Every finding on record at Hospice of the Prairie Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (6117E-H1) at the above-named Home Health Agency (HHA) on 09/28/23 to 09/29/23 resulted in the following standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 Emergency Preparedness Plan (EPP) the above-named Home Health agency (HHA) failed to review and update the EPP at least every 2 years. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: It was observed that the HHA failed to conduct a review of the entire EPP every 2 years. The last documented review of the plan showed it was revised in 2019 and a documented review was not completed as required. On 09/28/23 between 11:00 AM and 2:00 PM, while reviewing the EPP, the Administrator was present and acknowledged the findings.

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 interview and policy review the above-named Home Health agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach and include strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the HHA's EPP last revised in 2019 failed to show the EPP was based on an all hazards approach whose hazards were identified using an objectively reliable source such as data from National Preparedness System, published by the United States Department of Homeland Security’s Federal Emergency Management Agency (FEMA), or guidance as provided by the Agency for Healthcare Research and Quality (AHRQ). On 09/28/23 between 11:00 AM and 2:00 PM, while reviewing the EPP, the Administrator was present and acknowledged the findings.

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 agency’s Emergency Preparedness Plan (EPP) the above-named home health agency (HHA) failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency. This failure has the potential to place patients at risk for unmet needs during an emergency. Findings Include: Review of the HHA's EPP last revised in 2019 failed to include policies and procedures for the use of volunteers during an emergency. On 9/28/23 between 11:00 AM and 2:00 PM, while reviewing the EPP, the Administrator was present and acknowledge the findings.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (#6117E-H1) conducted at the above-named Home Health Agency (HHA) from 09/28/23 to 09/29/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiency cited.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on policy review, documentation review, and interview, the agency failed to ensure home health aides (HHAs) completed 12 hours of HHA in-service training during each 12-month period for 2 (HHA 4 and 8) of 4 HHA personnel files reviewed. Findings Included: A review of the agency’s “Home Health Aide Services Policy 1:18,” last revised in February of 2023, revealed, “All home health aides will receive a minimum of 12 hours of education, specifically addressing clinical topics pertinent to providing safe and effective home care, per calendar year.” The review of the policy revealed it failed to describe the standard of ensuring 12 hours of HHA education occurred during each 12-month period and, instead, described that the standard should be met every calendar year. Review of an “Employee Census” document dated 09/28/23 revealed the agency hired HHA 4 on 07/08/02. A review of a continuing education “2022-2023 Hours” document revealed HHA 4 received six hours of in-service training during the 12-month period from 07/08/22 to 07/08/23 (on 10/17/22). Review of an “Employee Census” document dated 09/28/23 revealed the agency hired HHA 8 on 09/04/01. A review of a continuing education “2022-2023 Hours” document revealed HHA 8 received six hours of in-service training during the 12-month period from 09/04/22 to 09/04/23 (on 10/27/22). During an interview on 09/29/23 at 9:30 AM, the Executive Director stated she did not realize the HHA in-service training requirements of at least 12 hours was to occur during each 12-month period. The Executive Director stated, “I thought I had until the end of the year.” The Executive Director acknowledged the standard was not met.