Every finding on record at Ness County Hospital Hospital District 2

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (iQIES #5EB9E-H1) at the above-named Home Health Agency (HHA) from 01/23/23 - 01/25/23 resulted in the following deficiency respective to the Emergency Preparedness Program requirements under 42 CFR 484.22.

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 interviews, document review, and facility policy review, it was determined the home health agency (HHA) failed to maintain an emergency preparedness testing program that complied with all applicable Federal, State, and local emergency preparedness requirements. This had the potential to affect all patients and staff. Findings Included: Review of the HHA's policy titled, “Emergency Preparedness Plan,” dated 01/02/19, revealed, "The staff of Ness County Home Health are employees of the Ness County Hospital. The staff will follow the emergency preparedness plans and procedures as outlined in the Ness County Hospital Emergency Operation Plan found in the procedure room or on the hospital shared network under Emergency Preparedness, the Employee Emergency Management Manual given to each employee upon hire also found on the hospital shared network under Emergency Preparedness and in the Home Health policies." Review of the above-referenced "Ness County Hospital Emergency Operations Plan," dated 09/2017, revealed, "Training and Testing The staff of the Ness County Hospital which includes the [name of other facility], Ness County Hospital Home Health, and [name of other facility] will participate in the annual in-service education covering CMS [Centers for Medicare and Medicaid Services] mandated annual training provided by the facility." The plan also indicated, "Testing of the emergency plan and procedures will be conducted 2 times per year. Testing will include conducting drills and/or exercises to test the emergency plan and procedures to identify any gaps and areas for improvement." Review of the HHA's emergency preparedness program documentation on 01/25/23 revealed the agency had a plan in place but had not maintained an emergency preparedness testing program that complied with applicable Federal, State, and local emergency preparedness requirements. This placed the HHA’s patients and community at risk for potential harm if an emergency were to occur. During an interview on 01/25/23 at 8:15 AM, the Chief Executive Officer (CEO) stated that the HHA was using the current Emergency Preparedness (EP) waivers and had not performed any community-wide or tabletop drills. He stated he would provide information from the hospital's EP Coordinator. During an interview on 01/25/23 at 9:15 AM, the Director of Nursing (DON) stated that the HHA had not performed any community-wide or tabletop EP drills. She indicated the agency did participate in yearly fire drills. During an interview on 01/25/23 at 10:00 AM, the hospital EP Coordinator stated that all new hires by the HHA were provided an initial training on EP. She stated these trainings were done during new hire orientation. The hospital EP Coordinator revealed she did not participate with the HHA's EP program beyond that.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (iQIES #HEB9E-H1) conducted at the above-named Home Health Agency (HHA) from 01/23/23 - 01/25/23 resulted in noncompliance with the Condition of Participation (CoP) for Quality Assurance/Performance Improvement (QAPI) respective to applicable CoP under 42 CFR 484, Subpart A through C and the following standard-level deficiencies cited.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview, document review, and agency policy review, the home health agency (HHA) failed to meet the Condition of Participation (CoP) for Quality Assessment/Performance Improvement (QAPI), as evidenced by failure to maintain a QAPI program as required. The facility failed to implement, evaluate, and maintain an effective, ongoing, data driven QAPI program. Findings Included: Review of a policy titled, "Ness County Hospital Quality Improvement Plan," dated as reviewed/revised 11/2008, revealed, "The Quality Improvement program will include all organized patient/resident/client services provided by hospital staff, medical staff, and/or contracted services with specific functions of the following." A list of "Facility Departments" included in the scope of the plan indicated the "Home Care Services" department was included. During an interview on 01/25/23 at 8:15 AM, the Chief Executive Officer (CEO) stated the HHA's policies for QAPI and Infection Control fell under the hospital's policies. He indicated he was not aware of any specific home health QAPI projects. Refer to tags G0642, and G0644, for further details.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interviews, document review, and facility policy review, the home health agency (HHA) failed to maintain a quality assurance/performance improvement (QAPI) program that measured, analyzed, and tracked quality indicators to enable the HHA to assess its processes, services, and operations. This deficient practice has the potential to affect all patients. Findings Included: Review of a policy titled, "Ness County Hospital Quality Improvement Plan," dated as reviewed/revised 11/2008, revealed, "The Quality Improvement program will include all organized patient/resident/client services provided by hospital staff, medical staff, and/or contracted services with specific functions of the following." A list of "Facility Departments" included in the scope of the plan indicated the "Home Care Services" department was included. During an interview on 01/25/23 at 8:15 AM, the Chief Executive Officer (CEO) stated the HHA's QAPI program fell under the hospital's policies. He indicated he was not aware of any specific home health QAPI projects and stated the HHA had not received any complaints. He stated he would provide information from the hospital's QAPI Coordinator. During an interview on 01/25/23 at 8:45 AM, the hospital's QAPI Coordinator stated the hospital did not perform the HHA's QAPI processes. She stated the HHA would be able to use the hospital's QAPI policy, but the HHA was responsible for gathering any data and implementing any performance improvement projects. She stated the HHA had not provided any projects or QAPI data to her. During an interview on 01/25/23 at 9:15 AM, the Director of Nursing (DON) confirmed the HHA had not provided any information to the QAPI Coordinator.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interviews, document review, and facility policy review, it was determined the home health agency (HHA) failed to monitor the effectiveness and safety of its services and quality of care and identify opportunities for improvement as a part of its quality assurance/performance improvement (QAPI) program. This had the potential to affect all patients. Findings Included: Review of a policy titled, "Ness County Hospital Quality Improvement Plan," dated as reviewed/revised 11/2008, revealed, "The Quality Improvement program will include all organized patient/resident/client services provided by hospital staff, medical staff, and/or contracted services with specific functions of the following." A list of "Facility Departments" included in the scope of the plan indicated the "Home Care Services" department was included. During an interview on 01/25/23 at 8:15 AM, the Chief Executive Officer (CEO) stated that the HHA's quality assurance/performance improvement (QAPI) program fell under the hospital's policies. He indicated he was not aware of any specific home health QAPI projects and stated he would provide information from the hospital's QAPI Coordinator. During an interview on 01/25/23 at 8:45 AM, the hospital's QAPI Coordinator stated that the hospital did not perform the HHA's QAPI program processes. She stated the HHA was responsible for its own data and performance improvement projects and that the HHA had provided no QAPI data to her. During an interview on 01/25/23 at 9:15 AM, the Director of Nursing (DON) confirmed the HHA had not provided information to the hospital's QAPI Coordinator. She stated the HHA had not utilized data collected and did not report falls unless there was an injury.