Every finding on record at Homecare of the Valley

A recertification survey was completed on 1/8/25. Two deficiencies were cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to document whether it had conducted an exercise based on the emergency plan, or had documented the agency's post-analysis review when the agency implemented their emergency plan during an actual emergency for the year 2024. Findings include: 1. Review of the emergency preparedness binder on 1/8/25, revealed the agency had not documented it had conducted an exercise of their emergency preparedness plan in 2024. Further review of the emergency preparedness binder revealed the agency had not documented if it had activated its emergency plan during an actual emergency in 2024. a. The agency failed to document the activation of its emergency preparedness plan during an actual emergency in 2024. During an interview on 1/8/25 at 9:33 a.m., the administrator/director of nursing (DON) stated the agency had experienced an emergency in the form of a rock slide that happened in July of 2024. The administrator/DON went on to state that this incident cut the agency off from multiple patients for a period of eight hours. The agency had implemented it's emergency plan which included having a nurse available on the other side of the rock slide to provide services to patients that required services during those eight hours. The administrator/DON acknowledged the agency had failed to document the activation and post-analysis of this emergency plan, and was unable to provide information if it needed to alter the emergency plan, based on information gathered during the emergency. The administrator/DON acknowledged regulation required the agency to document the activation and post-analysis of its emergency preparedness plan and/or a tabletop/mock drill and she would ensure to comply with this requirement in the future.

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 interview and record review the agency failed to have an accurate plan of care (POC) for 1 of 1 active patient records reviewed who received skilled nursing (SN) services for management of a suprapubic catheter (a tube that drains urine from the bladder through a surgically created opening in the abdominal wall)(Patient #2). Findings include: AGENCY POLICY According to an undated agency policy titled, Patient Plan of Care, (read in pertinent parts): "It shall be the policy of this Agency to develop and implement an individualized Plan of Care for each patient admitted for service, which is established and reviewed by a physician to insure appropriate application of services to the patient's condition." "To establish a process and procedure for the development, review, and, as indicated, revision of a Plan of Care for each patient. To ensure that the patient's Plan of Care consistently reflects the current problems, goals, and interventions relating to the services and care which have been ordered." "The admitting clinician develops the patient's Plan of Care based on his/her initial assessment finding in coordination with the physician, home health care staff, and interdisciplinary team members." "The Plan of Care is revised whenever necessary to accommodate changes in a patient's health status or environment and no less frequently than every sixty (60) days." 1. During an interview on 1/7/25 at 9:01 a.m., the administrator, who was also the director of nursing (DON), stated the quality assurance performance improvement (QAPI) manager, who was also a registered nurse (RN), created all POCs for the agency's home health care patients. The administrator stated either a RN, a physical therapist (PT) or occupational therapist (OT) would complete the start of care or recertification assessment of the patient, then the QAPI manager would take the information from the assessment(s) and generate a POC for the patient. During an interview on 1/7/25 at 9:28 a.m., the QAPI manager acknowledged she was responsible for generating all POCs for home health care patients and she also was responsible for conducting quality assurance reviews of POCs for accuracy. 2. The clinical record for Patient #2 was reviewed on 1/6/25. The POC for the certification period dated 9/22/24 to 11/20/24, signed by the physician on 9/23/24, revealed a start of care date of 8/9/21; diagnoses included neuromuscular dysfunction of the bladder, retention of urine, encounter for attention to cystostomy (medical management of surgical opening to the bladder), motor and sensory neuropathy, and paraplegia. POC orders included: SN visits one time a week every other week for seven weeks and one time a week for one week for assessment, education, and catheter changes once per month and as needed (PRN); PT one time a week for one week for evaluation; and OT one time a week for one week for evaluation. Patient #2's POC for the certification period dated 11/21/24 to 1/19/25, signed by the physician on 11/26/24, revealed a start of care date of 8/9/21; diagnoses included neuromuscular dysfunction of the bladder, retention of urine, encounter for attention to cystostomy, motor and sensory neuropathy, and paraplegia. POC orders included: SN visits one time a week every other week (duration not documented) and four PRN visits for for assessment, education, and catheter changes once per month and as needed (PRN); PT one time a week for one week for evaluation; and OT one time a week for one week for evaluation. a) The agency failed to ensure Patient #2 had an accurate POC. Specifically, the agency failed to ensure Patient #2's POC had accurate service types listed on the POC. Further review of the POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25 showed PT was to do an evaluation to: assess for knowledge/skill deficits, strength, functional mobility, balance/coordination and endurance; and to provide patient education on lower extremity strength exercises, mobility training, posture/balance training, and activity tolerance training. The POC showed two short term PT goals were met; two of the four long term PT goals were met and 2 of the long term goals were not met. The OT was to: evaluate the patient to assess Patient #2's strength and knowledge/skills deficits; to provide patient education in upper body strengthening exercises; and refer Patient #2 to a hand therapist for custom resting hand splints to decrease contractures. The OT short term and long term goals were achieved. Review of Patient #2's record showed on 11/18/23 Patient #2 was discharged from PT due to reaching her maximum functional potential with a home exercise program in place. Further review of Patient #2's record showed no documented evidence of PT services after 11/18/23. Review of Patient #2's record showed on 12/1/23, Patient #2 was discharged from OT due to achieving her OT goals with a home exercise program in place. Further review of Patient #2's record showed no documented evidence of OT services after 12/1/23. Review of Patient #2's record failed to show a physician order to discharge the PT and/or OT evaluations ordered on the POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25. During a home visit on 1/7/25 at approximately 1:35 p.m., Patient #2 stated she received SN services two times a month for assessment and suprapubic catheter changes once per month. Patient #2 stated PT and OT had provided her with services, but had not come to see her in the past year. During an interview on 1/7/24 at 9:28 a.m., the QAPI manager stated the PT and OT evaluation orders on the POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25 were left on the POCs by mistake. The QAPI manager stated when the RN added the PT and OT orders for Patient #2, the orders were added without an end date. Additionally, the orders were entered into Patient #2's record through a specific section of the agency's electronic medical record (EMR) system. The QAPI manager stated the lack of an end date and adding the orders through the specific section of the EMR caused the orders to mistakenly carry over to subsequent POCs including for the POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25. During continued interview, the QAPI manager stated she was responsible for providing a quality assurance check of all POCs to ensure the POCs were accurate. The QAPI manager stated she was aware of this issue with the agency's EMR and was able to remove an order if it was accidentally carried over from one POC to the next if she noticed the error. The QAPI manager acknowledged she failed to identify the PT and OT orders were mistakenly carried over on the POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25. The QAPI manager stated to correct this deficient practice she planned to educate the clinicians who completed start of care and recertification comprehensive assessments to add an end date on any physician orders to avoid orders carrying over on subsequent POCs. During an interview on 1/7/25 at 9:35 a.m., the administrator reviewed Patient #2's POCs for the certification periods dated 9/22/24 to 11/20/24 and 11/21/24 to 1/19/25 and stated the PT and OT orders were mistakenly carried over from an older POC as Patient #2 had not received PT and OT services in over a year. During an interview on 1/8/25 at 1:59 p.m., the administrator again acknowledged a RN, PT, or OT completed the start of care and/or recertification comprehensive assessments and entered their findings into the EMR. The EMR then used the data entered from the comprehensive assessment to generate a rough POC. The QAPI manager then analyzed the information from the comprehensive assessment(s) to finalize a patient's POC. The administrator stated the QAPI manager was also responsible for reviewing the POCs for accuracy and this created the potential for the QAPI manager to miss mistakes as she was reviewing her own work. The administrator stated the agency would reevaluate how POCs were generated and who completed the quality checks on the POCs to correct this deficient practice. During an interview on 1/7/25 at 10:05 a.m., the chief executive officer (CEO) stated he was appointed to his position in October of 2024. The CEO stated since his appointment, he had noted issues with the EMR system the agency used. The CEO stated it was important for POCs to be accurate and he would work to ensure the agency corrected this deficient practice.

