Every finding on record at Sac County Phns

The recertification survey dated 12/1/22 through 12/8/22 found the agency operating out of compliance with the following emergency preparedness regulations.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the agency's integrated health emergency preparedness plan and related policies and procedures and staff interview, the agency failed to ensure agency staff developed a policy and procedures to inform State and local emergency officials about homebound patients in need of evacuation due to an emergency situation. Failure to have procedures in place for how to inform State and local officials of homebound patients in need of evacuation due to an emergency situation potentially placed homebound home health patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the agency's undated emergency management plan revealed the plan failed to include notification to State and local officials of homebound patients in need of evacuation due to an emergency situation. The surveyor reviewed with the Administrator and the Administrator agreed the plan did not include notification to State and local officials of homebound patients in need of evacuation due to an emergency situation. Agency staff provided no further information prior to the end of the survey.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of agency emergency management plan and staff interview, the agency failed to ensure the development of a written policy and procedure to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. Failure to have procedures in place to inform State and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency, placed agency patients at risk for not receiving needed assistance during or due to an emergency situation. Findings include: Review of the undated agency emergency management plan, revealed the plan failed to identify a procedure for informing state and local officials of any on duty staff and patients they are unable to contact in the event of an interruption of services related to an emergency. The surveyor notified the Administrator of the plan not having a procedure for informing state and local officials of any on duty staff and patients they are unable to contact and the Administrator agreed the plan did not include a procedure. The agency provided no further information prior to the end of the survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan/policies, review of agency emergency preparedness training and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for 8 of 10 direct employees (Staff F and Staff G) and 11 out of 11 contracted staff. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: Review of the agency's Emergency Management Plan, revealed staff training for an in-service on Homecare Emergency Preparedness, Fire Drill, and Tornado Drill on 10/27/22. The signs in sheets lacked documentation Staff F, Office Manager and Staff G, Administrative Assistant did not have any documentation of training for emergency preparedness. The agency lacked documentation all staff received emergency preparedness training during orientation or biannually as required by regulation. Interview with the Administrator on 12/7/22 at 3:00 PM reported she had no documentation of training for any of the 11 contracted staff members. Agency staff provided no additional information prior to the end of the survey.

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), §485.625(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, 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 agency staff interview, agency policy review and review of training documentation, the agency failed to ensure participation in emergency preparedness exercises in 2020 or 2021, including an after action report to analyze the agency's response to the exercise. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: During interview on 12/7/22 at 3:00 PM, the Administrator reported participating in an exercise with the county coalition on 6/2/22. The Administrator provided the exercise to the surveyor to review. The agency failed to perform an after action report to analyze the agency's response to the exercise. The agency provided no further information received prior to the end of the survey.

