Every finding on record at Quality Nursing LLC

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 09/06/2023 to 09/08/2023 resulted in a finding of standard level deficiencies cited respective to the Emergency Preparedness Program Condition of Participation under 42 CRF 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 the emergency preparedness plan review, policy review, and staff interview, the Home Health Agency (HHA) failed to ensure the emergency preparedness (EP) plan included a process for cooperating and collaborating with regional and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's emergency preparedness plan not dated, revealed that there was no documentation that collaboration with regional and Federal emergency preparedness officials had been performed. During an interview on 09/06/2023 at 5:00 PM, the Administrator confirmed that collaboration and communication with local, State and Federal Emergency Management Agencies had not been performed as part of the undated EP plan. Review of the agency's policy titled "Emergency Preparedness Implementation Plan" revised 07/25/2018 revealed, "… Collaboration with Emergency Management Agencies: The Agency will fully collaborate and communicate with all Emergency Management Agencies including local, state and federal departments. This collaboration and communication will be the responsibility of the Incident Commander. Documentation will be maintained for all contacts or attempts to contact local, state, or federal Emergency Management Agencies. …"

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on medical record reviews, emergency preparedness policy review, and staff interview, the Home Health Agency (HHA) failed to ensure that an individualized emergency preparedness plan (EP) was developed during the comprehensive assessments performed by two of four (Registered Nurses (RNs)1, RN2) for seven of seven patients (P) 1, P2, P3, P4, P5, P6, P7) medical records reviewed for emergency preparedness plan development. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of medical records revealed the following: a. P1's comprehensive assessment performed on 05/23/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. b. P2's comprehensive assessment performed on 02/18/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. c. P3's comprehensive assessment performed on 06/08/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. d. P4's comprehensive assessment performed on 7/10/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. e. P5's comprehensive assessment performed on 03/24/2023 did not contain documentation than an individualized EP plan was developed by RN1 and RN2. f. P6's comprehensive assessment performed on 06/19/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. g. P7's comprehensive assessment performed on 08/29/2023 did not contain documentation that an individualized EP plan was developed by RN1 and RN2. During an interview on 09/06/2023 at 5:00 PM, the Administrator confirmed that individualized EP plans were not being developed by the RNs during P1, P2, P3, P4, P5, P6 or P7's comprehensive assessments. Review of the agency's policy titled "Emergency Preparedness Patient Emergency Plan" revised 07/25/2018 revealed, "… Purpose: Each patient shall be assessed for having an emergency preparedness plan as part of the comprehensive assessment. …"

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on emergency preparedness plan review, and staff interview, the Home Health Agency (HHA) failed to ensure that the emergency preparedness (EP) plan included a communication policy incorporating names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers; and failed to maintain a list of names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers. This deficient practice had the potential to affect all staff, volunteers and the patients providing or receiving services from the HHA. Findings include: Review of the agency's EP plan revealed no documentation of the names and contact formation for the agency staff, the entities providing services under arrangement for the HHA, the patients' physicians, or volunteers working at the HHA. During an interview on 09/06/2023 at 5:00 PM, the Administrator confirmed that the agency did not maintain the names and the contact information for the agency staff, the entities providing services under arrangement for thee HHA, the patients', the physicians, or the volunteers working in the agency in the EP plan. The Administrator confirmed that a communication policy regarding maintaining names and contact information was not developed.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on emergency preparedness plan review, and staff interview, the Home Health Agency (HHA) failed to ensure the emergency preparedness (EP) plan included a communication policy incorporating names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff; and failed to maintain a list of names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff in the EP binder. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's EP plan that was not dated revealed there was no documentation of names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff. During an interview on 09/06/2023 at 5:00 PM, the Administrator confirmed that the agency did not maintain the names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff in the EP plan. The Administrator confirmed that the HHA had not developed a policy regarding maintaining names and contact information for those individuals.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on the personnel file review, emergency preparedness plan review, policy review, and staff interview, the Home Health Agency (HHA) failed to ensure that emergency preparedness (EP) training for seven of seven staff members (Administrator/Registered Nurse (RN) 1, Assistant Administrator/RN2, RN3, RN4, Licensed Practical Nurse (LPN), Physical Therapist (PT), and the Receptionist) had been performed annually per policy or that the training program was reviewed and updated at least every two years. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of personnel files revealed that EP training had not been completed for the following staff members: 1. Administrator/RN1 - hire date 08/06/2018 2. Assistant Administrator/RN2 - hire date 11/08/2007 3. RN3 – hire date 01/04/2021 4. RN4 – hire date 10/26/2020 5. LPN - hire date 05/11/2023 6. PT - hire date 10/19/2018 7. Receptionist - hire date 03/13/2023 During an interview on 09/06/2023 at 5:00 PM, the Administrator stated that staff members received EP training at the last in-service meeting but stated that the documentation of what the in-service included was not kept. The Administrator confirmed there was no documentation of the EP training or training program. Review of the agency's policy titled "Emergency Preparedness Training" revised 07/25/2018 revealed the policy Purpose: "All staff need to have education and training on the emergency preparedness plan and policies." "An initial education program will be provided to all staff on the new Emergency Preparedness regulations, policies, and procedures. Included in education is the identification of individual roles during an emergency event. Upon hire all new employees will have education related to emergency preparedness policies and procedures. Annual education will be required by all employees related to emergency preparedness policies and procedures. Understanding will be validated via group conference, testing or question and answer discussions. Following an emergency event or whenever a change to the emergency preparedness. Documentation of education is maintained within the Agency."

