Every finding on record at Great Plains of Sabetha Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (62A85-H1) at the above-named Home Health agency (HHA) on 04/03/24 resulted in noncompliance the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102 with the following standard level deficiencies.

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, §485.542, §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 review of the Emergency Preparedness Plan (EPP), policy and procedure review, and interview the Home Health agency failed to maintain an up-to-date comprehensive emergency preparedness program plan (EPP). The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1. The agency failed to address the patient population, including persons at-risk, the type of services available during an emergency, and continuity of operations, including delegations of authority and succession plans, as required by the regulation. (Refer to E0007) 2. The agency failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, as required by the regulation. (Refer to E0009) 3. The agency failed to develop and implement emergency preparedness policies and procedures aligned with the requirements outlined in the regulation. (Refer to E0013) 4. The agency failed to develop and implement individualized emergency preparedness plans for patients as part of their comprehensive patient assessment for 7 of 7 patients reviewed, as required by the regulation. (Refer to E0017) 5. The agency failed to develop and implement policies and procedures regarding the use of volunteers in an emergency or other emergency staffing strategies, including the integration of State and Federally designated healthcare professionals to address surge needs during an emergency. (Refer to E0024) 6. The agency failed to ensure a documented training and testing program was in place as required (Refer to E0036) 7. The agency failed to 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. (Refer to E0037)

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP) and interview the Home Health agency failed to address the patient population, including persons at-risk, the type of services available during an emergency, and continuity of operations, including delegations of authority and succession plans, as required by the regulation. This deficiency may impact the facility's ability to effectively respond to emergencies and ensure the safety of its patients. Findings Include: Review of the EPP revealed an absence of information addressing the [patient/client] population, services available during an emergency, and continuity of operations, including delegations of authority and succession plans. During an interview on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed that the EPP did not include provisions addressing the patient population, services available during an emergency, and continuity of operations, revealing non-compliance with the regulatory requirements outlined in CFR Section 484.102(b).

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP) and interview the Home Health agency failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, as required by the regulation. This deficiency may hinder the facility's ability to effectively coordinate with external agencies and respond to emergencies in a unified manner. Review of the EPP indicated an absence of information addressing cooperation and collaboration with emergency preparedness officials at the local, tribal, regional, State, and Federal levels. During an interview on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed that the EPP did not outline a process for engaging in collaborative planning with relevant emergency preparedness authorities, revealing non-compliance with the regulatory requirements outlined in CFR Section 484.102(a)(4).

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Plan (EPP), policies and procedures review and interview the agency failed to develop and implement emergency preparedness policies and procedures aligned with the requirements outlined in the regulation. This deficiency may compromise the facility's ability to effectively respond to emergencies and mitigate risks to patient safety. Findings Include: Review of the agency's policies and procedures revealed an absence of documentation addressing emergency preparedness policies and procedures as required by CFR Section 484.102(b). During an interview on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed that the facility lacked specific policies and procedures related to emergency preparedness, including protocols for managing various emergency scenarios such as fire, equipment or power failures, care-related emergencies, water supply interruptions, and natural disasters. Additionally, there was no evidence to suggest that the facility's policies and procedures were reviewed and updated at least every two years, as mandated by the regulation.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's Emergency Preparedness Plan (EPP), policy and procedure review, record review, and interview the Home Health agency failed to establish and execute individualized emergency preparedness plans for patients as part of their comprehensive patient assessment, as mandated by the regulation for 7 of 7 patients reviewed (Patient 1-7). Failure to develop individualized emergency plans for patients may hinder the agency's ability to provide appropriate care and support during emergency situations, potentially compromising patient safety and well-being. Findings Include: Review of the agency's emergency preparedness policies and procedures revealed a lack of documentation addressing individualized emergency plans for patients. There were no provisions outlining discussions or strategies to develop personalized emergency plans for each patient in the event of disasters. During interviews conducted on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed the agency did not have procedures in place to incorporate individualized emergency plans into comprehensive patient assessments. There were no documented discussions or educational sessions with patients, caregivers, or other involved parties regarding steps to enhance patient safety during emergencies. Furthermore, there was no evidence to suggest that the agency's policies and procedures were reviewed and updated at least every two years, as mandated by the regulation. The absence of regular review and updates may contribute to the agency's failure to address the needs of patients during emergencies effectively. The lack of individualized emergency plans for patients may hinder the agency's ability to provide appropriate care and support during emergency situations, potentially compromising patient safety and well-being. Review or Patient records 1 through 7 lacked documented evidence by agency professional staff of an individual emergency preparedness plan as part of the comprehensive assessment for each patient. During an interview on 04/03/24 at 12:00 PM, the Administrator stated that there were no individualized plans for the HHA's patients during a natural or man-made disaster.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA) Emergency Preparedness Plan (EPP) and interview the Home Health agency failed to develop and implement policies and procedures concerning the utilization of volunteers in emergencies or other emergency staffing strategies, including the integration of State and Federally designated healthcare professionals to address surge needs during such situations. Failure to establish appropriate policies and procedures for emergency staffing may lead to delays in care delivery, increased patient wait times, and potential disruptions in service provision. Findings Include: Review of the agency's policies and procedures lacked specific guidance on the utilization of volunteers and other emergency staffing strategies to address surge needs during emergency situations, as required by CFR Section 484.102(b)(5). During an interview on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed the absence of comprehensive policies and procedures addressing the integration of volunteers and designated healthcare professionals into the agency's emergency response efforts. Furthermore, it was noted that while the agency's policies and procedures outlined general requirements for surge planning, they did not provide specific guidance on the process and role for integrating State and Federally designated healthcare professionals to address surge needs, as mandated by CFR Section 484.102(b)(5).

