Every finding on record at Pondera Medical Center

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 484.102 Emergency Preparedness (EP) Final Rule Requirement for Home Health Facilities effective 11/15/17, an EP survey was performed on 12/5/24. The facility completed a review of their EP plan on 9/20/23. No deficiencies were cited

A recertification survey was completed on 12/5/24. Condition Level and Standard Level citations were cited. The facility census on entrance was 13. Deficient practices were cited for a Recertification Survey. Deficiencies were cited at condition level. An Immediate Jeopardy was called during the survey for Home Health Services. IMMEDIATE JEOPARDY On 12/4/24 at 10:33 a.m.., the agency Administrator, Hospital Director of Nursing, and the Chief Executive Officer were notified that an Immediate Jeopardy existed in the area of §484.105 Condition of Participation: Organization and Administration of Services, which was related to G982. The Immediate Jeopardy concerns identified onsite included a failure to: (1) Provide Skilled Nursing Services (2) Provide continued nursing care and assessments related to wound care and cardiorespiratory care for patient #s 1, 6, and 9. Abbreviations: CMS Centers for Medicare/Medicaid Services EHR Electronic Health Record FMLA Family Medical Leave Act IQIES Internet Quality Improvement and Evaluation System mmHg Millimeters of Mercury NPWT Negative Pressure Wound Therapy NSTEMI Non-ST-Segment Elevation Myocardial Infarction OASIS Outcome Assessment Information Set POA Power of Attorney PT Physical Therapy ROC Resumption of Care RN Registered Nurse SOC Start of Care SN Skilled Nursing

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to encode and electronically submit each completed OASIS (Outcome Assessment Information Set) assessment to the CMS iQIES information system within 30 days of completing the assessment for 4 (#s 1, 3, 8, and 11) of 11 sampled OASIS validation reported patients; and failed to encode and electronically submit comprehensive discharge assessments, utilizing the OASIS data set, to the CMS iQIES information system within two days of completing the discharge for 3 (#s 1, 7, and 10) of 11 sampled patients. The agency's failure to transmit OASIS data in a timely manner resulted in CMS not receiving and processing the OASIS data. This in turn limited the agency's ability to review, analyze, and improve patient outcomes. Finding include: A. OASIS Late Submission Review of CMS State Report, Error Summary Report, with a report period between 1/1/24 -11/25/24, showed an Error Code of -3330 (Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.) The agency had 11 assessments with an assessment error rate of 11.83 percent. Review of the OASIS Agency Final Validation Report, from 8/1/24 to 11/30/24, showed the following patients with the error code -3330 (Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.): - Patient #1 had a SOC (M0090) date of 9/27/24. The agency’s OASIS submission date for patient #1, was 10/31/24. - Patient #3 had a SOC (M0090) date of 9/17/24. The agency’s OASIS submission date for patient #3, was 10/31/24. - Patient #8 had a SOC (M0090) date of 9/6/24. The agency’s OASIS submission date for patient #8, was 10/8/24. - Patient #11 had a SOC (M0090) date of 10/1/24. The agency’s OASIS submission date for patient #11, was 11/1/24. During an interview on 12/2/24 at 12:00 p.m., staff member B stated they would follow the agency’s policy and procedure on timely submission of OASIS. Review of the agency’s policy and procedure titled, Reporting OASIS Data, with a revision date of 9/2022, showed: “Policy: [Agency Name] will collect and encode OASIS (Outcome and Assessment Information Set) data on [Agency Name] patients. The indicated OASIS assessments of non-maternity and non-pediatric Medicare/Medicaid patients will be transmitted to the State database within thirty (30) days of completion following current regulatory guidelines… Procedure: … 5. It is the responsibility of the Home Health Clinical Manager to electronically transmit the accurate, encoded, OASIS data for all required assessments completed since the previous transmission to the U.S. Government iQIES information system within thirty (30) days from the date of completion (M0090) … 8. The [Agency Name] Associate will be responsible for transmitting all OASIS data sets during a lengthy absence of the Clinical Manager in order to be compliant with the thirty (30) day time frame…” B. Failure to Encode and Submit Discharge OASIS Data 1. Review of patient #1’s EHR showed the patient had a SOC date of 9/27/24. The patient’s last documented skilled service visit was 11/5/24. The EHR did not reflect a discharge OASIS was completed and reported to the CMS iQIES information system within two days of the patient’s end of services. A review of the agency’s active patient listing, provided on 12/2/24, showed patient #1 was listed as an active patient. The patient had no additional services provided from 11/5/24 to 12/2/24. During an interview on 12/3/24 at 3:07 p.m., staff member B stated patient #1 was believed to no longer need skilled services provided by the agency. She did not know why the patient had not been discharged from services or why a discharge OASIS was not completed. 2. Review of patient #7’s EHR showed the patient had a SOC date of 9/24/24. The patient’s last documented skilled service visit was 10/17/24. The EHR did not reflect a discharge OASIS was completed and reported to the CMS iQIES information system within two days of the patient’s end of services. A review of the agency’s active patient list, provided on 12/2/24, showed patient #7 was listed as an active patient. The patient had no additional services provided from 10/17/24 to 12/2/24. 