Every finding on record at Maple Creek Home Health & Hospice, Inc.

A dropped deemed/certification survey was conducted at Maple Creek Home Health from 5/13/2024 through 5/16/2024 to assess compliance with Emergency Preparedness. Deficiencies were identified and cited in the area of development of individual emergency plans.

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 record review, it was determined the home health agency (HHA) did not ensure individual emergency plans (IEP) were developed for the HHA's patients during a natural or man-made disaster or emergency. Specifically, the HHA did not provide IEP's for each patient as part of the comprehensive assessment for 5 of 7 patients. (Patient identifiers: 1, 2, 3, 5 and 6) Findings include: 1. During the dropped deemed survey from 5/13/2024 through 5/16/2024, the medical records for 7 sampled patients were reviewed. For 5 of 7 patients, no documented evidence could be found to indicate an individual emergency plans (IEP) in the event of an emergency had been developed for the sampled patients. 2. In an email received on 5/14/2024 at 4:31 PM from the administrator she stated, at this moment I am only able to locate two IEP. Last month we conducted an internal audit and identified that not all IEPs were being completed. Many were due to patient not wanting to work on it or discuss it, so the information was being left in the home. However, we do not have any documentation to support this. Going forward, a social worker will be going over IEP with our home health patients.

A dropped deemed/certification survey was conducted at Maple Creek Home Health from 5/13/2024 through 5/16/2024 to assess compliance with the 42 Code of Federal Regulations for Home Health agencies. Noncompliance was identified and a deficiency was cited in the following area: §484.80 Home health aide services.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) had not conducted home health aide supervisory visits at least every 14 days as required for 2 of 7 sample patients. (Patient identifiers: 5 and 7) Findings include: 1. Patient 5 was admitted to the agency on 1/13/2024, with a diagnosis of Acute respiratory failure with hypoxia. A review of patient 5's medical record was completed on 5/14/2024. Patient 9's plan of care (POC) included orders for home health aide visits, physical therapy visits and occupational therapy visits. Patient 5 was to receive home health aide visits 2 times per week for 4 weeks, beginning the week of 1/21/2024. During the 4-week period there was no documented evidence that aide supervisory visits were completed. Note: During this 4-week period, 2 aide supervisory visits should have been completed. 2. Patient 7 was admitted to the agency on 12/18/2023, with a diagnosis of Parkinson disease without dyskinesia. A review of patient 7’s medical record was completed on 5/14/2024. Patient 7 plan of care (POC) included orders for home health aide visits, physical therapy visits and occupational therapy visits. Eight home health aide visits were documented in the medical record from 12/18/2023 through 2/8/2024. There was no documented evidence that any aide supervisory visits were completed during that time period. Note: During this period 4 aide supervisory visits should have been completed. 3. In an interview with the agency administrator on 5/14/2024 at 3:23 PM she stated that she was not sure why the supervisory visits had not been completed and that the director of nursing (DON) during that time was no longer with the agency. She further stated that possibly the supervisory visits were not completed because both patients had refused visits multiple times.