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Training and Testing Program (EPP) and interview the Home Health agency failed to ensure a documented training and testing program was in place as required by CFR Section 484.102(d). This deficiency affects the preparedness of staff members and their ability to effectively respond to emergencies, affecting all patients, staff and visitors. Findings Include: Review of the agency's Emergency Preparedness Training and Testing Program between 11:30 AM and 3:00 PM with the Administrator confirmed an absence of documented training and testing procedures, indicating non-compliance with regulatory standards outlined in CFR Section 484.102(d). There was no evidence of a structured training component aimed at educating staff, contractors, and volunteers on the emergency preparedness program, including policies, procedures, and communication plans, as mandated by the regulation. Furthermore, the facility lacked any documented testing exercises conducted to evaluate the effectiveness of the emergency plan. The absence of regular testing sessions, as required by the regulation, indicates a failure to assess and improve the facility's emergency readiness capabilities.

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), §485.542(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, REHs at §485.542, "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 review of the Emergency Preparedness Program (EPP) and interview the Home Health agency failed to 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, as required by CFR Section 484.102(d)(1). This oversight impacts the readiness of personnel and may impede their ability to respond effectively during emergencies, potentially compromising patient and staff safety. Review of the facility's Emergency Preparedness Training Program revealed a lack of documented initial training provided to staff, individuals providing services under arrangement, and volunteers, in accordance with their anticipated roles during emergencies. During an interview on 04/03/24 between 11:30 AM and 3:00 PM, the Administrator confirmed the absence of comprehensive initial training sessions covering emergency preparedness policies and procedures. Staff expressed uncertainty regarding their roles and responsibilities during emergencies, indicating a lack of proper training and preparation. Furthermore, there was no evidence of emergency preparedness training being conducted at least every 2 years, as mandated by the regulation. The facility's failure to provide regular training sessions increases the risk of staff members being ill-prepared to respond effectively to emergencies.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site (Recertification) survey (62A85-H1) conducted at the above-named Home Health agency (HHA) from 04/02/24 to 04/04/24 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 418, Subpart C through E with the following standard-level deficiencies cited.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review, and staff interview, the Home Health agency (HHA) failed to ensure the patient's right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 3 of 7 sample patients (Patients 3, 4, and 6). The HHA's failure to ensure the patient's right to consent to frequency of services placed all patients currently on services at risk for unmet needs, care and services. Findings Include: Patient 3 Review of Patient 3' Admission Consent dated 03/27/24 lacked documented visit frequency for both skilled nursing (SN) and physical therapy (PT) disciplines. Review of the Plan of Care (POC) dated 03/27/24 indicated orders for SN at two times per week for two weeks, then one time per week for one week. There were also orders on the POC for PT at one time per week for one week, then three times per week for two weeks. Patient 4 Review of Patient 4's Admission Consent dated 03/26/24 lacked documented visit frequency for skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) disciplines. Review of the Plan of Care (POC) dated 03/26/24 indicated orders for SN at two times per week for three weeks, PT ordered frequency was one time per week for one week, then two times per week for two weeks, and the OT was for an evaluation only visit. Patient 6 Review of Patient 6's Admission Consent dated 10/18/23 lacked documented visit frequency for skilled nursing (SN). Review of the Plan of Care (POC) dated 10/18/23 indicated orders for SN visits at one time per week every other week for eight weeks. During an interview on 04/04/24 at 2:30 PM, Staff A, Administrator, stated that it is the expectation for the clinician performing the Start of Care Assessment visit and getting the consent signed to at least put their visit frequency on the consent form and then "eval" for any other disciplines that will be making an evaluation visit prior to developing the Plan of Care (POC). She confirmed the above findings of the agency's failure to ensure the patient's right to consent to visit frequencies of services.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview, it was determined that the Home Health agency (HHA) failed to ensure the patient's comprehensive assessment included patient input as to their specific goals and outcomes to be achieved from home health services for 7 of 7 sample patient reviewed (Patients 1 - 7). The agency's failure to ensure the patient's comprehensive assessment contained all required elements to reflect the patient's status at the time of the assessment including patient stated goals, placed all patients currently on service, at risk for adverse outcomes and unmet needs. Findings Include: Review of clinical records for Patients 1 through 7, showed that there were no patient stated goals included in the documentation of the Comprehensive Assessment at the Start of Care (SOC). There was also not documentation to indicated that the patient was included in establishing goals for their home health services. During an interview on 04/03/24 at 3:50 PM, the Administrator confirmed that the agency had not documented the patient specific goals in the Comprehensive Assessment because they felt it was included in the OASIS Assessment answers.