The recertification survey conducted by the Department of Inspections and Appeals from 12/1/22 through 12/8/22, found the agency operating in compliance with the Conditions of Participation for Home Health Agencies. The survey found the agency operating out of compliance with the following standard level regulatory requirements. The agency reported a current census of 39 patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames with the comprehensive assessments for 3 of 7 sampled patients (Patient #1, #2 and #7). Failure to ensure medications were reviewed at the time of each drug regimen review increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: According to the undated agency policy, titled Medication Profile/Drug Regimen Review, a Drug Regimen Review/Medication Profile is included with the comprehensive assessment to identify the most accurate list of all prescription medications, over the counter medications, herbal supplements, and dietary supplements that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This review will indicate potential clinically significant medication issues such as high-risk medications, omissions, and dosage errors, incorrect, inaccurate or unclear orders. The policy states patients will have a current, accurate medication profile in the clinical record. Medication profiles will be updated with each new, changed, or discontinued drug.The nurse will complete and document a medication review at all the required time points of the comprehensive assessment – SOC (start of care), ROC (resumption of care), F/U (follow up), Transfer and Discharge for patients requiring the completion of an OASIS...The nurse will assess the drug regimen, instruct and document: significant potential and actual side effects, duplicate drug therapy, ineffective drug therapy, medication non-compliance, and significant and potential drug interactions. During agency staff interview on 12/1/22 at 12:57 PM, the Clinical Manager reported the drug regimen review (DRR) is completed at all assessment time points. The DRR process just changed, as it had been completed on paper, however, with the implementation of the electronic health record, it is now performed in the computer system in the medication profile. The Registered Nurse completes the DRR with SOC, ROC, recertifications, and discharges. The electronic health record (EHR) allows them to check to see if there are interactions, and allow the nurse to sign it to show the review was completed. 1. Patient #7 had a start of care date of 8/16/22 and discharged from the agency with goals met on 11/22/22. Clinical record review revealed the following: a. An update to the comprehensive assessment at the time of resumption of care, dated 10/14/22, lacked documentation of a completed drug regimen review. b. The medication profile lacked documentation of a completed drug regimen review. c. An update to the comprehensive assessment at the time of discharge, dated 11/22/22, lacked documentation of a completed drug regimen review. d. The medication profile lacked documentation of a completed drug regimen review. The updates to the comprehensive assessment at the time of resumption of care and discharge lacked documentation of a completed drug regimen review. 2. Patient #1 had a start of care date of 4/4/22. Clinical record review revealed the following: a. An update to the comprehensive assessment at the time of recertification, dated 9/26/22, lacked documentation of a completed drug regimen review b. The medication profile showed drug regimen reviews were completed on 9/13/22 and 10/4/22. The clinical record lacked documentation of completion of the required drug regimen review at the time of the recertification. 3. Patient #2 had a start of care date of 11/22/16. Clinical record review revealed the following: a. An update to the comprehensive assessment at the time of recertification, dated 10/19/22, lacked documentation of a completed drug regimen review. b. The medication profile lacked documentation of a completed drug regimen review. The clinical record lacked documentation of completion of the required drug regimen review at the time of the recertification. The above findings were reviewed with agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation(Patient #1, #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to then undated agency policy, titled Care Planning process, ....the individualized plan of care will include, but will not be limited to: all pertinent diagnoses, mental, psychosocial, spiritual, and cognitive status, types of services, supplies, and equipment required, the frequency and duration of visits to be made by specific discipline for therapeutic interventions, prognosis, homebound status, rehabilitation potential, functional limitations, activities permitted, and nutritional requirements.... 1. Patient #3 had a start of care date of 9/6/19. