Every finding on record at Labette Health Foundation Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) on 09/14/23 resulted in noncompliance with 42 CFR 484.102(b)(1), E0017: HHA Comprehensive Assessment in Disaster and the following standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 interview and policy review the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP on 09/14/23, between the times 1:00 PM and 2:30 PM, showed there was no documentation to review in the emergency preparedness plan that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan. During an interview on 09/14/23 at 2:00 PM, the Director stated that there is no document in the emergency preparedness plan that addressed patient population, the services the facility has the ability to provide in an emergency; and continuity of operations including the delegation of authority and succession plan.

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 interview and policy review the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that included 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. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP on 09/14/23, between the times 1:00 PM and 2:30 PM, showed there was no documentation to review in the emergency preparedness plan that included 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. During an interview on 09/14/23 at 1:35 PM, the Director stated, that there is no document in the emergency preparedness plan that includes 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.

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 interview and policy review the Home Health Agency (HHA) failed to develop and maintain an individualized emergency preparedness plan (EPP) for each patient as part of the patient’s comprehensive assessment for 6 of 6 patient reviewed (Patients 3, 5, 6, 8, 9, and 10). This deficient practice has the potential to place patients at risk for harm or injury during an emergency. Findings Include: Review of the EPP on 09/14/23, between the times 1:00 PM and 2:30 PM, showed there was no documentation to review for an individualized emergency plan for each patient as part of the patient’s comprehensive assessment. Review of Patient’s 3, 5, 6, 8, 9 and 10, comprehensive assessments showed “Establishment of Individualized Emergency Preparedness Plan” …Status - Individualized emergency plan in patient’s record.” Review of Patient’s 3, 5, 6, 8, 9 and 10 records failed to show an individualized emergency plan in each patient’s record. During an interview on 09/14/23 at 11:39 AM, the Director stated that the facility does not have documentation of an individualized emergency plan for each patient as part of the patient’s comprehensive assessment.

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 interview and policy review the Home Health Agency (HHA) failed to develop and provide initial training in emergency preparedness (EPP) policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; Provide emergency preparedness training at least every 2 years; Maintain documentation of all emergency preparedness training; Demonstrate staff knowledge of emergency procedures and if the emergency preparedness policies and procedures are significantly updated, the facility must conduct training on the updated policies and procedures. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP on 09/14/23, between the times 1:00 PM and 2:30 PM, showed there was no documentation to show emergency preparedness training for 5 employees at least every 2 years. During an interview on 09/14/23 at 12:37 PM, the Director stated that the facility was not able to find documentation the emergency preparedness training was provided for 5 employees at least every 2 years.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (#60F72-H1) conducted at the above-named Home Health Agency (HHA) from 09/13/23 to 09/15/23 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 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 observation, record review, and staff interview the home health agency skilled staff 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 4 of 10 sample patients (Patients 2, 5, 8, and 9). The home health agency's failure to ensure the patient's right to consent to frequency of services places all patients currently on services, at risk for unmet needs, care and services. Findings Include: Patient 2 Review of Patient 2's clinical record revealed a document titled; "Skilled Nursing Plan of Care" was used as the patient consent form. Patient 2's skilled nursing plan of care form signed by the patient only indicated Physical Therapy (PT) services were to be provided and at a frequency of 1 time per week for 1 week, then 2 times per week for 8 weeks. There were no other services to be provided to the patient listed on the signed consent form. Review of Patient 2's plan of care indicated services to be provided to the patient to include Skilled Nursing (SN) at a frequency of 1 time were week for 1 week, then 2 times per week for 1 week, and 1 time per week for 7 weeks. Also included on the plan of care were orders for Home Health Aide (HHA) services at 1 time per week for 1 week, then 2 times per week for 8 weeks, as well as Occupational Therapy (OT) services at 2 times per week for 4 weeks. Patient 5 Review of Patient 5's clinical record revealed a document titled; "Skilled Nursing Plan of Care" was used as the patient consent form. Patient 5's skilled nursing plan of care form indicated that Skilled Nursing (SN) services were to be provided 2 times per week for 3 weeks, then 1 time per week for 4 weeks. Also included on the skilled nursing plan of care form was an evaluation by both Physical Therapy (PT) and Occupational Therapy (OT) services. This form was not signed by the patient or caregiver and there was not documentation in the record of consenting the patient for discipline or frequency of visits. Patient 8 Review of Patient 8's clinical record revealed a document titled; "Skilled Nursing Plan of Care" was used as the patient consent form. Patient 8's skilled nursing plan of care form signed by the patient only indicated Physical Therapy (PT) services were to be provided and at a frequency of 1 time per week for 1 week, then 2 times per week for 8 weeks. There were no other services to be provided to the patient listed on the signed consent form. Review of Patient 8's plan of care indicated services to be provided to the patient to include Occupational Therapy (OT) services at 2 times per week for 4 weeks. There was no documented evidence in the clinical record of the Occupational Therapist providing the patient the right to consent or refuse the OT services. Patient 9 Review of Patient 9's clinical record revealed a document titled; "Skilled Nursing Plan of Care" was used as the patient consent form. Patient 9's skilled nursing plan of care form signed by the patient only indicated Skill Nursing (SN) services and Home Health Aide (HHA) were both to be provided at a frequency of 2 times per week. Review of Patient 9's plan of care for the Start of Care (SOC) episode, dated 07/18/23 indicated services to be provided to include Physical Therapy (PT) and Occupational Therapy (OT) as well. There was no evidence of the patient being provided the opportunity to consent to the PT and OT services. During an interview on 09/13/23 at 3:15 PM, Staff A, RN, Administrator, stated that the only form used by the agency for consenting the patient to discipline and frequency of visits was the document titled, "Skilled Nursing Plan of Care". She also stated that the agency used a different consent form titled, "Admission Agreement" which did not contain any information related to the type of disciplines provide or at what frequency of visits. Staff A confirmed the above findings of not consenting the patients to all disciplines and frequency of visits.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and clinical record review the home health agency (HHA) failed to communicate with all physicians involved in the patients plans of care, in that, the primary referring physician was not made aware of additional health care practitioners giving orders included in the plans of care for 1 of 10 sample patients (Patients 3). This deficient practice has the potential to affect patient safety and to place all patients at risk for altered treatment outcomes. Findings Include: Patient 3 Review of Patient 3's current plan of care dated 08/18/23 revealed primary physician to sign and no other physicians listed to provide orders for the patient. Medications listed on the plan of care indicated the patient was to increase her dose of Furosemide (medication use to treat fluid buildup in the body) from 20 milligrams (mg) daily to 40 mg daily times 7 days for an increase in edema (swelling caused by fluid buildup), then go back to regular 20 mg dose. During a home observation visit on 09/15/23 at 8:30 AM when questioned by this surveyor about the current medication dose she stated that her Cardiologist manages her Furosemide. There is no documented evidence in the clinical record of the agency's skilled professional staff receiving orders from the patient's Cardiologist or notifying the primary care physician that the patient was taking medications monitored by another physician.