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 clinical record review, and staff interview it was determined, the Home Health agency (HHA) failed to contact the physician for specific orders when performing a Comprehensive Assessment and establishing an individualized Plan of Care (POC) for patients with general referrals for services for 2 of 7 sample patients (Patient 2 and 5). The Home Health agency's failure to ensure the physician was contacted for specific treatments and orders when establishing the patient's Plan of Care placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 2 Review of Patient 2's clinical record indicated the Home Health agency received a faxed referral from in patient facility on 03/19/24 for Skilled Nursing, Physical and Occupational Therapy services. The Home Health agency's Registered Nurse (RN) performed a Start of Care (SOC) Comprehensive Assessment including OASIS on 03/20/24. There was no documented evidence of the RN contacting the physician regarding the assessment that was made or requesting approval of the Plan of Care (POC) that would be established for the patient. Patient 5 Review of Patient 5's clinical record indicated the Home Health agency received a faxed referral from in patient facility on 03/15/24 for Skilled Nursing, Physical and Occupational Therapy services. The Home Health agency contacted the physician's office and received and order to start services on 03/18/24. The Home Health agency's Registered Nurse (RN) performed a Start of Care (SOC) Comprehensive Assessment including OASIS on 03/18/24. There was no documented evidence of the RN contacting the physician regarding the assessment that was made or requesting approval of the Plan of Care (POC) that would be established for the patient. During an interview on 04/03/24 at 3:45 PM, Staff A, Administrator stated "our physicians don't want to be bothered with all those calls, we go by our referral". The Administrator confirmed the above findings of no physician approval for the above patients Plans of Care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview, it was determined that the home health agency failed to ensure the plan of care was individualized to include interventions, goals, and safety precautions to manage patients medical diagnosis for 6 of 7 sample patients (Patient 1 - 6). This failed practice had the potential to place all patient at risk for adverse outcomes as well as unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/22/24 and a Certification Period from 03/22/24 to 05/20/24. The Primary Diagnosis was listed as: Compression Fracture Thoracic Vertebrae. Orders, Treatments, and Interventions included on the Plan of Care were for skilled nursing to instruct the patient on daily weights however, there was no diagnosis to support monitoring weights. The medication list contained Aspirin 81 mg oral tablet per day however, there were no bleeding precautions listed as part of the safety measures for the patient. Patient 2 Review of Patient 2's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/20/24 and a Certification Period from 03/20/24 to 05/18/24. The Primary Diagnosis was listed as: Hypertensive Chronic Kidney Disease. Other listed diagnosis on the Plan of Care included Encounter for attention to Artificial Openings of Urinary Tract System however, there were no orders, goals, or supplies listed relating to, or directions as to who maintains the ostomy. Patient 3 Review of Patient 3's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/27/24 and a Certification Period from 03/27/24 to 05/25/24. The Primary Diagnosis was listed as: Aftercare Following Joint Replacement Surgery. Other listed diagnosis on the Plan of Care included Type 2 Diabetes Mellitus. There were no written orders, goals, or supplies listed relating to monitoring diabetes. The medication list contained Aspirin EC 325 mg oral tablet twice a day for DVT prophylaxis however, there were no bleeding precautions listed as part of the safety measures for the patient. There was also a diagnosis of Long Term (current) Use of Insulin however, there was no insulin listed on the medications on the Plan of Care. Patient 4 Review of Patient 4's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/26/24 and a Certification Period from 03/26/24 to 05/24/24. The Primary Diagnosis was listed as: Urinary Tract Infection. Other listed diagnosis on the Plan