Every finding on record at Emmanuel Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/14/25. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan every 2 years. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/10/25 at 2:15 PM. The Plan lacked a date of when it was last updated or revised. 2. During an interview with the Administrator, Clinical Supervisor and Biller on 02/11/25 at 1:10 PM, it was stated that the Emergency Preparedness Plan has not been updated since 2021. During the same interview, the above finding was confirmed.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach, every two years. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/10/25 at 2:15 PM. The plan lacked documentation of Hazard Vulnerability Assessments for the years 2022, 2023 and 2024. 2. During an interview with the Administrator, Clinical Supervisor and Biller on 02/11/25 at 1:10 PM, the above finding was confirmed. .

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 02/14/25. Standard level deficiencies cited. Abbreviations: AM = Morning PM = Afternoon SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients MSW =Medical Social Worker OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Agency’s Error Summary report and staff interview, it was determined that in the last 12 months, the Agency failed to submit 202 of 458 reports on time. Finding include: 1. The Agency’s Error Summary report for 02/01/24 thru 01/30/24, was reviewed on 02/10/25 at 11:50 AM. The report included error # -3330. The report included 44.10% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator, on 02/11/25 at 12:00 PM.

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 the clinical records reviewed and staff interview, it was determined in 4 of 7 (Pts. #4, 3, 6 and 7) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 2. Pt. #3 was admitted to the home health services on 06/20/24 with the diagnosis of: Encounter for Orthopedic. The clinical record was reviewed on 02/11/25. The clinical record contained a POC dated 12/27/24, that required the SN to assess the patient’s heart rate and blood glucose, 2 times a week for 9 week and notify the Physician or heart rates below 60. The SN visit note dated 02/03/25 lacked documentation that the Physician was notified of the heart rate of 52. 3. Pt. #6 was admitted to the home health services on 10/03/22 with the diagnosis of: Encounter for Change. The clinical record was reviewed on 02/11/25. The clinical record contained a POC dated 05/25/24, that required the SN to assess the patient’s pain and blood glucose, 1 time a week for 9 week. The SN visit note dated 06/27/24 lacked the pain and blood glucose assessment. 4.Pt. #7 was admitted to the home health services on 10/02/24 with the diagnosis of: Type 2 Diabetes Mellitus was reviewed on 02/11/25. The clinical record contained a POC dated 12/01/24, that required the SN to assess the patient’s blood glucose and weight, 1 time a week for 9 week. The SN visit note dated 01/22/25 lacked the blood glucose and weight assessment. 5. The above findings were confirmed, during the interview with the Director of Nursing, on 02/11/25 at 11:30 AM and on 02/13/25 at 11:00 AM, with the Director of Nursing. Findings include: 1.Pt. #4 was admitted to home health services on 01/06/25 with the diagnosis of Encounter for Change or Removal of Non-surgical Wound Dressing. The clinical record was reviewed on 02/10/25. The record included a Physician order dated 01/10/25 which included the documentation, “Please refer patient to MSW for assistance with Medicare Part D enrollment.” The record lacked documentation of an MSW evaluation or visit.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on the review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/6/21 at 11:15 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information of all staff members, patients' Physicians and other allowed Practitioners. 2. During an interview with the Administrator and Clinical Manager on 12/8/21 at 11:45 AM, the Administrator confirmed the above finding.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care cc = cubic centimeters RN = Registered Nurse PM = afternoon/evening Pt./Pts. = Patient/Patients PCP = Primary Care Physician OT = Occupational Therapy/Therapist VFSS = Videofluoroscopic Swallowing Study

