Every finding on record at Concepts of Care Home Health, Inc

Emergency Preparedness Survey

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 record review and interview, the agency failed to conduct an exercise at least annually to test the emergency plan. A review of the agency’s Emergency Preparedness plan read in part: Section V. Testing. A. the Agency will participate in a full-scale exercise that is community based, or an individual, facility-based exercise annually. There was no evidence an annual exercise was conducted for 2023. On 11/15/2023 at 10:35 a.m., during an interview with S2BD (Branch Director), she confirmed the agency had no evidence that an annual exercise was conducted to test the emergency plan in 2023. During an interview on 11/15/2023 at 11:00 a.m., S1ADM (Administrator) confirmed the last annual exercise conducted to test the emergency plan was in April 2022, and none was conducted since that date.

Recertification Survey

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure Patient R1 was free from mental and verbal abuse for 1 random selected patient (R1). Patient R1. Review of the agency’s Abuse, Neglect, and Exploitation policy and procedure revealed, “…I. Abuse may be mental… verbal… A. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, sexual coercion, and intimidation… D. Verbal abuse refers to any use of insulting, demeaning, disrespectful, oral, written, or gestured language directed towards, and in the presence of, the patient… II. Agency management will: A. Initiate an investigation of the situation… E. Immediately suspend any agency employee, representative, or contractor suspected of abuse or neglect of a patient…” Review of the agency’s Client Complaint Form, for patient (Patient R1), dated 6/15/2023 revealed, “Description of Complaint: Received complaint from patient on above employee (S5PT, Physical Therapy) via phone on 6/15/2023. Patient stated that the therapist showed up at her home today at the same time as the nurse. The therapist then proceeded to roll down the window of her vehicle and began yelling at the patient from the parking lot of the patient’s apartment complex ‘don’t you remember we scheduled an appointment for today? Now you scheduled the nurse to come at the same time as our appointment. You messed up my entire last week’s schedule and now you are messing up my schedule for this week.’ Patient stated that she continued to ‘holler’ at her about if she had time today at the end of the day, she might go out of her way to see the patient for her appointment, and also that she was going to see her on Saturday, but now she could forget it. Patient stated that every time she tried to talk to therapist that the therapist would talk/yell over her, which increased her stress level. Patient stated that the therapist then proceeded to ‘screech’ out of the apartment parking lot, almost hitting one of the maintenance men with her car as she raced away. Patient was shaken up and embarrassed because the neighbors heard the entire thing, some even coming over to check on her… Spoke to nurse that was present during this episode and everything that patient stated above was confirmed by the nurse without giving any details of what was said by patient. Nurse’s description of the event matched the patient’s description…” On 11/15/2023 at 12:35 p.m., an interview was conducted with S2BD (Branch Director). She stated that what occurred between S5PT and Patient R1 was verbal abuse. On 11/15/2023 at 1:40 p.m., an interview was conducted with S3RN (Registered Nurse), the agency staff that investigated the complaint. S3RN stated that S5PT was inappropriate with the patient and he did not view the incident as abuse. On 11/15/2023 at 2:50 p.m., an interview was conducted with S3RN. He confirmed that S5PT was not suspended during the investigation of the complaint and continued providing services to patients.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by the SN (Skilled Nurse) failing to inform the physician of a patient’s pain intensity falling outside the established parameter for patient (#2), failing to ensure PT (Physical Therapy) visits were made per the POC for patient (#4), and failing to ensure the SN weighed patient (#4) per the POC for 2 (#2, #4) out of a total sample of 10 patients. 1. Patient #2. Review of the patient’s electronic clinical records revealed the start of care date was 10/25/2023. The patient’s diagnosis included Parkinson’s Disease. The certification period reviewed was 10/25/2023 to 12/23/2023. Review of the patient’s POC for certification period 10/25/2023 to 12/23/2023 revealed an order for “SN 1w3, 1every2wk6 (skilled nurse visit one time a week for three weeks, skilled nurse visit one time every two weeks for six weeks) ”. Further review of the patient’s POC revealed an order “Licensed Professional to report vital signs falling outside the following established parameters: …Pain > (greater than) 6…” Review of the patient’s skilled nurse visit notes dated 11/3/2023 revealed the SN documented the patient having pain of 8 on a pain scale 0-10. Review of the patient’s electronic clinical record revealed no evidence the SN reported the patient’s pain, which was greater than 6, to the physician per the POC. On 11/14/2023 at 10:20 a.m., an interview was conducted with S2BD (Branch Director). S2BD reviewed the patient’s electronic clinical record and confirmed that there was no evidence the SN reported the patient’s pain of 8 to the physician. 2. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 5/17/2023. The patient’s diagnoses included Rhabdomyolysis and Parkinson’s Disease. The certification period reviewed was 9/14/2023 to 11/12/2023. Review of the patient’s Plan of Care (POC) for certification period 9/14/2023 to 11/12/2023 revealed the following order - PT (Physical Therapy) effective 9/14/2023 2w1, 1wk4 (two times a week for one week, one time a week for four weeks). Review of the Physical Therapy (PT) visit notes revealed there was no evidence two PT visits were made as ordered for the week of 9/14/2023. On 11/14/2023 at 2:00 p.m., an interview was conducted with S2BD. She reviewed the patient’s electronic clinical record and confirmed that there was no evidence that two PT visits were made for the week of 9/14/2023 as ordered. 3. Patient #4. Review of the patient’s electronic clinical records revealed the start of care date was 5/17/2023. The patient’s diagnoses included Rhabdomyolysis and Parkinson’s Disease. The certification period reviewed was 9/14/2023 to 11/12/2023. Review of the patient’s Plan of Care (POC) for certification period 9/14/2023 to 11/12/2023 revealed the following order - SN (Skilled Nurse) effective 9/17/2023 1w2, 1every2wk6 (one time a week for two weeks, one visit every two weeks for 6 weeks). Further review of the patient’s POC revealed an order for “Skilled nurse to obtain weight q (every) visit and notify RN/MD (Registered Nurse/Medical Director) of weight gain or loss of 2-3 lbs (pounds) within 1 day or 5 lbs within 1 week.” Review of the patient’s SN visit notes dated 9/21/2023 and 9/29/2023 revealed that there was no evidence the SN obtained the patient’s weight on those skilled nurse visits. On 11/14/2023 at 2:00 p.m., S2BD reviewed the patient’s SN visit notes dated 9/21/2023 and 9/29/2023. S2BD confirmed that there was no evidence the patient's weight was obtained for the SN visits made on 9/21/2023 and 9/29/2023.