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 the emergency preparedness "Tabletop Exercise Extreme Heatwave" review, policy review, and staff interview, the Home Health Agency (HHA) failed to ensure that testing of the emergency preparedness plan (EP) had been performed annually. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's emergency preparedness "Tabletop Exercise Extreme Heatwave" provided by the Administrator revealed, there was no documentation of the date and year the exercise was performed, the facility’s analysis and response to the exercise, or how or if the facility needed to update its emergency program based on this analysis of the exercise. During an interview on 09/06/2023 at 5:00 PM, the Administrator confirmed that the tabletop exercise did not include the year when the exercise was performed, an analysis or response to the exercise. The Administrator confirmed that a full-scale community-based exercise had not been performed. Review of the agency's policy titled "Emergency Preparedness Testing" revised 07/25/2018 revealed, "The Agency will test their emergency preparedness plan at minimum annually. The testing will include testing of all components of the plan including risk assessment, policies and procedures, communication plan and emergency response. Full Scale Exercise: The emergency preparedness plan testing will include participation in full scale community-based exercise. In the event that a community event is not available then an individual facility based full scale exercise is required. If the Agency experiences an actual event that requires activation of the emergency plan, the Agency is exempt from engaging in a community based or individual facility based full scale exercise for one year following the actual event. Second Exercise: A second exercise that may include a full-scale exercise, individual hospice exercise or tabletop exercise should be conducted annually. Tabletop exercise will include a group discussion led by a facilitator using a narrated, clinically relevant emergency scenario with a set of problem statements, directed messages or prepared questions designed to challenge the emergency plan. All exercises or actual events will be documented and analyzed for effectiveness of emergency plan. Any identified issues or concerns that were identified will be addressed and the emergency plan updated accordingly."

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 09/06/2023 to 09/08/2023 resulted in a finding of substantial compliance respective to the applicable Condition of Participation under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below. The census was 70. The sample size was 12.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on interview and the "Notice of Patient Rights" document review, the Home Health Agency (HHA) failed to include the agency's policies for transfer and discharge found during one of three home visits patient (P) 6. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's "Notice of Patient Rights" not dated, found in P6's admission folder revealed that the agency's policies for patient transfer and discharge were not included in the "Notice of Patient Rights" document given to all patients upon admission. During an interview on 09/08/2023 at 3:00 PM during a homecare visit with Registered Nurse (RN) 4, P6 did not know the agency policy for discharging or transferring a patient. P6 stated "I don't know, I guess they just discharge me." During an interview on 09/06/2023 at 12:00 PM, the Administrator confirmed that the "Notice of Patient Rights" document provided to the patients did not contain the agency's policies for patient transfer and discharge. The Administrator confirmed that a policy for "Notice of Patient Rights" to include the patient's discharge/transfer rights had not been developed.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on the "Notice of Patient Rights" document review, and interview, the Home Health Agency (HHA) failed to include contact information for the agency's administrator, including the administrator's name, business address, and business phone number in one of one "Notice of Patient Rights” document. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's "Notice of Patient Rights" not dated, found in a sample patient admission folder, provided by the Administrator revealed, that the administrator's name was incorrect. During an interview on 09/06/2023 at 12:00 PM, the Administrator confirmed that the administrator's name was incorrectly printed on the "Notice of Patient Rights" and stated that the previous administrator's name was still on the document. The Administrator confirmed that a policy for "Notice of Patient Rights" had not been developed.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, interview, medical record review, document review, and policy review the Home Health Agency failed to 1) make referrals to the appropriate discipline (social services/social worker) for one of three patients (P5) reviewed during home visits and; 2) failed to coordinate care delivery services related to the time frame that telephone messages were shared with the physician and nurses for two of 12 patients (P) 4, and 12). The home health agency's failure to ensure that all patients received coordination of the care and services has the potential to affect the outcome of patients' health and wellbeing. Findings Include: 1. During an observation of P5 during a Physical Therapy (PT) homecare visit performed on 09/08/2023 from 1:15 PM to 1:50 PM, revealed the patient was tearful, and appeared hopeless. P5 had a