Every finding on record at Dpt Inc

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 5/14/24 through 5/16/24. Dakota Physical Therapy Home Health Care was found in compliance.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for Home Health Agencies, was conducted from 5/14/24 through 5/16/24. Dakota Physical Therapy Home Health Care was found not in compliance with the following requirement: G514.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure two of seven sampled patients (1 and 2) had an initial registered nurse (RN) assessment done within 48 hours of referral, return home, or their physician ordered start of care date. Findings include: 1. Review of patient 1’s medical record revealed: *She was discharged from a hospital with orders for home health and referred to the home health provider on Friday, March 8th, 2024. *Her diagnoses included chronic respiratory failure, pulmonary disease, complications of influenza and pneumonia, and a stage 3 pressure ulcer. *She was admitted to home health with an initial (RN) assessment done on Monday, March 11th, 2024, three days later. *She was rehospitalized on March 14th, 2024, for complications of acute respiratory failure, pneumonia, and influenza. 2. Review of patient 2’s medical record revealed: *She was discharged from a skilled nursing facility with orders for home health and referred to the home health provider on Friday, May 3rd, 2024. *Her diagnoses included lumbar disc degeneration and back pain. *She was admitted to home health on Monday, May 6th, 2024, three days later. 3. Interview on 5/15/24 at 8:30 a.m. with RN B revealed: *Patients referred to the home health agency on Fridays did not have their initial RN assessment until the following Monday because the provider did not have a nurse working on the weekends. *The provider had not notified the physician to obtain a start of care order for patients 1 and 2 beyond the required 48 hours from their referral. *She acknowledged that patients with delayed initial RN assessments were at an increased risk of rehospitalization. 4. Interview on 5/15/24 at 12:10 p.m. with office staff C revealed: *The provider's process was to get an order from the physician for a different start of care date if they could not admit a patient within 48 hours of the referral. *She agreed that patients 1 and 2 did not have an initial RN assessment within the required 48 hours and did not have a physician ordered start of care date. 5. Interview on 5/16/24 at 8:30 a.m. with administrator A revealed: *There had been difficulties staffing nurses that led to delayed patient admissions and initial RN assessments. *He acknowledged that patients 1 and 2 had not had initial RN assessments within 48 hours of referral and there was no physician ordered start of care date.

A recertification survey for compliance with 42 CFR Part 482, Subpart B, Subsection 484.102 Emergency Preparedness, requirements for Home Health Agencies, was conducted from 6/2/21 through 6/3/21. Dakota Physical Therapy Home Health Care was found not in compliance with the following requirement: E001.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on policy review and interview, the provider failed to establish a comprehensive emergency preparedness program that had the potential to affect all patients. Findings include: 1. Review of the provider's revised November 2017 Emergency Preparedness Plan policy review revealed: *It had an effective date of May 2001 with a last revised date of November 2017. *The purpose of the plan was to: -"Establish methods to provide continuing care to patients in the event of an emergency such as a natural or industrial disaster or loss of utilities. -"Provide the agency with guidelines for patient care when an emergency or disaster occurs." -"Provide guidelines to patients, families, and care givers to meet the patient's needs if staff is unable to provide care." *There was a criteria to assign patients a prioritization level based on their needs in the event an emergency occurred. -That should have been determined at the time of their admission. *If an emergency occurred the nurse coordinator: -Would declare it an emergency situation. -Notify the administrator. -Implement the staff notification. -Notify other healthcare agencies of their needs. -Triage the patients based on their priority level. -Communicate with the staff about their responsibilities. -Call each patient to check on them and determine if they had any additional needs. -Contact law enforcement or other agencies as needed. -Evaluate how the plan is going. *After an emergency occurred the agency would evaluate the plan to assess the effectiveness and modify it as needed. *Staff should have been trained on emergency preparedness annually and if any changes were made to the plan. Interview and policy review on 6/3/21 at 2:00 p.m. with registered nurse/nurse coordinator A regarding the emergency preparedness program revealed: *She confirmed they had not reviewed/revised the policy since November 2017. -She was not aware of the requirement to review and update the emergency preparedness policies at least every two years. *They had not: -Documented a community-based risk assessment that included strategies to address an emergency event. -Documented the collaboration with the local, regional, or state emergency managers to implement emergency procedures within the community setting. -Identified a specific procedure informing staff how to or who to contact in the event a patient required evacuation from their home. -Developed a complete communication plan. -Developed a system of medical documentation to preserve patient confidential information or to maintain secured medical records. -Documented their participation in a full-scale community-based exercise, facility-based functional exercise, mock disaster drill, table-top exercise, or other emergency preparedness training. -Documented their activation or response to actual emergencies that occurred such as the 2020 coronavirus pandemic or winter storm events. -Documented staff training in regards to their emergency preparedness plan. -Consistently documented all residents' prioritization level for their individualized needs in case of an emergency. *She confirmed they had not implemented a comprehensive emergency preparedness program that met the requirements indicated in the regulations. Interview on 6/3/21 at 2:45 p.m. with administrator B regarding the emergency preparedness program confirmed the above findings.

A recertification health survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health services, was conducted from 6/2/21 through 6/3/21. Dakota Physical Therapy Home Health Care was found in compliance.