A recertification survey was completed on 1/12/22. One deficiency was cited.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure a physical therapist (PT) completed an initial assessment visit within 48 hours of referral for 1 of 2 patient records reviewed with only rehabilitation therapy services (Patient #6). This deficiency was cited previously during a recertification survey on 3/22/19. Although the facility corrected the deficiency, based on findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY According to the agency policy, "Admission Course of Action," reviewed May 2020 (in pertinent parts): "A comprehensive assessment and OASIS [Outcome and Assessment Information Set] data will be conducted by a RN or PT within 48 hours of receiving the referral or Face to Face (F2F) and insurance verification, or within 48 hours of the patient's return home from an inpatient stay, or on the physician's order start of care date." 1. The clinical record for Patient #6 was reviewed on 1/11/22. The Plan of Care for the certification period dated 12/8/21 to 2/5/22 revealed a start of care date of 12/8/21; diagnoses included chronic pain, low back pain, spondylolisthesis (lumbar region). Plan of Care orders included physical therapy (PT) visits twice a week for one week, three times a week for one week and two times a week for five weeks to provide bed mobility training, transfer training, gait training, balance/coordination training, assess/monitor respiratory status, education on safety/environment risks, and patient/caregiver education. a) The agency failed to ensure an initial assessment visit was conducted by a PT within 48 hours of the referral. On 1/11/22 record review revealed the agency received referral information for Patient #6 on 11/30/21. Further review revealed a PT evaluation and comprehensive assessment were completed by PT #8 on 12/8/21, eight days after the referral date. Review of a comprehensive (initial) assessment conducted on 12/8/21, by PT #8, showed documentation Patient #6 was assessed by the PT as a fall risk. Further review of the assessment revealed Patient #6 had a history of falls, decreased oxygen cord safety (she frequently became tangled in the oxygen tubing while ambulating with her walker) and a fear of falling. Further record review failed to show evidence an order had been obtained from the physician for a delay in the start of care for Patient #6. There was no documented evidence found of communication with the physician regarding the delay or reason for the delay in start of care. During an interview on 1/12/22 at 11:37 a.m.., the administrator and the home care/therapy clinical manager stated the start of care date for Patient #6 was delayed as the agency intake department had not received all of the admission paperwork from the referral case manager. The home care/therapy clinical manager provided handwritten notes for 11/30/21, 12/1/21, 12/2/21 and 12/3/21 which demonstrated evidence of the agency's attempt to collect admission paperwork for Patient #6. However, the administrator and home care/therapy clinical manager stated they did not have documentation which indicated Patient #6's physician was notified of the delayed start of care.