3. Review of patient #10’s EHR showed the patient had a SOC date of 10/28/24. The patient’s last documented skilled service visit was 11/6/24. The EHR did not reflect a discharge OASIS was completed and reported to the CMS iQIES information system within two days of the patient’s end of services. A review of the agency’s active patient list, provided on 12/2/24, showed patient #10 was listed as an active patient. The patient had no additional services provided from 11/6/24 to 12/2/24. During an interview on 12/3/24 at 3:07 p.m., staff member B stated patient #10 should have been discharged from home health services. She did not know why a discharge OASIS was not completed for patient #10. An information request for documentation for patient #s 1, 7, and 10’s comprehensive discharge OASIS assessment, was submitted to the agency on 12/3/24 at 9:30 a.m. No additional documentation was provided by the end of the survey. During an interview on 12/3/24 at 9:30 a.m., staff member B stated they would follow the agency’s policy and procedure for ensuring the appropriate elements were completed at the time of a patient’s discharge. A review of the agency’s policy and procedures titled, Discharge of Patient, with a revision date of 20/2022, showed: - “Procedure: 2. The physician will be notified by each Home Health discipline of the indicated criteria for discharge. If he/she agrees to discharge, a verbal physician order will be written and sent to the physician by the discipline desiring discharge within 72 hours of the discharge date. [Agency Name] patients will receive advanced oral/written notice of the discharge as per [Agency Name] Expedited Determination Process and Home Health Advance Beneficiary Notice policies… 4. The last skilled discipline servicing the patient will complete the Discharge Outcome and Assessment Information Set (OASIS). A copy of this assessment will be copied and forwarded to the physician as the Discharge Summary…” A review of the agency’s policy and procedure titled, Reporting OASIS Data, with a revision date of 9/2022, showed: “POLICY: [Agency Name] will collect and encode OASIS (Outcome and Assessment Information Set) data on all [Agency Name] patients. The indicated OASIS assessments of non-maternity and non-pediatric Medicare/Medicaid patients will be transmitted to the State database within thirty (30) days of completion following current regulatory guidelines…”

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Comprehensive Assessment of Patients. Based on interview and record review, the facility failed to: - Complete the initial assessment visit within 48 hours of the referral, or within 48 hours of the patient's return home. The failure to complete the initial assessment visit to determine the immediate care and support needs of the patient placed the patients at risk for needs not being met for their health and safety (See G514). - Ensure the Physical Therapy Start of Care (SOC) initial assessment was completed within 48 hours of the referral. This deficient practice had the potential to impact the immediate care needs of the patient from the time of the referral to when the plan of care would be implemented (See G516). - Complete a resumption of care and a had a delay in the resumption of care. This deficient practice had the potential to delay necessary care for the patients (See G548). - Update and complete a comprehensive discharge assessment of the patient at the time of a patient’s discharge. This deficient practice had the potential to affect all patients being discharged from home health services (See G550).

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete the initial assessment visit within 48 hours of the referral, or within 48 hours of the patient's return home for 3 (#s 1, 4, and 6) of 11 sampled patients. The failure to complete the initial assessment visit to determine the immediate care and support needs of the patient placed the patients at risk for needs not being met for their health and safety. Findings include: 3. Patient #6 had a SOC date of 1/2/24, with primary diagnosis of malignant neoplasm of anterior wall of bladder. Review of patient #6's home health referral, dated 12/20/23, showed patient #6 was referred for SN services for nephrostomy tube care on 12/19/23. The patient's SOC was 14 days after the date of the referral. Review of patient #6's Hospital Discharge Summary, dated 12/15/23, showed under plan, the patient has home care coming in to help with dressing changes. During an interview on 12/3/24 at 11:51 a.m., staff member B stated the initial visit was to be completed within 48 hours of the patient's referral. 4. Patient #7 had a SOC date of 9/24/24, with a primary diagnosis of Multiple Sclerosis. Review of patient #7's Home Health referral order showed the agency received the referral order on 9/10/24 for physical therapy services. Review of patient #7's SOC assessment, dated 9/24/24, showed a date of referral for 9/10/24 and a SOC date of 9/24/24, 14 days after the referral. Review of patient #7s Physical Therapy Admission Visit, showed the initial visit and the comprehensive assessment was completed on 9/24/24. The initial assessment was completed 14 days after the agency received the referral. During an interview on 12/4/24 at 2:40 p.m., staff member B stated the the initial visit was to be done within 48 hours of the referral and would follow the agencies policy and procedure. 1.Review of patient #1's EHR, "Referral from [Hospital Name]," dated 9/23/24, reflected patient #1's referral for home health services was submitted on 9/23/24. Review of patient #1's EHR, "Nursing Admission Visit," dated 9/27/24, reflected patient #1 was admitted on 9/27/24, three days after discharge from the hospital. 2. Review of patient #4's EHR, "Referral from [Hospital Name]," dated 10/11/24, reflected the agency received a referral for home health services on 10/11/24. Review of patient #4's EHR, "Nursing Admission Visit," dated 10/15/24, reflected patient #4 was admitted on 10/15/24, four days after the agency received the referral. During an interview on 12/4/24 at 2:40 p.m., staff member B stated the expectation was for admissions to occur within 48 hours of the referral. Review of the agency's policy and procedure, "Start of Care Assessment-Resumption of Care," revised 10/2022, reflected," ...will conduct this visit within 48 hours of the patient's discharge from an inpatient admission of greater than 24 hours."

