Every finding on record at Northeast Kansas Multi County Health Department Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (60D6C-H1) at the above-named Home Health agency (HHA) on 08/29/23 to 08/30/23 resulted in the following standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 document review and interview, the Home Health Agency (HHA) failed to include information addressing the process for cooperation and collaboration with local, regional, state and federal emergency preparedness officials in their Emergency Preparedness Plan (EPP). This affects all residents and could result in a delayed response to an emergency situation. Findings Include: On 08/30/23 between 10:40 AM and 1:00 PM, while reviewing the Emergency Preparedness Program, it was observed the agency failed to ensure collaboration with local, regional, state and federal emergency preparedness officials emergency preparedness policies and procedures was being documented specific to their facility to ensure an integrated response during an emergency. The Administrator, Chief Operating Officer (COO), and Clinical Director were present and acknowledged the findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to include information outlining procedures for follow up for patients and staff in their Emergency Preparedness Plan (EPP). This affects all residents and could result in harm to patients if left unattended for an extended period of time due to an emergency situation. Findings Include: On 08/30/23 between 10:40 AM and 1:00 PM, while reviewing the Emergency Preparedness Program, it was observed the agency failed to ensure emergency preparedness policies and procedures for follow up for patients and staff, as well as timeframes in which these follow ups will be completed during an emergency. This failure has the potential to place patients at risk during an emergency. The Administrator, Chief Operating Officer (COO), and Clinical Director were present and acknowledged the findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP) the Home Health Agency (HHA) failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency. This failure has the potential to place patients at risk for unmet needs during an emergency. Findings Include: On 08/31/23 between 10:40 AM and 1:00 PM, while reviewing the Emergency Preparedness Program, it was observed the agency failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency. This failure has the potential to place patients at risk during an emergency. The Administrator, Chief Operating Officer (COO), and Clinical Director were present and acknowledged the findings.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (60D6C-H1) conducted at the above-named Home Health Agency (HHA) on 08/29/23 to 08/30/23 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 6 of 7 sample patients (Patients 1-6). The home health agency's failure to ensure the patient's right to consent to frequency of services placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1's Admission Consent dated 08/17/23 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Therapy (ST) were all marked however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 1's plan of care indicated SN visits to be "1w4 (1 time a week for 4 weeks); PT visits 1w1; 3w1; OT visits 2w2; ST visits 2w2". Review of Start of Care Assessment visit dated 08/17/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Observation during Patient 1's home visit with Occupational Therapy (OT) on 08/30/23 at 9:30 AM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 2 Review of Patient 2's Admission Consent dated 08/23/23 showed Skilled Nurse (SN), Physical Therapy (PT), Home Health Aide (HHA) were all marked however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 2's plan of care indicated SN visits to be "2w1 (2 times a week for 1 week); PT visits 1w1; 3w1; 2w1; HHA visits 0w1; 2w2". Review of Start of Care Assessment visit dated 08/23/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN and HHA or discussing the overall plan of care with the patient and/or caregiver. Observation during Patient 2's home visit with Physical Therapy Assistant (PTA) on 08/30/23 at 10;00 AM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 3 Review of Patient 3's Admission Consent dated 08/14/23 showed Skilled Nurse (SN), Physical Therapy (PT) were both marked however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 3's plan of care indicated SN visits to be "1w4 (1 time a week for 4 weeks); PT visits 2w1; 3w1; 2w1". Review of Start of Care Assessment visit dated 08/14/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Observation during Patient 3's home visit with Registered Nurse (RN) on 08/30/23 at 11:00 AM, review of home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 4 Review of Patient 4's Admission Consent dated 07/25/23 showed Skilled Nurse (SN), Physical Therapy (PT) were both marked however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Review of Patient 4's plan of care indicated SN visits to be "2w1;3w3 (2 times a week for 1 week, then 3 times a week for 3 weeks); PT visits 2w1". Review of Start of Care Assessment visit dated 07/25/23 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Patient 5 Review of Patient 5's Admission Consent dated 12/17/22 lacked evidence of any services or visit frequencies listed on the signed consent form. Review of Start of Care Assessment visit dated 12/17/22 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. Patient 6 Review of Patient 6's Admission Consent dated 7/029/22 showed Skilled Nurse (SN) and Social Worker (SW) both marked however, there was no evidence of the frequency of visit on the signed consent form. Review of Patient 6's plan of care dated 07/29/22 indicated SN visit to be daily for wound care and SW to evaluate the patient for needed assistance with community resources. Review of Start of Care Assessment visit dated 07/29/22 lacked documentation of the SN providing the patient or caregiver with a frequency of visits for SN or discussing the overall plan of care with the patient and/or caregiver. During an interview on 08/30/23 at 8:30 AM, Staff B, Clinical Manager, stated that it is he expectation that the clinician performing the Start of Care Assessment would complete the visit frequency line of the Admission Consent form and not just mark the disciplines. She confirmed the above findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the Home Health Agency (HHA) failed to ensure that services and treatments were provided only as ordered by the physician, in that, visits were made to provide wound care without physician orders for 1 of 7 sample patients (Patient 4). The home health agency's failure to contact the physician for additional orders when or prior to current orders were ending placed all patients currently on service, at risk adverse outcomes due to performing medical treatments without orders. Findings Include: Patient 4 Review of Patient 4's plan of care for episode dates 07/25/23-09/22/23 indicated Skilled Nurse (SN) visits to be "2w1; 3w3 (2 times a week for 1 week; 3 times a week for 3 weeks); Physical Therapy (PT) evaluation plus 1 visit for wound care consultation. Review of SN visit notes showed visits had been made 2 times for the first week of the episode, then 3 times for the next 3 weeks of the episode as ordered. However, four additional SN visits had been made on 08/21/23, 08/23/23, 08/25/23, and 08/28/23 for which there were no physician orders. The SN had also provided wound care to the patient's bilateral lower extremities as previously ordered. There was no documented evidence of the SN contacting the physician for new or continued orders to provide wound care as previously ordered or to continue a SN frequency of visits. During an interview on 08/30/23 at 9:15 AM, Staff A, Administrator, confirmed that the physician had not been contacted and new orders obtained for SN visits prior to the care and treatments being provided.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to send a transfer summary to the facility were the patient was receiving in-patient health care services for 1 of 1 patients (Patient 6). The deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care services. Findings Include: Patient 6 Review of Patient 6's clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/29/22 and a Discharge date of 11/25/22. Review of visit notes showed a transfer to the hospital on 08/30/22, again on 09/5/22 and again on 11/25/22 with a discharge. The home health agency completed a Transfer to In-Patient (TIF) Assessment on 8/30/22, 09/5/22, and 11/25/22 however, there was no documented evidence of a transfer summary created or sent to the receiving facility. During an interview on 08/30/23 at 4:00 PM, Staff A, Administrator, confirmed the agency was unable to provide any evidence of the Transfer Summaries being sent to the receiving facilities.