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 6/22/22 to 8/20/22, 8/21/22 to 10/19/22 and 10/20/22 to 12/18/22, included orders for Propranolol 40 mg twice daily. The Medication profile included orders for Propranolol 40 mg twice daily.. During a home visit observation on 12/6/22 at 10:51 AM, with Staff E, RN, the surveyor reviewed the patient's medications with the patient. The pharmacy set up bubble packs for the patient. The bubble pack included Propranolol 20 mg twice daily. Interview with pharmacy staff on 12/6/22 at 2:00 PM reported the pharmacy had initially received a script on 10/25/21 for Propranolol 20 mg twice daily. The Plan of Care lacked the correct dosage of Propanolol used by the patient. b. The Plans of Care, dated 6/22/22 to 8/20/22, 8/21/22 to 10/19/22 and 10/20/22 to 12/18/22, included orders for Fenofibrate 160 mg daily starting 11/16/22 and a previous dosage of Fenofibrate dosage of 54 mg daily. The Medication profile included orders for Fenofibrate 160 mg daily starting 11/16/22 and a previous dosage of Fenofibrate dosage of 54 mg daily. During the same home visit observation on 12/6/22, the surveyor reviewed the patient's medications with the patient. The pharmacy set up bubble packs for the patient. The bubble pack included Fenofibrate 145 mg. Interview with pharmacy staff on 12/6/22 at 2:00 PM reported the pharmacy had initially received a script on 10/25/21 for Propranolol 145 mg daily The Plan of Care lacked the correct dosage of Propranolol used by the patient. c. The Plans of Care, dated 6/22/22 to 8/20/22, 8/21/22 to 10/19/22 and 10/20/22 to 12/18/22, included orders for Lomotil 2.5 mg-0.025 mg for use up to 4 times per day as needed for diarrhea. The Medication profile included orders for Lomotil 2.5 mg-0.025 mg for use up to 4 times per day as needed for diarrhea. During the same home visit observation with Staff E, RN, the surveyor reviewed the patient's medications with the patient. The patient reported not having any lomotil on hand and the patient has not had any for several months. The Plan of Care included the lomotil which was no longer used by the patient. e. The Plans of Care, dated 6/22/22 to 8/20/22, 8/21/22 to 10/19/22 and 10/20/22 to 12/18/22, identified the following equipment and supplies were needed to meet the patient's needs: cane, grab bars, hospital bed, tub/shower bench, bubble packs, pill caddy, CPAP (continuous positive airway pressure) machine, diabetic supplies, reacher, walk in shower, hand held shower, pacemaker monitor, and walker. During the same home visit observation with Staff E, RN, the surveyor observed the RN assessing the patient's blood pressure. The RN instructed the patient to use the patient's blood pressure machine to obtain the measurement. The patient reported having the blood pressure machine for years. The Plan of Care lacked identification of the blood pressure machine as equipment needed to meet the patient's needs. During the same home visit observation on 12/6/22 at 10:51 AM, with Staff E, RN, the surveyor observed incontinence supplies in the patient's bedroom next to the patient's bed. Interview with the patient revealed the patient has used incontinence supplies for 3 years. The Plans of Care lacked identification of the incontinence supplies as supplies needed to meet the patient's needs. f. During the same home visit observation with Staff E, RN, the surveyor observed the patient's shower. The shower head was a normal one and not a hand held shower. Interview with the patient reported he/she had a hand held shower, but had the plumber remove it a couple of years ago due to the hand held shower did not have enough water pressure. The Plan of Care incorrectly identified the hand held shower as equipment needed to meet the patient's needs. 2. Patient #2 had a start of care date of 11/22/16. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 6/25/22 to 8/23/22, 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22, included orders for Simvastatin 10 mg daily. The Medication profile included orders for Simvastatin 10 mg daily. During a home visit observation on 12/6/22 at 8:30 AM, with Staff D, Licensed Practical Nurse (LPN), the surveyor reviewed the patient's medications with the patient's caregiver. The patient had bubble packs set up by the pharmacy. The bubble pack included Simvastatin 20 mg at bedtime. Interview with pharmacy staff on 12/6/22 at 1:45 PM reported the pharmacy had initially received a script on 9/16/22 for Simvastatin 20 mg. The Plan of Care lacked the correct dosage of Simvastatin used by the patient. b. The Plans of Care, dated 8/2/22 to 9/30/22, 10/1/22 to 11/29/22 and 11/30/22 to 1/28/23, included orders for Benztropine 0.5 mg 2 tablets daily. The Medication profile included orders for Benztropine 0.5 mg 2 tablets daily. During the same home visit observation with Staff D, LPN, the surveyor reviewed the patient's medications with the