Every finding on record at Jefferson Co Home Health Agency

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (642DA-H1) at the above-named Home Health Agency from 09/17/24 to 09/19/24, resulted in the following standard level deficiency respective to the Emergency Preparedness Program Conditions of Participation under 42 CFR 484.102.

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 document review and staff interview, the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that was based on and included a documented, facility-based and community-based risk assessment, that utilized an all-hazards approach and included strategies that addressed 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 agency's Emergency Preparedness Program failed to show evidence of a facility and community-based risk assessment performed annually. Review of a document titled, "Emergency Preparedness Plan - Hazard Vulnerability Analysis," showed, " ...1. The Administrator or designee is responsible for conducting the Hazard Vulnerability Analysis initially and annually prior to the start of the new calendar year. The document showed a facility and community-based risk assessment, dated 2017, was completed, however, there was no documentation to support a risk assessment had been completed annually since that date. During an interview on 09/19/24 at 1:30 PM, Staff A, Administrator, confirmed the above finding of no updated hazard vulnerability risk assessment being performed annually.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (642DA-H1) conducted at the above-named Home Health Agency (HHA) from 09/17/24 to 09/19/24 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 deficiencies cited.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record reviews and staff interview, the agency failed to provide services as ordered by a physician for 3 (Patients 1, 2, and 5) of 7 sample patients. This failed practice had the potential to place patients at risk for unmet needs and services, as well as adverse outcomes. Findings Include: Patient 1 Review of Patient 1's, "Home Health Certification and Plan of Care (POC)," dated 07/25/24, showed that Patient 1 was admitted with a primary diagnosis of cellulitis to right lower limb with orders for Skilled Nurse two times per week to perform wound care, and included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented on the two visits made during the week of 07/28/24. There was no documentation to support wound measurements were completed for the two scheduled visits or the two "PRN" (as needed) visits made during the week of 08/11/24. Patient 2 Review of Patient 2's, "Home Health Certification and Plan of Care (POC)," dated 04/01/24, showed that Patient 2 was admitted with a primary diagnosis of lymphedema with orders for Skilled Nurse three times per week to apply and monitor compression wraps. Orders included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented during the first three weeks of the episode period, dated from 07/30/24 through 09/27/24. Patient 5 Review of Patient 5's, "Home Health Certification and Plan of Care (POC)," dated 06/26/24, showed that Patient 5 was admitted with a primary diagnosis of diabetes with chronic ulcer and orders for Skilled Nurse three times per week to perform wound care, that included measuring the wound weekly. Review of skilled nursing visit notes showed no wound measurements were documented on the three visits made during the week of 09/01/24. During an interview on 09/19/24 at 2:30 PM, Staff A, Administrator, confirmed the above findings that skilled nursing failed to measure patient wounds as ordered on the Plans of Care.

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 record review and staff interview, the Home Health Agency (HHA) failed to ensure a discharge summary was sent to the physician within 5 business days of the date of discharge for 1 (Patient 7) of 2 discharged patients. This failed practice had the potential to affect patient safety and to place all patients at risk for adverse outcomes across the health care spectrum. Findings Include: Patient 7 Review of Patient 7's clinical record showed the "Home Health Certification and Plan of Care," with a Start of Care date of 07/11/24. Review of visit notes for the current certification period showed the patient died at home on 08/05/24. There was no documentation to support a discharge summary was sent to the physician. There was no documentation to support the agency notified the physician of the patient's death. During an interview on 09/19/24 at 10:30 AM, Staff A, Administrator, confirmed the agency had not send a discharge summary to the physician for the patient.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification Survey ASPEN #56CV11 at the above-named Home Health Agency (HHA) from 10/04/21 to 10/06/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey ASPEN #56CV11 conducted at the above-named Home Health Agency (HHA) from 10/04/21 to 10/06/21 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 deficiencies cited: Unduplicated census: 47 Sample size: 7

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview, record reviews, and policy review, it was determined that the agency failed to conduct a medication regimen review (a review of all patient medications done to avoid medication errors such as duplications or drug interactions) for one of two patients (Patient 2) when a new medication was added to Patient 2's Plan of Care (POC - a comprehensive plan that includes medications and interventions that guides the staff in providing patient care) after Patient 2's admission to the agency. This failure had the potential for the patient to experience negative side effects from drug interactions. Findings Include: A review of agency policy titled, "Medication Regimen Review Comprehensive," revised 08/2017, showed that medication regimen reviews were to be done throughout the patient's care period. A review of Patient 2's clinical record, "Home Health Certification and Plan of Care (POC)," dated 09/05/21, showed that Patient 2 was admitted to the agency on 09/05/20, with diagnoses that included encephalopathy (a brain disease that causes confusion) and convulsions (seizures). A review of Patient 2's clinical record, "Physician Order," dated 09/22/20, showed that on 09/22/20, Patient 2 was diagnosed with cellulitis (a skin infection) and prescribed cephalexin (an antibiotic used to treat infections) 500 milligram (mg) to be taken three times a day by mouth for ten days. A review of Patient 2's clinical record did not show that a medication regimen review had been completed after the cephalexin had been added to Patient 2's POC. During an interview conducted on 10/06/21 at 9:00 AM, Staff A, Home Health Director (HHD), stated that per agency policy, staff were to complete a medication regimen review when a new medication was added to a patient's POC after the patient's admission date. The HHD confirmed that Patient 2's cephalexin added on 09/22/20 was a new medication added after Patient 2's admission on 09/05/20. The HHD confirmed that the agency could not provide evidence that a medication regimen review had been completed after the cephalexin had been added to Patient 2's POC. The HHD acknowledged that the agency had not followed policy.

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 interview, record reviews, and policy reviews, it was determined that the facility failed to develop and implement an individualized Plan of Care (POC - a comprehensive plan that includes medications and interventions that guides the staff in providing patient care) for one of seven patients (Patient 5). This failure had the potential for care providers to not assess or respond to patients' health needs. Findings Include: A review of agency policy titled, "Plan of Care," revised 08/2017, showed that individualized POCs were to be developed based on comprehensive assessments. A review of Patient 5's clinical record, "Home Health Certification and Plan of Care (POC)," dated 09/03/21, showed that Patient 5 was admitted to the agency on 09/03/21 with diagnoses of calculus of kidney (kidney stone), a secondary diagnosis of cystitis without hematuria (an inflammation or infection of the bladder without blood in the urine), and history of urinary tract infection (bladder infection). Further review did not show any outcomes or goals related to calculus of kidney or cystitis without hematuria. During an interview conducted on 10/06/21 at 8:30 AM with Staff A, Home Health Director (HHD) and Staff B, Clinical Manager (CM), the HHD stated that patients' POCs should include outcomes and goals related to primary diagnoses. The agency did not provide evidence of outcomes and goals related to Patient 5's diagnoses of calculus of kidney and cystitis without hematuria. The CM confirmed that there was no evidence of outcomes and goals related to Patient 5's diagnoses of calculus of kidney and cystitis without hematuria. The HHD acknowledged that the agency had not followed policy.