Every finding on record at Ssm Health Businesses

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 2/28/2024. The Agency was not in compliance with the standard, 42 CFR 484.102, Establishment of the Emergency Program for this 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), §485.542(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 document review and interview, it was determined the Agency failed to establish a bi-annual testing plan for its Emergency Preparedness Program (EPP), inclusive of participation in a full-scale community-based exercise every 2 years. Findings include: 1. On 2/27/2024 at approximately 1:00PM, the agency’s Emergency Preparedness training and testing of staff was reviewed. There was no community-based training or testing of staff documented. 2. On 2/27/2024 at approximately 2:00PM, an interview was conducted with the System Director of Home Health (E #3) reported she was not familiar with the community-based exercise. E #3 was unable to show documentation of bi-annual testing of staff for emergency preparedness plan exercise.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 2/27/2024. The Agency was not in compliance with 42 CFR 484, Standards of Participation for Home Health Agencies for this survey. Abbreviations; E- employee Pt- patient POC- Plan of Care PT- Physical Therapy PTA- Physical Therapy Assistant SOC- Start of Care CPM- Continuous Passive Motion (machine) ml- milliliter

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined for 1 of 12 (Pt #7) patients records reviewed, the Agency failed to ensure the initial assessment was conducted within 48 hours of referral. 1. On 02/27/24, at 11:00 AM, the HHA policy "Assessment of Patient and Clent (revised 01/24/24)" was reviewed. The policy stated, "... Process... 2 An initial assessment is made by SN (skilled nurse), PT (physical therapy) or ST (speech therapy) within 48 hours of the verbal start of care date as indicated on the 485. The initial assessment may be delayed beyond the standard 48 hours by physician order or patient/family preference..." 2. Pt #7 Start of Care: 02/20/24 Diagnoses: Pressure ulcer deep tissue right heel. On 02/27/24, at approximately 11:15 AM, the clinical record of Pt #7 was reviewed. Pt #7 was referred to the HHA on 02/07/24. The Plan of Care for certification period 02/20/24 to 04/19/24 indicated the initial assessment was conducted on 02/20/24. There was no physician order changing the start of care date. 3. On 02/27/24 at approximately 11:30 AM, an interview with the HHA Supervisor (E #2) was conducted. E #2 reviewed Pt #1's record and verbally agreed the initial assessments were conducted more than 48 hours after the referral. E #2 stated "We have had some staff shortages. We should have gotten an order for a delayed start of care and did not."

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 document review, observation, and interview, it was determined for 1 of 7 (Pt #3) home visits, the Agency failed to ensure the patient’s home medication list was current and accurately reflected all medication names, dosages, and frequencies. Findings include: Pt #3 Start of Care (SOC): 2/17/2024 Diagnosis: Liver Cell Carcinoma During the home visit on 2/26/2024 at approximately 10:30 AM, a review of Pt #3’s medications were reviewed with the Physical Therapist (E #4). The Agency’s medication list initiated on the SOC and the medication list printed 2/26/2024 for certification period 2/17/2024 to 4/16/2024, listed the same medications. This list of medications was compared to the medication’s available for use in Pt #3’s home. The Agency’s medications list lacked the following medications: Alum-mag hydroxid-simeth 15 ml every 6 hours as needed over the counter medication. Sennosides (Sen-O-tab) 8.6 mg every day as needed over the counter medication. Fludrocotisone 0.1 mg tablet every day filled 2/7/2024. Atorvastatin 80 mg ½ tablet every night filled 1/22/2024. Zonisamide 100mg 2 capsules twice day filled 12/22/2023. Fludrocotisone, Atorvastatin, and Zonisamide are prescription medications with fill dates prior to the SOC. 2. A review of the Facility Visit Notes dated 2/19/2023 by PT and a visit note dated 2/21/2024 by a PTA, and the 2/23/2024 visit note by the RN did not indicate the medications were reconciled on these home visits. The 2/23/2024 home visit by the RN indicated the medications were reconciled and there were "No new/changed medications since last visit.” On 2/26/2024 the home visit with PT identified the above discrepancies. 3. On 2/28/2026 at approximately 10:00AM, an interview was conducted with the System Director (E #3). E #3 reviewed the discrepancies and agreed the medications were not on the medication list.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 2 of 2 (Pt #4 and Pt #6) patients with a CPM (Continuous Passive Motion) machine, the Agency failed to ensure the Plan of Care (POC) included a physician order for a CPM machine and specific instructions for use of the CPM. Findings include: 1. On 2/26/2024 at approximately 10:00 AM, the Home Health Agency policy titled, “Physician Orders” (revised 4/7/2023) was reviewed. The policy required, “Physician orders are obtained for patient care services including treatments, procedures and equipment before such services are furnished. B. Orders will provide specific directions for providing care and services…” 2. Pt#4 Start of Care (SOC): 2/19/2024 Diagnosis: After Care Following Joint Replacement. The record was reviewed on 2/26/2024 at approximately 12:00 PM. The Plan of Care (POC) dated 2/19/2024 to 4/18/2024, indicated under “Durable Medical Equipment”, Pt #4 had a CPM machine. During the Home Visit on 2//26/2023 at 3:00 PM, the CPM was observed. The POC dated 2/19/2024 to 4/18/2024 lacked a physician order and instructions for the use of the CPM. 3. Pt #6 Start of Care (SOC): 2/22/2024 Diagnosis: After Care Following Joint Replacement. The record was reviewed on 2/27/2024 at approximately 10:00 AM. On 2/27/2024, the POC dated 2/22/2024 to 4/21/2024, indicated under “Durable Medical Equipment”, Pt #6 had a CPM machine. The POC dated 2/22/2024 to 4/21/2024 lacked a physician order and instructions for the use if the CPM machine. 4. During an interview on 2/27/2024 at approximately 11:30 AM with the Branch Manager (E #1), E #1 verbally confirmed the Plan of Care for Pt #4 and Pt #6 lacked a physician’s order and instructions for use of the CPM. E #1 stated the physician’s order and instructions were not transferred over from the patient’s hospital discharge summary.

