 6. Patient #6 had a start of care date of 1/12/21 and discharge date of 2/9/21. The patient received skilled nurse, and home health aide services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 1/12/21 to 3/12/21 identified an electronic signature that included the nurses name, signature date and time but lacked a title. b, The skilled nurse comprehensive assessment, dated 1/12/21, identified and electronic signature that included the nurses name, signature, date and time but lacked a title. b. The skilled nurse visit notes, dated 1/14, 1/18, 1/22, 1/25, 1/27/22 2/1, 2/3, 2/5, 2/8 and 2/9/22, identified an electronic signature that included nurses name, signature, date and time but lacked a title. c. The home care aide visit notes, dated 1/14, 1/18, 1/20, 1/22, 1/29/22, 2/1, 2/3, 2/5 and 2/8/22, identified an electronic signature that included the aides name, signature, date and time but lacked a title. 7. Patient #7 had a start of care date of 1/5/22 and discharge date of 1/28/22. The patient received skilled nurse from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 1/5/22 to 3/5/22 identified an electronic signature that included the nurses name, signature date and time but lacked a title. b, The skilled nurse comprehensive assessment, dated 1/5/22, identified and electronic signature that included the nurses name, signature, date and time but lacked a title. b. The skilled nurse visit notes, dated 1/7, 1/12, 1/14, 1/18, 1/21, 1/24 and 1/28/22, identified an electronic signature that included nurses name, signature, date and time but lacked a title. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. Findings include: According to the agency's policy, titled Electronic Signature, dated 03/2022, the signature line of a document signed electronically will include the authenticator's name, date and time of authentication. The policy failed to include credentials/title. 1. Patient #1 had a start of care date of 5/11/22. The patient received skilled nurse, and home health aide services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 5/11/22 to 7/9/22 identified the nurses name, signature date and time but lacked a title. b. The skilled nurse visit note and comprehensive assessment, dated 5/11/22, identified nurses name, signature date and time but lacked a title. c. The home care aide visit note, dated 5/16/22, identified aides name, signature date and time but lacked a title. 2. Patient #3 had a start of care date of 4/22/22. The patient received skilled nurse, occupational therapy and physical therapy services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 4/22/22 to 6/20/22 identified the nurses name, signature date and time but lacked a title. b. The skilled nurse visit note and comprehensive assessment, dated 4/25//22, identified nurses name, signature date and time but lacked a title. c. The skilled nurse visit note and follow up assessment, dated 4/29//22, identified nurses name, signature date and time but lacked a title. d. The skilled nurse visit notes dated 5/3, 5/5, 5/9 and 5/13/22 identified nurses name, signature date and time but lacked a title. 3. Patient #5 had a start of care date of 4/26/22. The patient received skilled nurse, occupational therapy and physical therapy services from the agency. The patient's clinical record included the following: a. The Home Health Certification and Plan of Care dated 4/26/22 to 6/24/22 identified the nurses name, signature date and time but lacked a title. b. The skilled nurse visit note and comprehensive assessment, dated 4/27//22, identified nurses name, signature date and time but lacked a title. c. The skilled nurse visit notes dated 5/3 and 5/10/22, 5/9 identified nurses name, signature date and time but lacked a title.