Every finding on record at Kismet Elk, LLC

A recertification survey for compliance with 42 CFR Part 484, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 11/21/22 through 11/22/22. Wel-Home Health Elk Point was found not in compliance with the following requirement: E0001.

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, §485.625, §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 policy review and interview, the provider failed to establish a comprehensive emergency preparedness (EP) program that had the potential to affect all patients. Findings include: 1. Interview on 11/22/22 at 10:45 a.m. with registered nurse (RN)/administrator A during review of the provider’s EP program revealed: *The cover of the undated Disaster and Emergency Preparedness Plan had identified the plan as belonging to another agency located in Iowa. *The 9/7/21 Hazard and Vulnerability assessment tool had been identified as the Iowa agency. -RN/administrator A stated the provider used the Iowa agency EP plan for their plan as well. *A 9/8/21 Annual Evaluation of Hazard Vulnerability analysis had been filled out. -The above analysis had not identified which agency it belonged to. -No recent evaluation had been completed. *RN/administrator A confirmed: -She held an EP meeting with the staff in September 2022. -They had not participated in a full or tabletop exercise. -The staff sat around a table and discussed what a disaster might look like. -She had not documented any participation in a full-scale community-based exercise, facility-based functional exercise, mock disaster drill, table-top exercise, or other emergency preparedness training. -The meeting discussion had not been documented, except to get a list of those staff attending. -There was no collaboration with the South Dakota local, regional, or state emergency managers to implement emergency procedures within the community setting. 2. Review of the Iowa agency Disaster and EP communication for the emergency operations plan (EOP) indicated: *The agency had developed and maintained an EP communication plan to comply with Federal, state, and local laws. *The communication plan was: -To have been reviewed and updated annually. -To have included contact information for Federal, state, tribal, regional, and local EP staff. *Contact information for "Other sources of assistance" included phone numbers for the EP responders, including: -Federal Emergency Management Agency (FEMA). -State EP responders had been identified for: --Iowa Homeland Security. --"Hazmat Team Iowa region 4." --Iowa State Emergency Coordinator. -Tribal EP – Winnebago Tribe of Nebraska. -Regional EP: Public Works/Engineering Woodbury County (Iowa). -Local EP: Woodbury County (Iowa) Joint Emergency/Management team. -Other sources: Iowa Highway Patrol. *The undated EP Operations Plan and Policies indicated the provider would work with the county emergency response agencies as requested and listed an Iowa address. There was no South Dakota state, regional, county, tribal, or local town emergency responders listed in the communication plan. 3. Review of the provider’s plan for availability of necessary medical information during a disaster with RN/administer A revealed: *The provider's office had no paper or electronic patient charts. -Staff members brought their computers to the office when they worked at the agency. *The medical history, medication orders, contact details, level of functioning, and patient preferences were stored in their electronic or paper medical record at the Iowa office. *The provider’s home health office in Elk Point was located in an assisted living facility. -If the internet was functioning the staff could send the information through the assisted living computer. -If the phones were working RN/administrator A could call to provide information. 4. Interview on 11/22/22 at 11:45 a.m. with RN/administrator A and vice president of operations (VPO) regarding the provider’s EP program confirmed: *The provider shared the EP plan with the Iowa agency. *The communication plan had not contained contact information for the South Dakota EP responders, but it should have. *The provider had not: -Participated in full-scale or table-top exercises. -Documented EP meetings/trainings. -Communicated with state, regional, or local emergency management officials. 5. Review of the provider’s undated Disaster and Emergency Preparedness Plan and undated EOP and policies revealed: *The agency was to coordinate efforts with the area emergency management agencies to respond and recover from high priority emergencies that impacted the community, such as the local health department, law enforcement, and office of emergency management. *Resources that could be used are ambulance transport, National Guard, Red Cross, law enforcement, fire department, state highway patrol, regional, and tribal EP organizations. *The home health director, clinical director, or managers would inform state and local EP officials by phone or in person about patients in need of evacuation. *The Governing Body was ultimately responsible for succession planning and delegation of authority. Review of the provider’s undated Testing Program for EOP revealed: *The agency would conduct exercises to test the EOP at least annually by: -Participating in a full-scale exercise that was community or facility-based. -Conducting an additional exercise that may include: --A second full-scale exercise that is community or facility-based. --A table-top exercise that included a group discussion, using a narrate, clinically relevant scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge the EOP. *If the provider is part of a healthcare system consisting of multiple separately certified healthcare facilities, the agency may choose to participate in the healthcare system’s coordinated EOP. If elected the provider must demonstrate: -Each separately certified facility within the system actively participated in the development of the unified and integrated EOP. -Each separately certified facility is capable of actively using the unified EOP and was in compliance with the program.

A recertification survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health services, was conducted from 11/21/22 through 11/22/22. Wel-Home Health Elk Point was found not in compliance with the following requirement: G444. Wel-Home Health Elk Point's vaccination program was reviewed for compliance with the Centers for Medicare and Medicaid (CMS) Quality, Safety and Oversight (QSO) memorandum QSO-23-02-ALL, dated October 26, 2022, on 11/22/22. Wel-Home Health Elk Point was found in compliance.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on admission packet review and interviews, the provider failed to ensure patients were provided with the South Dakota Department of Health (SD DOH) toll-free home health hotline phone number to file a complaint. Findings include: 1. Review of the provider's admission packet revealed a 2019 Patient Bill of Rights that was provided to each patient at the time of their admission. Review of the Bill of Rights revealed: *Home care providers had an obligation to: -Protect and promote the rights of their clients. -Advise clients of the state's home health hotline, which received complaints or questions about local home care agencies. Further review of the Bill of Rights revealed the state phone number provided to file complaints was no longer in service. The current SD DOH Home Health toll-free hotline had not been added to the provider's Patient Bill of Rights, or to any other area located in the admission packet. 2. Interview on 11/22/22 at 11:45 a.m. with registered nurse (RN)/administrator A and vice president of operations (VOP) B regarding the toll-free hotline number revealed neither RN/administrator A nor VOP B had been aware the South Dakota home health hotline number had changed. RN/administer A stated the provider had not received any complaints from patients in the past two years.