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Physical Therapy Start of Care (SOC) initial assessment was completed within 48 hours of the referral for 2 (#s 7 and 10) of 11 sampled patients. This deficient practice had the potential to impact the immediate care needs of the patients from the time of the referral to when the plan of care could be implemented. Findings include: 2. Patient #10 had a SOC date of 10/28/24, with a principal diagnosis of Atrial Fibrillation. Review of patient #10's Primary Care Visit, dated 10/17/24, showed: "Assessment and Plan: …Laterality: bilateral - other symptoms and signs involving the musculoskeletal system: Has been doing some physical therapy but it has been hard logistically for her son to get her to her appointments so we will work on transitioning her over to some home health for few weeks to complete her sessions. She will be homebound at the [Name of Assisted Living Facility] if her son is unable to get her to appointments so at this point feel that this is our best option to help with her continued progress..." Review of patient #10's referral showed the agency received a referral from the provider for home health physical therapy on 10/22/24. Review of patient #10's Physical Therapy Admission Visit, showed the initial visit and the comprehensive assessment was completed on 10/28/24. The initial assessment was completed six days after the agency received the referral. During an interview on 12/2/24 at 12:00 p.m., staff member B stated they would follow the agency's policy and procedure for timeline of start of care for the initial assessment and the completion of the comprehensive assessment for therapy only initiated start of cares. Review of the agency's policy and procedure, titled, Start of Care Assessment, with a revision date of 10/2022, showed: "Policy: [Agency Name] Registered Nurse (RN), Physical Therapist (PT), or Speech-Language Pathologist (SLP) will use the Outcome Assessment Information Set (OASIS) Start of Care (SOC) Assessment form for each nursing or therapy patient evaluation/admission visit. A comprehensive assessment will be included in the evaluation. [Agency] RN, PT, or SLP will also use the OASIS SOC Assessment/comprehensive form at the first visit following an inpatient stay while under the services of [Agency] (Resumption of Care)… Procedure: 1. Upon acceptance of referral to [Agency Name] the Home Health Clinical Manager will assign the patient to the appropriate discipline (RN, PT or SLP) for evaluation. 2. The "Admission Process" policy will be followed using the OASIS Start of Care Assessment. 3. If both Skilled Nursing and PT or SLP services are ordered the RN will complete the OASIS Start of Care Assessment and comprehensive assessment. If a patient is referred for therapy services only, a PT or SLP will complete the comprehensive assessment and the OASIS SOC Assessment at the evaluation visit on or within 5 days following the therapy start of care date. 4. An OASIS comprehensive assessment (Resumption of Care) will be completed following an inpatient stay. An RN, if nursing services are being utilized, or the PT or SLP, in a therapy only case, will conduct this assessment visit within 48hrs of the patient's discharge from an inpatient admission of greater than 24hrs..." 1.Patient #7 had a SOC date of 9/24/24, with a primary diagnosis of Multiple Sclerosis. Review of patient #7's Home Health referral order showed the agency received the referral order on 9/10/24 for physical therapy services. Review of patient #7's SOC assessment, dated 9/24/24, showed a date of referral for 9/10/24 and a SOC date of 9/24/24, 14 days after the referral. Review of patient #7s Physical Therapy Admission Visit, showed the initial visit and the comprehensive assessment was completed on 9/24/24. The initial assessment was completed 14 days after the agency received the referral. During an interview on 12/4/24 at 2:40 p.m., staff member B stated the the initial visit was to be done within 48 hours of the referral and would follow the agencies policy and procedure.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to complete a resumption of care for 1 (#9); and delayed completion of a resumption of care within 48 hours for 1 (#1) of 11 sampled patients. This deficient practice had the potential to delay necessary care for the patients. Findings include: 1.Review of patient #1's EHR reflected a readmission to the hospital on 9/30/24, for sepsis. Review of patient #1's EHR, "Discharge Summary from [Hospital Name]", dated 10/5/24, reflected patient #1 discharged home with orders for skilled nursing, physical therapy, and occupational therapy. Review of patient #1's EHR, "RN Resumption of Care," dated 10/8/24, reflected patient #1 readmitted to the agency's care on 10/8/24, three days after discharge from the hospital. 2. Review of patient #9's EHR physician orders, dated 11/25/24, reflected an order to readmit, with, "PT to eval and treat. ..." During an interview on 12/3/24 at 10:46 a.m., staff member B stated the agency did not have an Oasis Resumption of Care for patient #9. Staff member B stated she did not know why the Resumption of Care was not completed. Staff member B stated the nurse responsible for completing the resumption of care was unavailable for interview. Review of the agency's policy and procedure, "Start of Care Assessment-Resumption of Care," revised 10/2022, reflected," ...will conduct this visit within 48 hours of the patient's discharge from an inpatient admission of greater than 24 hours."