difficult time maneuvering around the home in their electric scooter and became short of breath during ambulation throughout the duration of physical therapy. During an interview on 09/08/2023 at 1:30 PM, P5 stated "The last time a social worker had been to visit was about two years ago and [SW] promised that I'd get help, but I never did." P5 stated "I need more services. My scooter has been broken for 2 weeks and the scooter company is waiting for the physician's order to have it repaired. When I go out to buy groceries, my scooter stops working on hills and I get stuck." P5 stated that "the dressing [wound dressing] had fallen off the [left thigh] wound days ago, and I can't put the dressing back on without help." P5 then stated, "I've been with this agency for about eight years, but I need to be discharged for eight weeks at a time because of Medicare rules." Review of P5's medical record revealed P5's start of care was 03/24/2023 and was currently in the third certification period of 07/22/2023 to 09/19/2023. P5's order was to receive skilled nursing services and physical therapy services once a week. There was no documentation that P5 had been offered or had a social work consult since the start of care. There was no documentation that P5 had requested additional services, the electric scooter was not working properly, or the wound dressing was not remaining intact. During an interview on 09/08/2023 at 5:00 PM, the Administrator stated that P5 declined a social worker visit when it was offered, but confirmed there was no documentation of P5's refusal in the medical record. The Administrator was unaware that P5's electric scooter was not working properly or that it required a physician's order to have it repaired. The Administrator was not aware of P5's wound dressing falling off, requiring a nursing visit. Review of the agency's "Notice of Patient's Rights" not dated revealed, "… You have the right to participate in, be informed about and consent to or refuse care in advance of and during treatment, where appropriate, with respect to: Completion of all assessments; the care we will furnish to you, based on the comprehensive assessment; establishing and revising the plan of care; the disciplines, types of health care professionals that will furnish the care you receive under the plan of care; the frequency of visits made by our staff to your home to provide care; expected outcomes of care including patient-identified goals …" 2. a. Review of P4’s "Home Health Certification and Plan of Care" dated 07/10/2023, signed by the Administrator/Registered Nurse (RN) 1 on 07/10/2023 and the physician on 08/07/2023 identified a start of care on 07/10/2023 for the certification period of 07/10/2023 to 09/07/2023. The diagnosis included the following: type 2 diabetes, hypertension, coronary artery (heart) disease and vitamin D deficiency. Mental status (cognitive ability) was "oriented and forgetful." Review of the telephone message pad from Friday 08/25/2023 at 2:30 PM, signed by the Licensed Practical Nurse (LPN) identified (P4) "will not take Metformin (a medication used to treat type 2 diabetes for high blood sugar levels), concerns over side effects, other options." Review of the "SN (Skilled Nurse) Visit Note" on 08/25/2023 at 2:34 PM revealed the Chief Complaint/Reason for Visit: "Type II diabetes and Metformin medication education." Comments: "Patient is bradycardia (slow heart rate) with an apical pulse rate of 54 BPM (slower than normal heart rate below 60 beats per minute) is asymptomatic." The "SN Visit Note" did not include information regarding P4 discontinuing the Metformin, P4's response to stopping the Metformin or P4's concerns over side effects. Review of the "Physician Order" on 08/28/2023 not timed, revealed "discontinue Metformin, start Glipizide (medication to lower blood sugar) 5mg 1 tab PO QD (five milligrams, one tablet by Mouth once a day)." During an interview on 09/06/2023 at 4:20 PM with the Administrator, regarding the process for on call persons answering the phone when the Home Health Agency office was closed from Friday through Monday, the Administrator confirmed the Home Health Agency did not have an on-call policy for when the nurses and physicians were not available Friday, Saturday, and Sunday stating, "there is no on call policy." Administrator stated RN2/Assistant Administrator worked the weekend answering service and alternates with other nurses, stating that "They write the notes [when patients call when the agency is not open] and you have to dig to find out what happened, there should be an easier way." On 09/07/2023 at 5:00 PM interview with the Assistant Administrator regarding the physician's 08/28/2023 order to discontinue Metformin, the Assistant Administrator stated, "I don't know why the doctor waited three days to discontinue Metformin and knowing the patient wasn't taking it." The Assistant Administrator stated that the message P4 left was forwarded to the medical assistant at the physician's company. The Assistant Administrator confirmed the physician did not address P4's medication until Monday, stating the physician office was not open on Friday, "unless it is an emergency they will not respond until the next business day." During a telephone interview on 09/08/2023 at 9:22 AM with the LPN (who wrote a telephone message from P4) regarding on call answering phone and taking messages, LPN stated, "When I receive a call, I explain the office is closed to call back on Monday. I will hold messages until the following Monday." LPN stated on 08/25/2023 at 2:30 PM "P4 was told the office is closed." P4 stated their concern and said they wanted to speak to the medical assistant from physician's office." The LPN asked P4, "is it urgent? LPN stated P4 response was they will call on Monday. LPN stated, "I should have asked [RN1/Administrator] if I should document calls." LPN stated, "I was not sure of direction [procedure] for being on call" confirming it was a learning curve. LPN stated, "from here on out, I will document resolution of calls and text Nursing." 