Every finding on record at Pemi Baker Community Health

An Emergency Preparedness Survey was conducted on 05/07/25 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR part 484.102 Appendix Z - Rev. HHA Issued: 04/16/21 with no deficiencies cited.

A recertification survey was conducted on 5/7/25 through 5/9/25 pursuant to 42 CFR Part 484 for Home Health Agencies with deficiencies cited.

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 interview and record review it was determined the Home Health Agency (HHA) failed to follow the written plan of care for the frequency of visits for 1 of 10 patients reviewed for physician ordered visits in a sample of 10 patients. (Patient identifier is #10). Findings include: Review on 5/9/25 of Patient #10's Plan of Care for the certification period of 2/25/25 to 4/25/25 revealed a physician's order for Skilled Nursing, 1 time a week for 4 weeks, beginning on 3/3/25, and then 1 time a week for 1 week beginning on 4/1/25. Review on 5/9/25 of Patient #10's Skilled Nursing visits revealed nursing visits were conducted on 3/3/25, 3/10/25 and 3/18/25. There were no other visits documented and no missed visits notifications to the physician. Interview on 5/9/25 at 11:07 a.m. with Staff A (Administrator) confirmed that Patient #10 did not get the ordered Skilled Nursing visits. Review on 5/9/25 of Patient #10's Plan of Care for the certification period of 2/25/25 to 4/25/25 revealed a physician's order on 4/8/25 for PT 1 times a week for 3 weeks. Review on 5/9/25 of Patient #10's PT visit revealed PT visits on 4/8/25, 4/9/25, 4/11/25, 4/14/25, 4/16/25, 4/17/25, 4/22/25, 4/23/25 and 4/24/25. Interview on 5/9/25 at 11:00 a.m. with Staff A confirmed that Patient #10 received more visits than ordered.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review it was determined the Home Health Agency (HHA), failed include all orders and treatments for 1 patient in a survey sample of 10 patients. (Patient identifier is Patient #7.) Findings include: Review on 5/8/25 of Patient #7's Communication note, dated 8/7/24, revealed that Patient #7 was taking antibiotics for a urinary tract infection and had been taking Eliquis (anticoagulant) for about a week. Review on 5/8/25 of Patient #7's plan of care for the certification period 6/24/24 to 8/22/24 revealed that there were no medication orders for antibiotics or Eliquis. Review on 5/8/25 of the facility's policy titled "Physician Plan of Care", with a review date of 3/2025, revealed "6. Revisions to the plan of care and/or discharge plan will be communicated to the patient, caregivers(s), patient representative(s), and all physicians writing orders for the plan for the plan of care...9. PBH & HH (Pemi-Baker Hospice and Home Health) staff and contract providers promptly inform the physician of any changes that suggest a need to alter the Plan of Care." Interview on 5/8/25 at approximately 1 :00 p.m. with Staff A (Administrator) revealed that the new medications should have been added to the plan of care.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the agency failed to ensure there was a policy in place that detailed how often a skilled professional assistant was supervised by a skilled professional; which included communication and oversight regarding the patient's status for 3 of 4 patients reviewed for supervisory visits in a sample of 10 patients. (Patient identifiers are #5, #8 and #10.) Findings include: Patient #5 Review on 5/8/25 of Patient #5's plan of care for the certification period 10/12/24 to 12/10/24 revealed a physician's order for OT (Occupational Therapy) 2 times per week for 3 weeks beginning on 11/25/24. Review on 5/8/25 of Patient #5"s OT visits revealed that on 12/3/24 and 12/5/24 the visits were completed by a COTA (Certified Occupational Therapy Assistant). Further review of patient #5"s medical record revealed that there were no supervisory visits made for the COTA. Interview on 5/8/25 at approximately 8:15 a.m. with Staff A (Quality Director) confirmed that the agency did not have a policy and procedure for communication and oversight between the skilled professional and assistant regarding the patient's response to services furnished by the assistant. Interview with Staff A further confirmed that there were no OT supervisory visits made to for the COTA visits provided to Patient #5. Patient #8 Review on 5/8/25 of Patient #8's Plan of Care for the certification period of 2/26/25 to 4/26/25 revealed a physician's order for OT to evaluate and an order for OT 2 times a week for 4 weeks beginning on 3/10/25. Review on 5/8/25 of Patient #8's OT visits revealed that there were OTA visits completed on 3/11/25, 3/13/25, 3/18/25, 3/19/25, 3/26/25, 3/27/25, 4/2/25 and 4/4/25. Further review of the visits revealed that there was no documentation in the clinical record to show the supervision of the OTA by the OT. Interview on 5/8/25 at 1:20 p.m. with Staff A confirmed that for Patient #8 there were no OT supervisory visits made. Patient #10 Review on 5/9/25 of Patient #10's Plan of Care for the certification period of 2/25/25 to 4/25/25 revealed a physician's order on 3/4/25 for PT 1 time a week for 1 week, 3 times a week for 3 weeks, then 2 times a week for 4 weeks. Further review revealed that on 4/8/25 a physician's order for PT 1 times a week for 3 weeks. Review on 5/9/25 of Patient #10's PT visits revealed there were PTA visits completed on 3/28/25, 4/11/25, 4/17/25, 4/22/25 and 4/24/25. There were no PT supervisory visits noted after 3/12/25. Review on 5/9/25 of Patient #10's Plan of care for the certification period of 2/25/25 to 4/25/25 revealed a physician's order for OT to evaluate, and order for OT 2 times a week for 6 weeks starting on 3/10/25, then 2 times a week for 1 week start on 4/21/25. Review on 5/9/25 of Patient #10's Plan of Care for the certification period of 4/26/25 to 6/24/25 revealed a physician's order for OT 2 times a week for 6 weeks beginning 4/28/25. Review on 5/9/25 of Patient #10's visit revealed that there were COTA visits on 3/11/25, 3/12/25, 3/19/25, 3/20/25, 3/27/25. 4/2/25, 4/3/25, 4/9/25, 4/10/25, 4/15/25, 4/17/25, 4/23/25, 4/30/25, 5/1/25, 5/7/25 and 5/8/25. Further review revealed no OT supervisory visits made. Interview on 5/9/25 at 11:00 a.m. with Staff A confirmed that there were no OT supervisory visits and the only PT supervisory visit was made on 3/12/25. Interview on 5/8/25 at 1:35 p.m. with Staff A revealed that the Home Health Agency did not have a policy regarding the supervision of skilled professional assistants (OTA and PTA).