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure there was coordination of care between care providers to ensure Pt. needs are met. This was found in 1 of 2 (Pt. #7) closed clinical records reviewed. Findings include: 1. Pt. #7. SOC 1/25/21. Diagnoses: Acute Lymphoblastic Leukemia, Chronic Diastolic (Congestive) Heart Failure and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 12/7/21 at 1:00 PM. The record contained the OT evaluation dated 2/3/21 and signed by the Physician, requiring the OT to provide service 1 time a week for 1 week, then 2 times a week for 4 weeks. The OT missed visit note dated 2/9/21 included documentation the patient’s daughter canceled the visit for that week with no reason given. The OT missed visit note dated 2/12/21 included documentation the Pt. refused the visit, no one was there to be with Pt. The OT Discharge Summary form dated 2/12/21 included: “Discontinued service due to refusal of service”. Meanwhile, the SN provided service 1 to 2 times a week from 1/25/21 to 3/23/21 without interruptions. The record lacked any care coordination between the SN and OT regarding the OT's inability to provide service. The record also lacked documentation the Agency notified the Physician that OT services were not provided as ordered, prior to the Agency’s discharge. 2. The Agency policy titled, “Care Planning, Coordination of Services and Quality of Care” was reviewed on 12/8/21 at 10:30 AM. The policy required: “…Coordination of Care The Agency must…3. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines...” 3. The Agency policy titled, "Missed Visits / Attempted Visit" was reviewed on 12/9/21 at 10:00 AM. The policy required: "...Special Instructions Field staff/worker should notify immediately the physician and agency or his/her respective mother agency (in case of contractor) through fastest means of communication (phone/cellular phone or fax)…" 4. During an interview with the Administrator and Clinical Manager on 12/8/21 at 1:10 PM, both confirmed the SN and OT failed to coordinate care to ensure OT services were provided, and that the Physician was notified OT services were not provided.

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: A. Based on a review of clinical records, interview during a home visit, Agency policy, and staff interview, it was determined the Agency failed to ensure clinical documents were complete. This was found in 2 of 7 (Pts. #2 and 7) clinical record reviewed. Finding include: 1. Pt. # 2. SOC 1/15/21. Diagnoses: Encounter for Change or Removal of Nonsurgical Dressing and Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 12/7/21 at 3:00 PM. The record contained SN visit notes 1 to 2 times a week from 9/14/21 to 11/29/21 which included documentation, the SN assessed and provided wound care to 1 wound located to the sacrum. A home visit was conducted on 12/7/21 at 11:15 AM with Employee #1. During the home visit, the Pt. stated he currently has 3 chronic wounds (right buttock, left buttock and sacrum). During an interview with the Administrator and Clinical Manager on 12/8/21 at 1:10 PM, the Administrator stated the Pt. does have 3 wounds. As of 12/7/21, the record lacked a weekly assessment of the left and right buttock wounds from 9/14/21 to 11/29/21, as required by the Agency's policy. The SN visit notes dated 10/18/21 and 11/19/21 contained documentation the SN changed the patient’s Foley catheter. During an interview with the Administrator and Clinical Manager on 12/8/21 at 1:10 PM, the Administrator stated “I used a Foley catheter size 18 Coude and 30 cc balloon…” The visit notes indicated lacked the size of the catheter and balloon inflation of the catheter. 2. Pt. #7. SOC 1/25/21. Diagnoses: Acute Lymphoblastic Leukemia, Chronic Diastolic (Congestive) Heart Failure and Unspecified Dementia without Behavioral Disturbance. The closed clinical record was reviewed on 12/7/21 at 1:00 PM. The record included a Speech Therapy evaluation dated 4/16/21 and signed by the Physician, recommending a "VFSS". The SN visit note dated 5/17/21 included documentation the SN conducted discharge planning, and contacted the Physician with “Orders Received: Will follow up Video-swallow. Follow up with PCP”. The same SN visit note included, “Make sure you go for Video-swallow when schedule is provided to you…” The Agency’s forms titled, “Discharge Summary” and “Patient Discharge Plan and Instructions” both dated 5/24/21 and completed by the SN, lacked instructions for the Pt. to follow-up with the PCP for VFSS. The Discharge Summary also lacked a summary of the Speech Therapy services provided and unmet needs, as required by the Agency’s policy. 3. The Agency’s policy titled, “Wound Assessment and Documentation Policy” was reviewed on 12/8/21 at 11:00 AM. The policy required: “Purpose To perform a comprehensive wound assessment… 4. Wound measurements shall be performed once a week and documented…” 4. The Agency’s policy titled, “Clinical Records” was reviewed on 12/8/21 at 11:15 AM. The policy required: “…b. Authentication. All entries must be …clear, complete…” 5. The Agency policy titled, “Discharge Summary” was reviewed on 12/8/21 at 11:40 AM. The policy required: “…Purpose To record a summary of care received by the client from the start of care through discharge. To document client status at the time of discharge, identified unmet needs…” 6. During an interview with the Administrator and Clinical Manager on 12/8/21 at 1:10 PM, both confirmed the clinical record was incomplete.