The Emergency Preparedness requirements were evaluated in conjuction with the recertification survey on 03/11/2021. The Facility was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with a Focused Infection Control Survey (FIC) on 3/11/21. The facility was not in compliance with the Standards for Home Health Agencies and the requirements for Infection Control for COVID, 42 CFR 484, as evidenced by: Abbreviations: Employee E Number # Open to air OTA Patient Pt

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on documentation review and staff interview it was determined for 2 of 2 (Pt #12 and #17) patient deaths at home, the Agency failed to ensure adverse events were tracked, analyzed and preventive actions were implemented. This has the potential to affect all home health patients-current census 133. Findings include: 1. The clinical record of Pt #12 was reviewed on 3/10/21 at 11:00 AM. Pt #12 admitted on 10/25/20 with diagnoses of essential hypertension, status post fall with abrasion left elbow and right knee, past history of cerebral vascular accident with right hemiplegia. Documentation indicated Pt #12 died at home on 10/26/20. 2. The clinical record of Pt #17 was reviewed on 3/10/21 at 1:00 PM. Pt #17 admitted 12/10/20 with diagnoses pneumonia, subdural hematoma from trauma, fracture rib and non-pressure ulcer left heel. Documentation indicated Pt #17 died at home 12/26/20. 3. The Agency policy review date 2/22/19, titled, "Event Reporting" was reviewed on 3/10/21 at 10:30 AM. Under "DEFINTIONS: III. I. Any "Event" that involves any severe injury or unexpected death;..." Under "PROCESS: II. Reporting: A. All "staff members" and/or their manager are responsible for ensuring "Events" of any type that they witness, become aware of or are involved in are reported through the "Online "Event Reporting System: in a "timely" manner. Under "DOCUMENTATION: I. B. The factual information of the "Event" is recorded...The "Event" Description should include what, when, how and where the "Event occurred." 4. On 3/10/21 at 1:00 PM, a request was made for the "Event Report" of Pt #12 and #17. At 1:30 PM, a review of the "Event Report" for Pt #12 and #17 indicated, the report was completed on 3/10/21. 5. On 3/10/21 at 1:45 PM, an interview was conducted with the Administrator (E#2). E#2 verbalized no "event" was reported for Pt #12 and #17. E#2 stated, " I just added the information into the system today." E#2 confirmed the deaths of Pt #12 and #17 were not reported as an event per Agency policy.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, document review and staff interview, the Home Health Agency (HHA) branch office, failed to follow standard transmission-based precautions to decrease the potential for transmission of the COVID-19 virus. This has the potential to affect all persons entering the branch office with a current patient census of 43. Findings include: 1. On 03/09/2021 at approximately 4:00 PM, a tour of the branch office was conducted. There was no signage on the entrance door to alert patients, staff, or visitors to wear a mask, and that a pre-screening for COVID-19 was required prior to entering. Upon entering the branch office there was no thermometer available for temperature checks and no pre-screening being conducted. 2. On 03/10/21 at 9:15 AM, the "Instructions to use Employee Screening at the Door URL" (implemented by the agency, 07/24/2020) sheet was reviewed. The sheet refers to a Website that allows access to a form labeled "SSM Employee Access Screening." This form required all persons entering the branch office to be pre-screened for the COVID-19 virus. This form was not being utilized at the branch office. 3. On 03/09/2021 at 4:10 PM, an interview with the Branch Office Assistant (E #1) was conducted. E #1 confirmed there were no pre-screenings being conducted prior to entering the facility and stated "I just started here and I didn't know we were supposed to be doing that."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined the nurse failed to communicate with the physician regarding needs of the patient related to current care. This failure has the potential to affect all patients receiving care, currently a census of 133 patients. Findings include: 1. The clinical record of Pt #5 was reviewed on 3/9/21. Review of the plan of care dated 1/20/21 included the following: "page 8, Wound: anterior right medial chest, other skin or non-surgical wound, Port-a-cath site. Observe for S/S (signs and symptoms) of infection and report to MD if issues, OTA (open to air)." The nurse visit note of 2/18/21, in "Plan for next visit" related to the port, "Right chest port last flushed 1/16 will need monthly flushes set up". There is no communication to the physician to obtain orders for flushing the port to maintain patency. 2. An interview with the Administrator (E#2) was conducted on 3/11/21 at 9:30 am. E#2 reviewed the record of Pt #5 and agreed there was no follow up regarding the needs of Pt #5's port-a-cath related to flushing. E#2 stated, "We were not proactive and should have made contact with the physician."