2. b. Review of P12's "Home Health Certification and Plan of Care" dated 08/24/2023, signed by the Assistant Administrator/RN2 on 08/28/2023 and the physician on 09/05/2023 identified a start of care on 08/24/2023 for the certification period of 08/24/2023 to 10/22/2023. The diagnosis included the following: chronic obstructive pulmonary heart disease, lipoprotein deficiency, osteoarthritis right knee and anxiety disorder. Mental status was "oriented and forgetful." Review of the telephone message pad from Friday, 08/27/2023 at 1:10 PM, signed by the LPN identified (P12) "wants a nurse to come look at a lump in his/her vein." Review of the "SN (Skilled Nurse) Visit Note" on 08/30/2023 at 11:52 AM revealed the "Chief Complaint/Reason for Visit: COPD (chronic obstructive pulmonary disease). The "SN Visit Note" from 08/30/2023 and the next SN visit on 09/06/2023 did not include information addressing P12's concern from 08/27/2023 when they complained about "a lump in his/her vein." Review of the "SN Visit Note" on 09/08/2023 included the following: "SN (skilled nurse/RN4) asked patient about a lump in a vein he mentioned to office but never mentioned to SN. Patient told RN4 "has a small lump near left wrist that has been present a few months. Patient with small firm deep lump (not visible to naked eye have to palpate) to inner radial side of left wrist." During a 09/07/2023 at 5:15 PM interview with Assistant Administrator regarding P12's message on 08/27/2023 with their concerns about a lump in their vein, not addressed until 09/08/2023. Assistant Administrator stated, "That is something that needs to be changed; messages (how we document follow-up on patient concerns)."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on the "ACH PIP [Acute Care Hospitalization Performance Improvement Project] Report Update–Document" review, policy review, and interview, the Home Health Agency (HHA) failed to analyze and perform Project Performance Improvement Project (PIP) updates for the 2023 ACH PIP. This deficient practice had the potential to affect all patients receiving services from the HHA. Findings include: Review of the agency's "ACH PIP Report Update-Document" provided by the Administrator revealed that the 2023 PIP was titled "Identify Trends in Acute Care Hospitalization". The start date of the PIP was not documented. The ACH PIP did not include the data for patient hospitalizations, or the on-going analysis and updates had not been completed for this project. During an interview on 09/06/2023 at 11:20 AM, the Administrator confirmed that the on-going analysis and update of the ACH PIP to identify trends in acute care hospitalization was not completed. There was no data entered on patient hospitalizations. The Administrator confirmed the ACH PIP did not include the month/day/year of when the ACH PIP was started. Review of the agency's policy titled "Quality Assessment and Performance Improvement" undated, revealed, "… Data will be collected to allow the agency to monitor its performance. Data will be collected, measured, and analyzed. … The agency will assess for improved efficient processes. Data collection will be prioritized based on the organization's mission, care services provided, and populations served. …"

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, and interview, the Home Health Agency (HHA) failed to ensure that one of one Home Health Aide was competent to perform health aid tasks assigned by a Registered Nurse (RN) prior to caring for patients. This deficient practice had the potential to affect three patients receiving aide services from the HHA. Findings include: Review of the Home Health Aide's personnel file revealed that the Home Health Adie's start date was 12/12/2020. Review of the competency in the Home Health Aide's personnel file revealed there was no demonstration of skills performed by the Home Health Aide in the presence of an RN, required to ensure the aide was competent to perform the tasks assigned. During an interview on 09/07/2023 at 4:20 PM, the Administrator confirmed that competency was not completed or signed off by an RN for the Home Health Aide. The Administrator confirmed that the agency did not have a policy regarding Home Health Aide competencies.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on personnel file review, and interview, the Home Health Agency (HHA) failed to ensure that one of one Licensed Practical Nurse (LPN) was competent to perform nursing skills routinely performed for patient's receiving care from the HHA. This deficient practice had the potential to affect patients receiving care from the LPN. Findings include: Review of the LPN's personnel file revealed, LPN was hired on 05/11/2023 but there was no demonstration of skills performed by the LPN, in the presence of an RN, required to ensure the LPN was competent to perform nursing skills prior to providing patient care. During an interview on 09/07/2023 at 4:20 PM, the Administrator confirmed that competency was not completed and signed off by an RN for the LPN. The Administrator confirmed the agency did not have a policy developed regarding LPN competencies.