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to update and complete a comprehensive discharge assessment of the patient at the time of a patient’s discharge for 2 (#s 7 and 10) of 11 sampled patients. This deficient practice had the potential to affect all patients being discharged from home health services. Findings include: Patient #10 had a SOC date of 10/28/24, with a principal diagnosis of Atrial Fibrillation. A review of patient #10’s Physician Orders, dated 10/30/24, showed, Physical Therapy Services for one visit one time a week, and then on 11/3/24, for one to two visits for three weeks. A review of patient #10’s Therapy Visits showed the following physical therapy visits were completed: - Start of Care, on 10/28/24, - PT Regular Visit, on 10/30/24, -PT Regular Visit, on 11/6/24, no further visits were documented in the patient’s EHR. A review of patient #10’s EHR, did not reflect a discharge order, a discharge OASIS assessment, or a criteria for discharge. An information request for documentation for patient #10’s discharge order, discharge criteria, and/or discharge OASIS, was submitted to the agency on 12/3/24 at 9:30 a.m. No additional documentation was provided by the end of the survey. During an interview on 12/3/24 at 9:30 a.m., staff member B stated they would follow the agency’s policy and procedure for ensuring the appropriate elements were completed at the time of a patient’s discharge. A review of the agency’s policy and procedures titled, Discharge of Patient, with a revision date of 10/2022, showed: - “Policy: It is the responsibility of the Registered Nurse and/or Therapist to obtain a discharge order from the physician when discontinuing services for a patient under admission of the [Agency Name]. Patients will be given advanced oral/written notice of their pending discharge and [Agency Name]'s Expedited Determination Process and Home Health Advance Beneficiary Notice (HHABN) policies will be followed… Procedure: 1. A Registered Nurse, Physical Therapist, Occupational Therapist, or Speech-Language Pathologist may use the following criteria for discharge from their specific services: - Patient is transferred to an inpatient facility and remains hospitalized over the recertification date, or the patient/family informs [Agency Name] that inpatient residence is permanent. (See Patient Transfer Policy) - Patient is deceased - Patient no longer resides in [County Name] County - Patient has failed to complete the Face-to-Face encounter for physician certification required by particular reimbursement sources - Patient no longer desires Home Health services (See Discharge Against Medical Advice policy) - Physician discharges patient - Patient no longer meets Medicare/Medicaid/3rd Party reimbursement eligibility, receives advanced notification of pending discharge, and chooses to no longer receive the services/items. - Patient is too sick for safe home care - Patient and/or family is uncooperative, non-compliant, and/or abusive to staff - There is an unsafe home environment for agency staff -Established goals of discipline are met - Agency is unable to meet the needs of the patient 2. The physician will be notified by each Home Health discipline of the indicated criteria for discharge. If he/she agrees to discharge, a verbal physician order will be written and sent to the physician by the discipline desiring discharge within 72 hours of the discharge date. [Agency Name] patients will receive advanced oral/written notice of the discharge as per [Agency Name] Expedited Determination Process and Home Health Advance Beneficiary Notice policies. 3. If a patient requests discharge from services and the physician is not agreeable to discharge due to the belief that the discharge may be detrimental to the patient's well-being, the Discharge Against Medical Advice policy will be followed. 4. The last skilled discipline servicing the patient will complete the Discharge Outcome and Assessment Information Set (OASIS). A copy of this assessment will be copied and forwarded to the physician as the Discharge Summary…” 1.Patient #7 had a SOC date of 9/24/24, with a primary diagnosis of Multiple Sclerosis Review of patient #7's physician orders, dated 9/10/24, showed Physical Therapy visits 1-2 times per week for four weeks. Review of patient #7's PT discharge visit note, dated 10/17/24, showed the patient was discharged from PT services. Review of the active patient list showed patient #7 was still receiving services. The patient had not received any services from 10/17/24 to 12/5/24. Review of patient #7's POC, dated 9/24/24, showed PT visits 1-2 times per week for four weeks. During an interview on 12/5/24 at 2:40 p.m., staff member B stated the agency follows the policies and procedures for completing the discharge OASIS.

