Every finding on record at St John's Home Care

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 1/9/25. Based upon the findings of the survey team, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 1/6/25 to 1/9/25.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, staff interview, specialist recommendation, policy and procedure review, the agency failed to ensure supplies available for patient use were not expired for 1 of 1 supply room. The findings were: 1. Observation of the supply room on 1/8/25 at 2:16 PM with the RN Clinical Manager showed the following concerns: a. Nine BD 3 milliliter (ml) syringes which expired on 11/30/24. b. Three BD 10 ml syringes which expired on 12/31/24. c. One Magellan hypodermic safety needle 23 gage by 1 inch which expired on 10/31/23. 2. Interview at that time with the Clinical Manager revealed the agency checked for expirations monthly. She verified the medical supplies were for client use and were expired. 3. Review of the website "fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines"[sec] accessed on 1/21/25 showed "...The expiration date is a critical part of deciding if the product is safe to use and will work as intended... It is important to know and stick to the expiration date on your medicine. Using expired medicines is risky and possibly harmful to your health." 4. Review of policy "Guidelines for Dating Medications and Supplies" approved on 12/9/24 included "...5. Refer to safety data sheet (SDS) and or manufacturer's instructions for use (IFUs) for questions..."

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys on 12/13/21 through 12/16/21. Unless otherwise indicated, the general use of the terms "facility" or "facilities" refers to all providers and suppliers affected by this regulation. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the emergency plan and staff interview, the facility failed to ensure the emergency plan addressed the patient population and the type of services the facility had the ability to provide in an emergency. The findings were: 1. Review of the facility's policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed neither addressed the patient population nor the services the facility could provide in an emergency. 2. During an interview on 12/16/21 at 1:40 PM the administrator confirmed the facility's emergency plan did not address the patient population nor the services the facility could provide in an emergency.

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 emergency preparedness policies and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed a procedure to notify State and local emergency preparedness officials about home health patients in need of evacuation from their residences due to an emergency situation. The findings were: 1. Review of the facility's policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed no procedure to notify State and local emergency preparedness officials about home health patients in need of evacuation from their residences due to an emergency situation. 2. During an interview on 12/16/21 at 1:40 PM the administrator confirmed the facility lacked a procedure to notify officials of patients in need of evacuation due to an emergency.

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 emergency preparedness policies and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed a procedure to follow up with on-duty staff and patients to determine services that are needed in the event there is an interruption in services during an emergency. In addition, there lacked a procedure to inform State and local officials of any on-duty staff or patients the facility was unable to contact. The findings were: 1. Review of the policies "Emergency Management Plan" and "Home Care- Emergency Preparedness" (approved 11/11/21) showed neither addressed a procedure to follow up with on-duty staff and patients to determine services that are needed in the event there is an interruption in services during an emergency. In addition, there lacked a procedure to inform State and local officials of any on-duty staff or patients the facility was unable to contact. 2. On 12/16/21 at 1:40 PM the administrator confirmed the facility did not have written procedures for following up with on-duty staff and patients during an emergency nor a procedure to notify officials of any on-duty staff or patients they were unable to contact.

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), §485.625(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 review of the communication plan and staff interview, the facility failed to ensure the communication plan included names and contact information for employees, entities providing services under arrangement, patients' physicians and volunteers. The findings were: 1. Review of the facilities policy "Home Care-Emergency Preparedness" (approved 11/11/21) showed it did not include the names and contact information for employees, entities providing services under arrangement, patients' physicians, or volunteers. 2. During an interview on 12/16/21 at 1:40 PM the administrator confirmed the written policy did not contain the required contact information. She stated she had that information in her computer, but acknowledged that information would not be available in the event of a power outage.

A recertification survey was conducted by Healthcare Licensing and Surveys from 12/13/21 through 12/16/21. In addition a COVID19 focused infection control survey was conducted.

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, staff interview and review of manufacturer instructions for use, the facility failed to ensure point of care equipment was cleaned as required for 1 of 3 random observations. The findings were: 1. Observation on 12/14/21 at 10:30 AM showed the home health nurse #1 used a thermometer, blood pressure cuff, and a pulse oximeter (to read pulse and oxygen saturation) to obtain vital signs. The nurse used a Sani-Cloth wipe to disinfect the equipment for less than a minute then placed the equipment into a plastic bin. Continued observation showed the nurse used another Sani-Cloth wipe and cleansed the clipboard, and computer. The following concerns were identified: a. Interview with nurse #1 on 12/14/21 at 11:23 AM revealed he was not sure about wet contact time for proper disinfection of equipment. He further stated he thought the process was to wipe down the equipment, then let air dry. b. Interview with the administrator on 12/15/21 at 9:20 AM revealed she was not aware of the wet contact time instruction for proper disinfection of point of care equipment. c. Review of the Sani-Cloth wipes instructions for use showed ""To disinfect and deodorize: Unwrap clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full 2 minutes..."

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the facility failed to ensure the plan of care was developed in partnership with the patient (or representative) and caregiver(s) for 7 of 7 patients (#1, #2, #3, #4, #5, #6, #7). The findings were: 1. Review of the following plans of care showed no evidence the patient (or representative) and caregiver(s) were involved in the development of the plan: a. The plan of care for patient #2, for the certification period of 9/18/21 to 11/16/21. b. The plan of care for patient #4, for the certification period of 3/20/21 to 5/18/21. c. The plan of care for patient #5, for the certification period of 10/21/21 to 12/19/21. d. The plan of care for patient #7, for the certification period of 11/12/21 to 1/10/22. 2. During an interview on 12/15/21 at 3 PM the administrator confirmed there was no evidence the patients or families were involved in the development of the plans of care. She stated the goals that were established on the plan of care came from the patient or family, but said there was no documentation to show that. e.The plan of care for patient #1 for the certification period of 12/10/21 to 2/7/22. f. The plan of care for patient #3 for the certification period of 5/10/21 to 7/8/21. g. The plan of care for patient #6 for the certification period of 12/10/21 to 2/7/22.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on personnel file review, staff interview, and review of the Wyoming Board of Nursing licensing requirements, the facility failed to ensure 1 of 1 home health aide (HHA #1) was credentialed in accordance with state law. The findings were: 1. Review of the personnel file for home health aide #1 showed she was hired on 12/26/20. Further review of her file showed she had a current certified nurse aide (CNA) certification with the Wyoming Board of Nursing, but not a home health aide endorsement. 2. During an interview on 12/14/21 at 3:30 PM the administrator confirmed HHA #1 only had a CNA certification. She stated she was not aware of the requirement for aides working in home health to be endorsed as a home health aide by the Wyoming Board of Nursing. 3. Review of the Chapter 2 Licensing and Certification Requirements, effective 4/6/20, by the Wyoming Board of Nursing showed "Home Health Aide: Applicant shall: (i) Meet qualifications for CNA by examination or endorsement; (ii) Complete a Board-approved Home Health Aide training and competency evaluation program (sixteen (16) hours); and (iii) Submit completed application and fees; and evidence of Home Health Aide training completion.