Every finding on record at County of Van Buren

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/27/23 through 11/30/23and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements of the Establishment of Emergency Preparedness.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness policies and agency staff interview, the agency failed to ensure development and maintenance of an emergency preparedness communication plan that must include contact information for Federal, State, tribal, regional and local emergency preparedness staff and other sources of assistance. Failure to include contact information for Federal, State, tribal, regional and local emergency preparedness staff puts patients at risk of not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency policy, titled Emergency Preparedness Plan, dated 3/2023, revealed the policy lacked documentation of contact information for Federal, State, tribal, regional and local emergency preparedness staff or other sources of assistance. During an interview on 11/30/23 at 11:40 AM, the surveyor notified Administrator of an inability to find contact information for Federal, State, tribal, regional and local emergency preparedness staff and/or other sources of assistance. The Administrator agreed the policy did not include the needed contact information. The agency provided no further information prior to the end of the survey.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the agency emergency preparedness policies and staff interview, the agency failed to ensure the development and maintenance of an emergency preparedness communication plan that included a method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. Failure to have procedures in place for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care puts patients at risk of not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency policy, titled Emergency Preparedness Plan, dated 3/2023, revealed the policy lacked a procedure for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care. During an interview on 11/30/23 at 11:40 AM, the surveyor notified Administrator of an inability to find a procedure for sharing information and medical documentation for patients. The Administrator agreed the policy did not include a procedure for sharing information and medical documentation. The agency provided no further information prior to the end of the survey.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/27/23 through 11/30/23. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 30 patients at the time of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 2 sampled patients requiring a resumption of care assessment (Patient #3). The agency performed resumption of care assessments on 5 patients in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled OASIS Policy, dated 11/2019, resumption of care assessment will be completed within 48 hours of the patient return to the home from hospital admission of 24 hours or more for any reason other than diagnostic testing, or on physician-ordered resumption date. Patient #3 had a start of care date of 10/14/15. Clinical record review revealed: 1.The update to the comprehensive assessment at the time of resumption of care, dated 7/14/23, documented the patient was discharged from the hospital on 7/13/23. The nurse completed the assessment on 7/17/23, 4 days after the patient returned home. The assessment was completed 2 days late as required by regulation and the agency's own policy. 2.The update to the comprehensive assessment at the time of resumption of care, dated 11/3/23, documented the patient was discharged from the hospital on 11/2/23 and the agency received faxed discharge summary on 11/3/23. The nurse completed the assessment on 11/6/23, 3 days after the agency knowledge of the patient return home. The assessment was completed 1 day late as required by regulation and the agency's own policy. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 6 sampled patients. (Patient #4, #5 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings: According to the agency policy, titled Nursing Care Service, dated 7/2018, the nurse will develop and implement an individualized care plan for the client by providing nursing services, treatments, and diagnostic procedures as ordered requiring specialized nursing skills. The care plan will be signed by the ordering physician. During an interview on 11/28/23 at 1:41 PM, Administrator reported the wound measurements are completed weekly and include length, width and depth. 1.Patient #5 had a start of care date of 9/1/23. Clinical record review revealed: a.Plan of Care, dated 9/1/23 to 10/30/23, included orders for skilled nursing visits every 2 weeks. i.Skilled nursing visits, dated 10/20/23 and 11/3/23. ii.Recertification visit note, dated 10/26/23. iii.The record lacked documentation of an interim physician order for the extra skilled nursing recertification visit, dated 10/26/23. b.Plans of Care, dated 9/1/23 to 10/30/23 and 10/31/23 to 12/29/23, included skilled nursing orders to measure wound at each nurse visit. i.Skilled nursing visits, dated 10/20/23 and 11/17/23, included documentation of an open area on Left 2nd toe but lacked documentation of wound measurements. 