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 interviews and record review, the agency failed to ensure a plan of care was developed for 2 (#s 4 and 10) of 11 sampled patients. This deficient practice had the potential to affect all patients receiving home health services as outlined by the plan of care. Findings include: 1.Review of patient #4's EHR, Nursing Admission Visit, dated 10/15/24, reflected patient #4 was admitted on 10/15/24. Review of patient #4's EHR reflected no plan of care documented for the start of care on 10/15/24, through 11/5/24, when patient #4 discharged. During an interview on 12/4/24 at 10:36 a.m., staff member B stated the agency did not have the plan of care for patient #4 and she did not know why the plan of care was not completed. 2. Review of patient #10’s EHR, PT Admission Visit, dated 10/28/24, showed patient #10 had an initial visit and comprehensive assessment completed on 10/28/24. Review of patient #10’s EHR did not reflect a plan of care was completed for patient #10. An information request for documentation of patient #10’s plan of care, was submitted to the agency on 12/3/24 at 3:12 p.m. No additional documentation was provided by the end of the survey. During an interview on 12/4/24 at 2:57 p.m., staff member B stated they could not find a plan of care was developed for patient #10. She stated it was the expectation that a plan of care be established for all patients on home health services. A review of the agency’s policy and procedure titled, Plan of Care, with a revision date of 9/2022, showed: “Policy: The Plan of Care (POC) for each patient is developed in consultation with the [Agency Name] licensed nursing staff, therapists, patient, patient's family/caregiver and physician. The Plan of Care covers all pertinent diagnoses, the patient's mental status, types of services to be received, equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral to other facility, measurable and obtainable goals, and other appropriate items...”

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 interviews and record review, the agency failed to complete visits as ordered by the physician for 2 (#s 7 and 9) of 11 sampled patients. Findings include: Review of patient #9's EHR, Plan of Care, dated 6/10/24, reflected patient #9 was to receive the following: "- ...Nursing 10/11/2024-11/02/2024 - 1 every week for 4 weeks ..." to complete cardiopulmonary assessments, wound care, medication management, and diabetic foot care. Review of patient #9's EHR reflected no nursing visits were completed from 10/19/24 through 11/1/24, when patient #9 was readmitted to the hospital. During an interview on 12/3/24 at 3:39 p.m., patient #9 stated she "...did a better job on her wound care than the therapy girl, she needs to take 1st aide class. They were a no-show last Friday, and a no-show today, so I gave up on her. It happens a lot. I'll do it myself, She's not very good anyway. ..." During an interview on 12/4/24 at 2:40 p.m., staff member B stated the agency's expectations for missed visits included documenting why the visit was missed, and follow-up to reschedule the visit, and document the rescheduling. Staff member B stated she could not find a documented reason for the missed visits and the nurse responsible for the visits from 10/19/24-11/1/24 was no longer available. 1.Patient #7 had a SOC date of 1/2/24, with a recertification period of 10/28/24 through 12/26/24, with primary diagnosis of Malignant Neoplasm of anterior wall of bladder. Review of patient #7's physician order for services, dated 12/15/24, showed the patient was to receive nursing services for nephrostomy cares. Review of patient #7's POC, with a certification period of 10/28/24 through 12/26/24, showed the patient was to receive SN visits 1one time per week for nine weeks for monitoring abdominal wound, nephrostomy tube sites and complete cardiorespiratory assessments with vital signs. Review of patient #7's visit schedule showed three missed visits for the certification period. During an interview on 12/5/24 at 11:51 a.m., staff member B stated SN visits were "paused" due to the absence of the nurse who was also the Clinical Manager.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow accepted standards of practice by reusing single use dressing on negative pressure wound therapy for 1 (#1) of 11 sampled patients. Failure to follow proper infection prevention standards placed patient #1 at risk of increased infection and pain. Findings include: Review of patient #1's EHR reflected patient #1 had a physician order for wound care for a septic bursitis of the left knee that had perforated through the skin, as follows: "- Home NPWT orders: -125 mmHg and continuous, small black sponge kit, 2x/week dressing change, 1 canister per week, 6-to-8-week duration." Review of patient #1's [Hospital Name], "Inpatient Progress Note," dated 9/23/24, reflected patient #1's culture of the left knee fluids was found to include, " ...Streptococcus parasanguinis..." Review of patient #1's EHR, "Nursing Regular Visit", dated 10/11/24, reflected patient #1 had a dressing change completed with a note from the visiting nurse stating the following: "- ... The foam dressing that was given to patient wouldn't attach to the vac pump. Reused the small foam dressing foot with difficulties getting it to seal. Sealed and suctioning at 125 mmHg when leaving patient's home. ..." During an interview on 12/4/24 at 2:40 p.m., staff member B stated nurses were expected to, "...always use new supplies when changing a dressing. If the nurse did not have the supplies, a clean dressing should be put on to cover the wound and the nurse should obtain the correct supplies and return to finish changing the dressing." Staff member B stated the nurse involved was no longer working at the agency. Staff member B stated she did not know why the nurse would have reused a dirty dressing on the negative pressure wound therapy dressing for patient #1. Staff member B stated the reuse of the dressing materials was inappropriate. During an interview on 12/5/24 at 10:42 a.m., staff member B stated the agency did not have a policy or procedure for wound dressing changes and dressing changes were not covered in the skills checklist for nurses. Staff member B stated dressing changes were to be followed in accordance with the physician orders.