of Care included Hypertensive Heart Disease with Heart Failure and Chronic Diastolic (Congestive) Heart Failure. There were no written orders, or goals related fluid overload or monitoring daily weights. Patient 5 Review of Patient 5's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 03/18/24 and a Certification Period from 03/18/24 to 05/16/24. The Primary Diagnosis was listed as: Encounter for Surgical Aftercare Following Surgery of the Circulatory System. The medication list contained Aspirin 81 mg oral tablet per day however, there were no bleeding precautions listed as part of the safety measures for the patient. Patient 6 Review of Patient 6's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 01/19/24 and a Certification Period from 01/19/24 to 03/18/24. The Primary Diagnosis was listed as: Hemiplegia Following Cerebral Infarct Affecting Left Nondominant side. Other listed diagnosis on the Plan of Care included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Chronic Diastolic (Congestive) Heart Failure. There were no written orders, or goals related fluid overload or monitoring daily weights. During an interview conducted on 04/03/24 at 3:50 PM, Staff A, Administrator confirmed the above findings of the agency not having an individualized Plan of Care with interventions to manage patient medical diagnosis.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observation, policy/procedure document review, and staff interview, it was determined the Home Health agency (HHA) failed to follow acceptable standards of practice, including the use of standard precautions to prevent infections for 1 of 3 patient hoe visits (Patient 3). This failed practice of not adhering to standard precautions had the potential to place all patients on services at risk of infection and hospitalization. Findings Include: Patient 3 Review of agency document titled, "Bag Technique" indicated that the clinician's bag is not to be placed on the floor, is to be closed during the visit and that a barrier is to be used under the bag and equipment. Review of Patient 3's clinical record, indicated a Start of Care (SOC) date of 03/27/24 and a primary diagnosis of Aftercare Following Joint Replacement Surgery. During home visit observation on 04/04/24 from 9:00 AM to 9:45 AM, the Registered Nurse (RN) was observed to provide a routine head to toe assessment of the patient, including vital signs. The RN placed her clinician's bag on the floor using a barrier and gathered her vital sign equipment from inside her bag. She then went to the recliner the patient was in and knelt on the floor beside the chair without a barrier placed on the floor under her knees. The RN also place her vital sign equipment on the floor beside the chair without a barrier and then picked it up and used it on the patient. When the RN completed her visit and cleaned her reusable medical equipment with a dissentient wipe she failed to allow any time for the equipment to air dry before placing it back into her clinician's bag. During an interview, on 04/04/24 at 3:35 PM with Staff A, Administrator confirmed that the RN failed to adhere to standard precaution and follow the agency's bag technique appropriately.

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 interview and record review, it was determined the Home Health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient care services for 1 of 7 sample patients (Patient 6). The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Patient 6 Review of Patient 6's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 10/18/23 and a certification period from 10/18/23 to 12/16/23. Review of visit notes for the certification period from 10/18/23 to 12/16/23 showed a recertification visit was made on 12/13/23 for Skilled Nurse to continue to pre-fill patient medications ever two weeks. Review of visit notes for the certification period from 12/17/23 to 02/15/24 showed a transfer to the hospital on 12/17/23. The Home Health agency (HHA) failed to perform a transfer OASIS assessment or a transfer summary however, they did perform discharge OASIS and a discharge summary. During an interview on 04/03/24 at 3:30 PM, Staff A, Administrator, stated "this was a VA (Veteran Administration) patient and OASIS and a transfer summary are not required". The Administrator then confirmed that the agency has not sent a transfer summary to the receiving facility.