Every finding on record at Nations Healthcare, LLC

Emergency Preparedness Survey

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct an exercise at least annually to test the emergency plan. A review of the policy, titled” Emergency Operations Plan 2023”, read in part: Section VI. Testing. A. the Agency will participate in a full-scale exercise that is community based, or an individual, facility-based exercise annually. Review of the agency’s Emergency Preparedness Plan binder revealed that there was no evidence the agency conducted an annual exercise to test the emergency plan since 4/6/2022. On 10/18/2023 at 12:19 p.m., an interview was conducted with S1Admin (Administrator). She confirmed the agency had no evidence of an annual exercise that was conducted to test the emergency plan since 04/06/2022.

Recertification Survey

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 record review and interview, the agency failed to ensure the patient's written individualized POC (Plan of Care) was followed as evidenced by the SN (Skilled Nurse) failing to perform and record blood sugar readings for patient (#3) and failing to ensure the SN weighed and recorded the weights for patient (#6) per the POC for 2 (#3, #6,) out of 17 sampled patients. 1. Patient #3. Review of the patient’s electronic clinical records revealed the start of care date was 10/6/2023. The patient’s diagnosis included Type 2 Diabetes Mellitus with Foot Ulcer. The certification period reviewed was 10/6/2023 to 12/4/2023. Review of the patient’s POC for certification period 10/6/2023 to 12/4/2023 revealed an order for “SN 1w1, 3w8, 1w1 effective 10/6/2023 (skilled nurse visit one time a week for one week, three visits a week for eight weeks, one visit a week for one week effective 10/6/2023).” Further review of the patient’s POC revealed an order for “…Skilled nurse to perform blood sugar via finger stick every visit…” The POC further revealed, “…Notify physician of: …Fasting blood sugar greater than (>) 200 or less than ( Random blood sugar greater than (>) 300 or less than ( Review of the patient’s skilled nurse visit notes dated 10/9/2023, 10/11/2023, and 10/13/2023 revealed that there was no evidence the patient’s blood sugar reading was obtained. On 10/17/2023 at 3:40 p.m., an interview was conducted with S1Admin (Administrator). S1Admin reviewed the patient’s electronic clinical record and confirmed that there was no evidence the patient’s blood sugar reading was obtained on those dates. S1Admin confirmed the SN should have performed the blood sugar checks and documented the results in the patient’s clinical record. 2. Patient #6. Review of the patient's electronic clinical record revealed the start of care date was 8/29/2022. The patient's diagnoses included Venous Insufficiency, Peripheral Vascular Disease, and Lymphedema. The certification period reviewed was 08/24/2023 to 10/22/2023. Review of the patient's POC for certification period 8/24/2023 to 10/22/2023 revealed an order for skilled nurse 1wk8 (skilled nurse visit one time a week for eight weeks). Further review of the patient's POC revealed an order for "Skilled nurse to assess patient’s weight log every visit.” Further review of the POC revealed an order “…Notify physician of: Weight greater than (>) 235 lbs (pounds) or less than ( Review of the patient's SN visit notes dated 8/30/2023, 9/7/2023, 9/11/2023, 9/21/2023, 9/27/2023, 10/5/2023, and 10/10/2023 revealed that there was no evidence the patient's weight was obtained. On 10/18/2023 at 12:30 p.m., an interview was conducted with S1Admin. S1Admin reviewed the patient’s electronic clinical record and confirmed that there was no evidence the patient’s weight was obtained on those dates. S1Admin confirmed the SN should have obtained the patient’s weight and documented the results in the patient’s clinical record.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the SN (Skilled Nurse) failed to promptly notify the physician of missed dialysis treatments for 1 (#16) out of 17 (#1-17) sampled patients. Review of Patient #16’s electronic clinical record revealed a start of care date of 03/05/2023. The patient’s diagnoses included in part, Sepsis, Chronic obstructive pulmonary disease, End stage renal disease and Dependence on renal dialysis. Review of the patient’s POC (Plan of Care) for certification period from 03/05/2023 to 05/03/2023 revealed an order for SN to monitor compliance to dialysis appointments. Review of the SN visit notes for the week of 03/05/2023 revealed that a SN visit was conducted on 03/10/2023. The patient informed the SN that she had not went to dialysis this week because she was too weak and she was not going tomorrow (03/11/2023). Further review of the note failed to reveal that the patient’s doctor was notified of the missed dialysis treatments. Review of the Nursing Schedule Communication form dated 03/05/2023 sent to the NP (Nurse Practitioner) revealed that Patient #16 was schedule for dialysis on Tuesday, Thursday and Saturday. According to the patient’s dialysis schedule, the patient missed a dialysis treatment on 03/07/2023 and 03/09/2023 and she was not going to go for her treatment on 03/11/2023. A review of a Patient Communication dated 03/14/2023 sent to the NP four days after the patient informed the SN of the missed dialysis treatments read in part, “Patient has not been going to dialysis for two weeks now…” On 10/18/23 at 1:20 p.m., a phone interview was conducted with S2RN (Registered Nurse). S1Admin(Administrator) was present. S2RN confirmed that during the skilled nurse visit on 03/10/23, the patient informed her that she didn’t go to dialysis that week and was not going for her treatment on 3/11/2023 because she was too tired to go. When asked why did she wait until 4 days later to notify the NP that the patient had missed her dialysis treatments the week of 03/05/2023, she stated that she called the NP on 03/10/2023 and the NP informed her the patient was not one of her patients. She confirmed that she did not contact the dialysis doctor. A review of the patient’s electronic record was conducted with the S1Admin who confirmed that there was no documented evidence that the doctor was notified of the patient’s missed dialysis treatments for the week of 03/05/2023. After further review of the patient’s record, S1ADM confirmed that the NP was notified on 03/12/2023, which was four days after the patient informed S2RN that she had missed her dialysis treatments. S1Admin confirmed that S2RN should have notified the patient’s doctor before 03/14/2023.