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Organization and Administration of Services. Based on interview and record review, the facility failed to: - Provide Skilled Nursing Services (See G982). - Provide continued nursing care and assessments related to wound care and cardiorespiratory care (G982). - Ensure an administrator was actively involved, available, and responsible for all day-to-day operations of the agency (See G948). - Ensure that a clinical manager was available during the agency hours of operation (See G950). - Ensure the agency’s governing body approved in writing a pre-designated person to assume the roles and responsibilities of the administrator when the administrator was not available (See G954). - Ensure patients’ needs were continuously assessed in the absence of the clinical manager (See G966). The accumulated effect of these deficient practices had the potential to: - contribute to risk of infection, decline of patient condition, and risk of re-hospitalization; - affect the continuity of clinical care for all staff providing, and patients being provided, home health services. IMMEDIATE JEOPARDY On 12/4/24 at 10:33 a.m.., the agency Administrator, Hospital Director of Nursing, and the Chief Executive Officer were notified that an Immediate Jeopardy existed in the area of §484.105 Condition of Participation: Organization and Administration of Services, which was related to G982. PLAN TO REMOVE IMMEDIACY: An acceptable plan to remove the Immediate Jeopardy was received on 12/5/24 at 1:30 p.m. Plan for Removal of Immediacy for: §484.105: Condition of Participation for Organization and Administration. - “Skilled Nursing: Effective, 12/4/2024, staff member B, will serve as the clinical manager for Logan Health Conrad- Home Health and will provide skilled nursing services for patients requiring that service. Approval has been given by the Logan Health Conrad President to offload current duties so staff member B can step into the Home Health clinical manager role. A lead has been identified in both the clinic and the rehab department to help support this. Additional duties will be offset by the other members of the senior leadership team as determined by the President. A requisition has been submitted for a traveler RN to fill the long-term need for a clinical manager. Consultative support for the role will be provided through Logan Health in Kalispell and partners at Billings Clinic Lewistown. Consultative support will be provided to staff member B to learn the rules and regulations of Home Health. This education and training will take place primarily via Teams to ensure it can start immediately. Additionally, the Kalispell Home Health team is working to provide onsite support to the Logan Health Conrad Home Health Agency during this transition. A full-time administrator for Home Health has been identified through Kalispell Home Health as [staff member P]. This administrator will be brought to the Logan Health Conrad governing board for approval on 12/5/2024 no later than 12 p.m. Board chair is aware. - Patient #6 Patient #6 was brought into the Rehab department on 12/4/24, by her spouse, and assessed by [staff member I]. Patients spouse reports he is changing dressings at home without difficulty. Please see attached assessment note from this visit. Assessment from 12/4/24, will be shared with the ordering provider. If the provider deems home health services should continue for the patient, a new plan of care will be created and skilled nursing services will be provided according to the order and plan of care. The provider will direct ongoing services for this patient. Call to [NFI's] office on 12/5/24 at 11:15 a.m., to discuss patient assessment from 12/4/24. Spoke with [NF1's Nurse] and reviewed patient case as well as the PT wound assessment from yesterday. Note faxed to provider's office for review as well. Discussion with [NF1's Nurse] on how to proceed with patient care and if home health services should be continued. [NF1's Nurse] to relay message and will return call once she is able to speak with [NF1]. - Patient #1 Patient #1 is scheduled to see staff [member I], at 2:00 p.m., today for assessment. If it is determined that wound care is no longer required, the patient will be discharged from service pending physician order. Patient’s daughter stated in phone conversation on 12/3/24, that patient is doing well, and wound has healed nicely. Please see attached assessment note from this visit. Assessment from 12/4/24, will be shared with the ordering provider. If the provider deems home health services should continue for the patient, a new plan of care will be created and skilled nursing services will be provided according to the order and plan of care. The provider will direct ongoing services for this patient. Spoke to [NF2] on 12/5/24 at 11:45 a.m., regarding patient discharge from home health services. Physical Therapist assessment from 12/4/24, discussed with provider. Note sent to provider office as well. Received verbal order from provider to discharge patient from home health services. Discharge order sent to provider office for signature. Provider will write orders for patients to be seen as an outpatient for monitoring of wound. Patient will follow up with primary care as directed. - Patient #9 Patient #9 was contacted by the Home Health office to have Physical Therapy see her at 4:00 p.m., on 12/4/2024. Patient refused home health service and states, “I am doing fine and don’t need anyone to come by. I won’t be home this afternoon anyways I am going to run errands with a girlfriend.” See telephone encounter attached. Ordering physician notified. [NF3] attempted to contact patient and was unable to do so. See physician note attached. Patient has scheduled follow-up in clinic with [NF3] on 12/10/24. The patient has requested a discharge from home health services. The patient will be given the option to have a clinician come to her home to complete the discharge. If the patient refuses to have a clinician enter the home for discharge, a non-visit discharge will be completed. Adult Protective Services has been notified of the concern for patient’s living conditions. Additionally, community resources have been identified to support the patient during her transition period and to assist her with her move to an assisted living facility. These services will be offered to the patient during a check in with home health on 12/5/24. The patient’s physician will also be notified of any conversations and changes with the patient. The patient has a follow up on 12/10/24. During this visit, if the physician determines home health services are appropriate and the patient consents to home health, a new plan of care will be