patient's caregiver. The patient had bubble packs set up by the pharmacy. The bubble pack, filled on 11/7/22, included Benztropine 1 mg twice a day. Interview with pharmacy staff on 12/6/22 at 1:45 PM reported the pharmacy had initially received a script on 9/16/22 for Benztropine 1 mg twice a day. The Plan of Care lacked identification of the correct dosage of Benztropine used by the patient. c. The Plans of Care, dated 8/2/22 to 9/30/22, 10/1/22 to 11/29/22 and 11/30/22 to 1/28/23, included orders for Konsyl 28.3% powder with instruction for the patient to take 1 tablespoon twice daily. The Medication profile included orders for Konsyl 28.3% powder with instruction for the patient to take 1 tablespoon twice daily. During the same home visit observation with Staff D, LPN, the surveyor reviewed the patient's medications with the patient. The patient's caregiver reported switching to Fiber Well gummies 5 grams (g) a couple of months ago . The Plan of Care lacked identification of the Fiber Well gummies used by the patient and included Konsyl powder which was no longer in use by the patient. 3. Patient #1 had a start of care date of 4/4/22. Clinical record review, home visit observation and accompanying interviews revealed the following: The Plans of Care, dated 8/2/22 to 9/30/22, 10/1/22 to 11/29/22 and 11/30/22 to 1/28/23, included orders for Tylenol 325 milligrams (mg) with instructions for the patient to take 2 tablets every 4 hours as needed for pain. The Medication profile included orders for Tylenol 325 milligrams (mg) with instructions for the patient to take 2 tablets every 4 hours as needed for pain. . During a home visit observation on 12/5/22 at 1:00 PM, with Staff C, Registered Nurse (RN), the surveyor reviewed all medications used by the patient. The patient had a bottle of Tylenol on the kitchen counter. The bottle contained Tylenol Extra Strength 500mg. The patient reported the bottle is the only bottle used since admitted to the agency (4/4/22). The Plan of Care lacked the correct dosage of Tylenol used by the patient. The above findings were reviewed with the Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 3 of 7 sampled patients with new verbal/interim orders. (Patients #3, #5 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: The undated agency policy, titled Components of Clinical Record, included...the individualized plan of care will be revised or added to at intervals, as necessary, to continue to meet the patient needs. The physician will be notified of any changes that suggest a need to alter the plan of care. Revisions/updates will be noted by agency RN with use of the addendum to Plan of care, form 487 and dated and signed by the physician. Interview on 12/6/22 at 10:15 AM with the Clinical Manager reported the agency does have a Plan of Care update they can go into during the visit in the EHR (electronic health record). The Clinical Manager demonstrated this to the surveyor on one of the patients and the Plan of Care generated did not show changes of medication dose and frequencies from the original Plan of Care for that certification period. 1. Patient #5 had a start of care date of 9/30/22. Clinical record review revealed: a. The Plan of Care, dated 9/30/22 to 11/28/22, included physician orders for skilled nursing services two times per week for one week, then three times per week for on week for daily dressing changes until the patient's doctor appointment on 10/5/22. b. An interim verbal order, dated 10/5/22, included orders effective 10/6/22 for skilled nursing visit one time per week for one week to allow the nurse to visit the patient on 10/6/22 and then the patient will go to the wound clinic on 10/7/22 and new orders will be established at that time. The Plan of Care lacked an update with the ordered change in skilled nurse frequency. c. An interim verbal order, dated 10/7/22, included orders for a change in nurse frequency, beginning 10/8/22 for skilled nurse visits one time per week for one week and 3 times per week for one week for the nurse to perform wound care to the left ankle as follows: cleanse would with soap and water, pack loosely with Aquacel AG and cover and secure with mepilex border dressing using aseptic technique and apply sens socks on bilateral legs after the dressing application. The Plan of Care lacked an update with the ordered change in skilled nurse frequency. d. An interim verbal order, dated 10/12/22, included new orders for Doxycycline Monohydrate 100 mg (milligrams) twice daily, Fluticasone 50 micrograms (mcg) per inhalation nasal spray 1 spray in each nostril twice daily and Loratadine 10 mg daily as needed for allergies. The Plan of Care lacked an update with the ordered change in medications. e. An interim verbal order, dated 10/14/22, ordered beginning 10/14/22 the skilled nurse frequency of 0 times per week for 1 week and then 2 times per week for 6 weeks and 1 time per week for 1 week and instructed the nurse to complete dressing changes on Mondays and Wednesdays and the patient would see the wound clinic on Fridays. The Plan of Care lacked an update with the ordered change in skilled nurse frequency. 