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 failed to ensure Home Health Aide (HHA) supervisory visits were conducted no less frequently than every 14 days for 1 of 3 patients reviewed for HHA supervisory visits in a sample of 10 patients. (Patient identifier is #8.) Findings include: Review on 5/8/25 of Patient #8's Plan of Care for certification period of 2/26/25 to 4/26/25 revealed a physician's order for HHA 1 time a week times 1 week beginning 2/26/25, then 2 times a week for 6 weeks beginning on 3/3/25. Review on 5/8/25 of Patient #8's Plan of Care for certification period of 4/27/25 to 6/25/25 revealed a physician's order for HHA 2 times a week for 7 weeks and 3 visits as needed beginning 4/28/25. Review on 5/8/25 of Patient #8's HHA visits revealed that the HHA made visits on 2/28/25, 3/3/25, 3/6/25, 3/14/25, 3/17/25, 3/20/25, 3/24/25, 3/31/25, 4/3/25, 4/11/25, 4/14/25, 4/17/25, 4/21/25, 4/24/25 and 4/28/25. Review on 5/8/25 of Patient #8's Registered Nurse notes revealed there was 1 HHA supervisory visit made on 4/21/25. There were no other HHA supervisory visits made during the above certification periods. Interview on 5/8/25 at 1:40 p.m. with Staff B (Executive Director) confirmed that there were no other HHA supervisory visits documented other than on 4/21/25. Review on 5/9/25 of the facility policy titled "LNA Assigned Duties" revised 4/2/25 revealed, "...Purpose: To ensure the quality and competence of the LNA [Licensed Nursing Assistant] staffing... 5. The registered nurse or other appropriate skilled professional must make an on-site visit to the patient's home no less frequently than ever 14 days..."

An Emergency Preparedness survey was conducted on 6/7/22 pursuant to 42 CFR 416.54 with deficiencies cited.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and E.P.P. (Emergency Preparedness Plan) review, it was determined that the facility failed to ensure the completed emergency plans and related documents were available for review during survey. Findings include: Review of the E.P.P. on 06/07/22 between 11:45 a.m. and 2:15 p.m. with Staff A (Executive Director) and Staff B (Emergency Preparedness Coordinator) revealed only some E.P.P. documents, client trainings, and disaster drill trainings were available for review due to recent staff changes. The additional E.P.P. documents and policies were located by the facility and delivered by email for review on 06/09/22. The facility failed to house the E.P.P. in a central or readily available location for instant access during an emergency event or to facilitate the required review's. Interview on 06/07/22 between 11:45 a.m. and 2:15 p.m. with Staff A and Staff B confirmed the above findings and available documentation.

A health recertification survey was conducted 6/6/22 to 6/7/22 pursuant to CFR Part 484, for Home Health Agencies with no deficiencies cited.