developed according to the physician order and home health services will be provided accordingly. Called patient at home to check in with her on 12/5/24 at 12:15 p.m. Patient reports she is doing her wound care at home and has adequate supplies to do so. Patient reports that she feels her wounds are doing better at this time. Patient is currently residing in her home and is waiting for furniture to be delivered to the assisted living facility, which she states should be there today. Her plan is to move into the assisted living facility tomorrow. Patient offered community resources to help her with her transition to assisted living and patient reports, "You are bothering me, and I don't want your help. Stop calling me, I have too much to do." Asked patient again how we could support her during this transition, and she hung up the phone.” REMOVAL OF IMMEDIACY The removal of the immediacy was verified onsite by the State Survey Agency on 12/5/24 at 1:45 p.m. Once the immediacy was removed, the deficiency remained at a Condition Level.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure an administrator was actively involved, available, and responsible for all day-to-day operations of the agency. This deficient practice had the potential to affect the continuity of clinical care for all staff providing, and patients being provided, home health services. Findings include: During an interview on 12/3/24 at 9:30 a.m., staff member B stated she was responsible for annual staff evaluations, timecards, and she supervised the out-patient therapy department. She stated she did not provide day-to-day oversight of the home health agency. She said she believed that role was managed by staff member C. Staff member B said she had been covering the skilled nursing needs for the agency since 11/8/24, while staff member C was out of the office on medical leave. During an interview on 12/3/24 at 3:00 p.m., staff member B stated she was not aware of the continued need for skilled nursing services for patients which were on services. An information request for documentation of the home health agency administrator’s job description, was submitted to the agency on 12/2/24 at 3:12 p.m., and 3/3/24 at 9:30 a.m. No additional documentation was provided by the end of the survey.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure that a clinical manager was available during the agency hours of operation. This deficient practice had the potential to affect all patients receiving home health services. Findings include: During an interview on 12/2/24 at 11:00 a.m., staff member M stated staff member C was out of the office on medical leave. Staff member M stated staff member B was covering for staff member C, but she was out of the office on personal leave, in another city, on her way back to the agency. Staff member M stated they did not currently have any other RNs providing skilled nursing services. She stated there was no RN available that day since there were no services which required the need of an RN. During an interview on 12/3/24 at 9:30 a.m., staff member B stated she was covering for staff member C, while staff member C was out of the office on extended leave. Staff member B stated she would perform any required skilled nursing needs while staff member B was out of the office. During an interview on 12/4/24 at 8:56 a.m., staff member B stated she had not been providing full-time nursing coverage of the home health agency while staff member C was out of the office. She stated she was not aware there were still patients on home health services which required continued nursing care. Review of the agency’s Job Description for Supervisor [Clinical Manager] for Home Health, showed: “Job Specific Duties: - Supervises the day-to-day operating needs of assigned area(s) including, but not limited to; patient services, assigned practice operations, staff concerns, compliance, process improvement, physician practice coordination/support, and financial functions. - Ensures optimum patient care services from initial contact to close of services... Schedule Details: -Maintains regular and consistent attendance as scheduled by department leadership. -[Agency Name] operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed..."

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency’s governing body approved in writing a pre-designated person to assume the roles and responsibilities of the administrator when the administrator was not available. This deficient practice had the potential to affect the continuity of clinical care for all staff providing, and patients being provided, home health services. Findings include: Review of the agency policy and procedure, titled Administrative Coverage, with a revision date of 9/2022, showed: “Policy: There will be an appointed Administrator for [Agency Name] and an alternate Administrator appointed during operating hours in the absence of the Administrator… Procedure: 1. The Administrator will appoint an alternate in his/her absence. 2. The Home Health Clinical Manager will inform the home health staff, if necessary, who has been appointed for administrative contact.” During an interview on 12/2/24 at 11:00 a.m., staff member M stated the administrator, staff member C, was out of the office on medical leave. Staff member M stated staff member B was covering for staff member C, but she was out of the office, in another city, on her way back to the agency. During an interview on 12/3/24 at 9:30 a.m., staff member B stated she did not realize that she was considered the home health agency’s administrator. Staff member B stated she had been in her current role since 1/2023. She stated she considered that role to have been managed by staff member C. She said prior to staff member C, NF4 was the long-standing administrator for the home health agency, but NF4 had not been in that position for over a year. An information request for documentation of the administrator approved in writing by the governing body, was submitted to the agency on 12/2/24 at 3:12 p.m., and 12/3/24 at 9:30 a.m. No additional documentation was provided by the end of the survey.