2. Patient #3 had a start of care date of 9/16/19. Clinical record review revealed: a. The Plan of Care, dated 10/20/22 to 12/18/22, included physician orders for skilled nursing and home care aide services and included orders for fenofibrate 54 mg (milligrams) daily. b. A faxed interim verbal order, dated 11/16/22, ordered an increased dosage of fenofibrate to 160 mg daily. During a home visit on 12/6/22 at 10:51 AM with Staff E, Registered Nurse (RN), the surveyor asked the RN on whether the agency has a working plan of care. The RN stated they usually keep the most recent plan of care in the home and showed the surveyor the Plan of Care. The Plan of Care lacked an update with the change in fenofibrate. 3. Patient #7 had a start of care date of 8/16/22. Clinical record review revealed: a. The Plan of Care, dated 8/16/22 to 10/14/22, included physician orders for skilled nursing and home care aide services. b. An interim verbal order, dated 9/15/22, ordered Lorazepam 0.5 mg (1/2 tablet) twice daily. The Plan of Care lacked an update with the order for Lorazepam. The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 3 of 7 sampled patients (Patients #2, #3 and #5). Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: The undated agency policy, titled Care Planning, identified coordination of Care will assure communication occurs with all physicians involved in the plan of care, integrates orders from all physicians, and integrates all services to assure the identification of patient needs, patient safety, treatment effectiveness and coordination of care by all disciplines. Interview with the agency Administrator on 12/1/22 at 12:20 PM reported if treatment varies from the Plan of Care, the nurse will notify the physician. 1. Patient #2 had a start of care date of 11/22/16. The Plans Of Care (POC), dated 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22 , identified diagnoses of type 2 diabetes and included orders for the skilled nurse to assess diabetic status, and report significant changes to the physician and perform insulin administration. Clinical record review revealed the following: a. Skilled nurse visit notes, dated 10/5, 10/8, 10/9, 10/11, 10/14, 10/19, 10/20, 10/21, 10/28, 11/2, 11/5, 11/6, 11/7, 11/10, 11/12, 11/13, 11/17, 11/25, and 12/1/22, documented the review of blood sugars were not applicable. b. Skilled nurse visit notes, dated 10/17, 10/29, 11/16, 11/18, 11/27, 11/28, and 12/3/22 were reviewed, however did not document what the readings were. The nurse failed to perform tasks as ordered on the Plan of Care. 2. Patient #5 had a start of care date of 9/30/22. The POC, dated 9/30/22 to 11/28/22 and 11/29/22 to 1/27/22, included physician orders for skilled nursing to perform a complete physical assessment each visit with emphasis on wound care, assessment of diabetes, hypertension and blood sugar levels. The nurse was also to report blood sugar levels greater than 200 milligrams (mg) per deciliter (dl). Clinical record review revealed: a. Skilled nurse visit notes, dated 10/1, 10/8, 10/9, 10/12, 10/19, 10/26, 11/2, 11/9, 11/16, 11/23, 11/25, and 11/30/22 lacked a complete physical assessment each visit with emphasis on assessment of diabetes, hypertension and blood sugar levels. b. Skilled nurse visit note, dated 10/24/22, documented a random blood sugar level of 219 mg/dl. The note lacked physician notification of the reading as ordered on the Plan of Care. The nurse failed to perform tasks as ordered on the Plan of Care. 3. Patient #3 had a start of care date of 9/6/19. The POC, dated 10/20/22 to 12/18/22, included physician orders for skilled nursing to perform a complete physical assessment each visit with emphasis on diabetes, hypertension, chronic kidney disease, anticoagulants, and depression. Clinical record review revealed a skilled nurse visit note, dated 11/16/22, lacked a complete physical assessment each visit with emphasis on diabetes, hypertension, chronic kidney disease, anticoagulants, and depression. The nurse failed to complete all tasks as ordered on the Plan of Care The above findings were reviewed with the agency Administrator and Clinical Manager. Agency staff provided no additional information prior to the end of the survey.