Every finding on record at Spring Meadows Home Health Care, LLC

Recertification survey completed. Standard level deficiencies cited.

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: A. Based on review of the Emergency Preparedness Program and Staff interview, it was determined that the Agency failed to provide staff training on the Emergency Preparedness Plan. Findings include:1. The Emergency Preparedness Program was reviewed on 08/24/2022 at 12:30 PM. The program lacked documentation of the Agency providing staff training on the Emergency Preparedness Plan.2. During an interview with the Acting Administrator and Director of Nursing on 08/24/2022 at 2:30 PM, the findings of the Agency failing to provide staff training on the Emergency Preparedness Program were confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: LPN = Licensed Practical Nurse POC = Plan of Care PT = Physical Therapy RN = Registered Nurse SOC = Start of Care

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: A. Based on the clinical record review and Staff interviews, it was determined the Agency failed to ensure a comprehensive assessment by the RN for all patients. This was found in 1 of 7 records (Pt. #1) reviewed. Findings include: 1. Patient #1 SOC not documented The clinical record was reviewed on 08/24/22 at 10:00 AM and 08/25/22 with the Acting Administrator and didnot include a comprehensive assessment. On 08/24/22 at 10:00 AM, during the interview with the Acting Administrator, it was stated that RN failed to conduct the initial comprehensive assessment. 2. During interviews with the Acting Administrator and the Director of Nursing on 08/25/2022 from 1:30 PM until 3:15 PM, the above findings were confirmed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: A. Based on review of clinical records and Staff interview, it was determined that the Agency failed to ensure staff established and followed the Plan of Care. This was found in 5 of 7 (Pts. #1, 3, 5, 4 and 7) clinical records reviewed. 4. Pt. #4 SOC 05/12/2022 Diagnosis: Pressure Ulcer to Left Buttocks, stage 2. The clinical record was reviewed on 08/24/2022 at 9:45 AM. The clinical record included a POC dated 07/11/2022. The POC included, “SN to perform complete physical assessment each visit with emphasis on Pressure Ulcer Left Buttock Stage 2… including Pressure Ulcer Right Buttocks Stage 1…” SN notes dated, 07/14/2022 and 08/04/2022 documented the pressure ulcers were cleansed with a baby wipe and ointment applied. This was not included in the POC. 5. Pt. #7 SOC 12/11/2022 Diagnosis: Type 2 diabetes mellitus with foot ulcer. The clinical record was reviewed on 08/24/2022 at 10:30 AM. The clinical record included a home health aide care plan dated, 01/24/2022. The care plan included oral care to be provided every visit. HHA visit notes dated, 01/25/2022, 01/29/2022 and 02/01/2022 lacked documentation of oral care provided. The record also included a POC dated 02/09/2022 that included, “… Orders for Discipline and Treatment… PT Frequency: treat and evaluate…” The record lacked documentation that a PT evaluation was provided. 6. During interviews with the Acting Administrator and the Director of Nursing on 08/24/2022 from 1:30 PM until 3:15 PM, the above findings were confirmed. Findings include: 1. Patient #1 SOC not documented The clinical record was reviewed on 08/24/22 at 10:00 AM and 08/25/22 with the Acting Administrator and lacked the establishment of a written POC. 2.Pt. #3 SOC 07/12/22 Diagnoses: Wedge Compression Fracture T11-T12 Vertebra, sequela and Essential (primary) Hypertension. The clinical record was reviewed on 08/24/22 at 10:30 AM. The POC dated 07/12/22 required the Physical Therapist to Evaluate and treat the patient. The PT did not evaluate the patient until week #2 (07/22/22) and the plan of care was not signed or modified by the physician. 3. Pt. #5 SOC 07/15/22 Diagnoses: Pressure Ulcer of Other Site, Stage 2 and Type 2 Diabetes Mellitus with other specified complications. The clinical record was reviewed on 08/24/22 at 11:00 AM. The POC dated 07/15/22 required the Physical Therapist to Evaluate and treat the patient. The PT did not evaluate the patient until week #2 (07/21/22) and the plan of care was not signed or modified by the physician. The same POC required the Aide to provide personal care. The record lacked the Aide visit notes. On 08/25/22 at 9:30 AM, during the interview with the Acting Administrator, it was stated that the patient’s family refused the Aide. The plan of Care was not modified by the physician to discontinue the Aide services.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: A. Based on clinical records review and Staff interview it was determined the Agency failed to provide supervision of the home health aide every 14 days. This was found in 1 of 2 (Pt. #7) clinical records reviewed with home health aide services ordered. Findings include: 1. Pt. # 7 SOC 12/11/2021 Type 2 diabetes mellitus with foot ulcer. The clinical record was reviewed on 08/24/2022 at 10:30 AM. The record included a doctor’s order for home health aide services 3 times a week for 2 weeks beginning 01/24/2022 and a plan of care dated 02/09/2022 which included, “HHA Frequency: 2wk8…” The home health aide provided services for the patient beginning 01/24/2022 through 03/05/2022. On 02/23/2022 the Registered Nurse documented a supervisory visit of the home health aide. The record lacked any additional supervisory visits for the home health aide from 01/24/2022 through 03/05/2022. 2. During an interview with the Acting Administrator and the Director of Nursing on 08/24/2022 at 2:30 PM, the above findings were confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: A. Based on the clinical record review and Staff interview, it was determined that the clinical records lacked required assessments and notes. This was found in 2 of 7 (Pt. #1 and 5) records reviewed. Findings include: 1. Patient #1 SOC not documented The clinical record was reviewed on 08/24/22 at 10:00 AM and 08/25/22 with the Acting Administrator and lacked the comprehensive assessment and the plan of care-physician orders. 2. Pt. #5 SOC 07/15/22 Diagnoses: Pressure Ulcer of Other Site, Stage 2 and Type 2 Diabetes Mellitus with other specified complications. The clinical record was reviewed on 08/24/22 at 11:00 AM. The record lacked the physician order to discontinue the Aide services that were included on the plan of care dated 07/15/22. On 08/24/22 at 1:30 PM, during the interview with the Acting Administrator, it was stated that the Aide did not provide any services due to the family's refusal. The record did not include any supporting documentations, notes or physician orders. 3. The above findings were confirmed during the interview with the Acting Administrator, on 08/24/22 between 1:30 PM and 3:00 PM.