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure patients’ needs were continuously assessed in the absence of the clinical manager. This deficient practice had the potential to affect all patients receiving home health services. Findings include: Review of the agency’s Job Description for Supervisor [Clinical Manager] for Home Health, showed: “Job Specific Duties: - Supervises the day-to-day operating needs of assigned area(s) including, but not limited to; patient services, assigned practice operations, staff concerns, compliance, process improvement, physician practice coordination/support, and financial functions. - Ensures optimum patient care services from initial contact to close of services. Works with leadership to respond to patient concerns, fosters an environment of immediate service recovery and transparency for patient billing, questions, and issues. Drives culture to improve patient experience, service, and access…” During an interview on 12/2/24 at 11:00 a.m., staff member M stated staff member C was out of the office on medical leave. Staff member M stated staff member B was covering for staff member C. During an interview on 12/3/24 at 9:30 a.m., staff member B stated she was covering for staff member C, while staff member C was out of the office on extended leave. During an interview on 12/4/24 at 8:56 a.m., staff member B stated she had not been providing full-time nursing coverage of the home health agency while staff member C was out of the office. She stated she was not aware there were still patients on home health services which required continued nursing care and had not been continually assessing the needs of the home health patients.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nursing services, including assessments related to cardiorespiratory care and wound care, were provided for 3 (#s 1, 6 and 9) of 11 sampled patients. This deficient practice had the potential to result in harm for risk of infection, decline of condition, and risk of re-hospitalization for the patients. Findings include: During an interview on 12/4/24 at 9:56 a.m., staff member B stated staff member C was the only RN available to complete skilled nursing visits and she had been unavailable since 11/8/24, due to FMLA. Staff member B stated she was covering in the interim for staff member C until she was anticipated to return in approximately a week from the start of the FMLA, on 11/8/24. Staff member B stated the facility was notified that staff member C's FMLA was to be extended until 12/19/24. She stated when they were informed that her FMLA was to be extended, they made the decision to no longer accept any new patient’s that were referred needing skilled nursing. Staff member B stated they were just informed that staff member C would not be returning from FLMA before her retirement date. She stated they currently did not have someone available to cover the agency’s skilled nursing needs. As a result of not providing the skilled nursing services the following patients were affected as follows: 1.Review of patient #6's EHR reflected the following: -Patient #6 had a ROC on 10/29/24, for a rectification period of 10/28/24 to 12/26/24, with a primary diagnosis of malignant neoplasm of anterior wall of bladder, receiving chemotherapy. -Skilled Nursing Services were ordered for once a week for nine weeks, for monitoring abdominal wound, nephrostomy tube sites, and complete cardiorespiratory assessments. -Last skilled nursing visit was on 11/5/24 for wound care. -From 11/6/24 through 12/3/24, patient #6 had not received skilled nursing as ordered, with four missed visits in four weeks. During a phone interview on 12/3/24 at 12:14 p.m., patient #6's POA stated he had been doing the dressing changes for patient #6 for the last four weeks. He stated he was aware the nurse was out sick but had thought she was returning in a week. Patient #6 was not offered alternative nursing services from the agency during that time. 2. Review of patient #1's EHR reflected the following: -Patient #1 had a SOC of 9/27/24, with a recertification period of 9/27/24 through 11/25/24. Patient #1 had a primary diagnosis of streptococcal arthritis of the right knee of the bursa and cellulitis of the left lower limb. -Patient #1 had a SOC on 9/27/24 for NWPT care by skilled nursing services for two times a week for four weeks. - Patient #1 was then readmitted to hospital on 10/1/24 through 10/5/24, for sepsis. - Patient #1 was discharged from the hospital and returned to home health services on 10/8/24. - On the resumption of care, skilled nursing was ordered for three times a week for four weeks for NWPT care and dressing changes. - On 10/16/24, a new order was placed for skilled nursing to discontinue the NWPT and start dressing changes for one time a week for two weeks. - On 10/29/24, a new order was placed for skilled nursing for one time a week for three weeks. After the order change on 10/29/24, patient #1 was seen by SN on 11/5/24, for wound care; there were no further visits provided by any discipline from 11/5/24 to 12/3/24. During an interview on 12/3/24 at 12:01 p.m., patient # 1 stated her daughter was completing her wound care and she had an appointment the following week for the infection in her blood. 3. Review of patient #9's EHR reflected the following: -Patient #9 had an ROC on 10/8/24, with a recertification period from 10/8/24 to 12/6/24, with a primary diagnosis of venous insufficiency, none pressure chronic ulcer of the right lower leg. -Patient #9 had an order for skilled nursing for one time a week for four weeks for cardiorespiratory assessment, medication management, diabetic foot-care, and wound care to the lower legs for three venous statis ulcers. - Patient was seen by skilled nursing services on 10/11/24 and 10/18/24. There were no further skilled nursing visits for the weeks of 10/20/24 through 11/1/24. - The patient was admitted to the hospital on 11/2/24, for suspected NSTEMI. - On 11/25/24, the provider ordered a resumption of care for PT to evaluate and treat for wound care. - On 11/29/24, patient #1 was scheduled for a ROC physical therapy visit. This visit was declined by the physical therapist because of the patient’s unsafe living situation. -A phone call was made to the patient to reschedule for 12/3/24. This visit was cancelled by the agency due to the physical therapist being out of the office. No further attempts were made to reschedule the patient for services as of 12/3/24. Patient #s 1 and 6 were immune compromised, and their wounds had not been assessed by skilled nursing in four weeks. This deficient practice had the potential to result in harm for risk of infection, decline of condition, and risk of re-hospitalization. Patient #9 had the potential for harm related to the high risk for hospital readmission related to cardiorespiratory disease, infection risk, and had not been reassessed by the agency since being discharged from the hospital on 11/25/24.