2.Patient #4 had a start of care date of 4/6/23. Clinical record review revealed: a. Plan of Care, dated 9/22/23 to 11/20/23, included orders for skilled nursing visits one time weekly and home care aide visits 1-2 times weekly. b.Skilled nursing visit, dated 10/19/23. c.Transfer to inpatient facility, dated 10/31/23. d.The record lacked documentation a skilled nursing visit was made the week of 10/22/23 to 10/28/23, or documentation as to why the visit was missed. The record lacked documentation of an interim physician order for the missed skilled nursing visit, dated the week of 10/22/23. During an interview on 11/30/23 at 11:55 AM, the Administrator reported she reviewed the clinical record and found documentation the RN made a visit to administer the flu vaccine for the patient, dated 10/26/23, but failed to document a skilled nursing visit note. 3.Patient #7 had a start of care date of 8/31/23 and a discharge date of 10/27/23. Clinical record review revealed: a.Plan of Care, dated 8/31/23 to 10/29/23, included orders for physical therapy to evaluate and treat. b.Interim physician order, dated 9/5/23, included order for physical therapy twice a week from 9/5/23 to 10/13/23. c.Physical Therapy Assistant visit, dated 9/26/23. d.Physical Therapy visits, dated 9/18/23, 10/3/23, 10/6/23. e.Physical Therapy missed visit documentation, dated 9/21/23. f.The record lacked documentation of a second Physical Therapy visit during the week of 9/24/23 to 9/30/23, or documentation as to why the visit was missed. The record lacked documentation of an interim physician order for the missed Physical therapy visit, the week of 9/24/23. he above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 2 of 4 sampled patients without home visits. (Patients #5 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Supplemental Primary Care Provider Orders, dated 11/2023, order intake will be performed by an agency RN (registered nurse) or LPN (licensed practical nurse). Verbal orders will be confirmed and followed up by written, signed and dated physician orders. According to agency policy, titled Nursing Care Service, dated 7/2018, the nurse will obtain physician’s signature for any supplemental orders given in the 60-day period. Orders will be incorporated in the patient’s chart within 14 days. During an interview on 11/28/23 at 1:41 PM, the Clinical Manager reported the agency completes a rolling care plan in the electronic medical record after an interim physician order has been obtained. During an interview on 11/30/23 at 11:45 AM, the Clinical Manager reported updated plans of care were printed for the surveyor prior to the home visits completed. The electronic medical record system is new for the agency and the staff training received was not very good, it is easy to forget certain steps, staff are still learning how to use the system. 1. Patient #7 had a start of care date of 8/31/23. Clinical record review revealed: a. The Plan of Care, dated 8/31/23 to 10/29/23, included physician orders for skilled nursing services and physical therapy to evaluate and treat the patient. b. An interim physician order, dated 9/5/23, included documentation for physical therapy 2 times a week from 9/5/23 to 10/13/23 c.An interim physician order, dated 9/16/23, included documentation to change Coumadin to 3 mg (milligrams) tablet: take half a tablet on Saturdays and whole tablet on other days. d.An interim physician order, dated 9/19/23, included documentation to recheck INR (International Normalized Ratio) (blood test to check how long it takes your blood to clot) on 9/21/23. e.An interim physician order, dated 9/21/23, included documentation to change coumadin to 3 mg Friday, 4 mg Saturday and Sunday, then 3 mg daily, and recheck INR in 2 weeks. f.An interim physician order, dated 10/3/23, included documentation no change in coumadin dosage, recheck INR in 4 weeks. g.An interim physician order, dated 10/10/23, included documentation for physical therapy 2 times a week from 10/14/23 to 10/27/23. h.An interim physician order, dated 10/19/23, included documentation for infuenza vaccine 1 time dose. i.An interim physician order, dated 10/19/23, included documentation no change to current coumadin dosage and recheck INR in 1 month. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 2. Patient #5 had a start of care date of 9/1/23. Clinical record review revealed: a. The Plan of Care, dated 10/31/23 to 12/29/23, included physician orders for skilled nursing services. b. An interim physician order, dated 11/17/23, included documentation to start Florastor capsules. c. An interim physician order, dated 11/17/23, included documentation to start cranberry capsules. The agency failed to ensure the Plan of Care was updated to include all patient care orders. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.