Every finding on record at Stonerise Home Health Services LLC

An emergency preparedness survey was conducted Stonerise Home Health on February 12, 2024 to February 14, 2024 as part of a recertification survey conducted during the same survey period. The agency was not in compliance with the Emergency Preparedness Conditions of Participation for Home Health Agencies.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review, documentation review, and interview, it was revealed the facility failed to update or maintain their Emergency Management Plan with current required information. The failure to maintain current information has the potential to have a negative impact on all staff and patients in the agency. A review of the record, titled "Emergency Management Plan (EPP) Notebook" revealed that the agency did not have a current updated license, no evidence of any insurance, an evacuation plan for the agency, and no evidence that the plan has been reviewed since 2021. The (EEP) notebook still had the previous address of the facility and the evacuation plan for a different location. The facility failed to update relevant location, emergency fire exit information and required emergency preparedness information. The current address evacuation plan was not added to the notebook to replace the old evacuation plan. There was no evidence of the staff being trained on a new evacuation plan for the current agency. An interview was conducted with Employee #1 on 2/13/24, at 1:00 p.m. Employee #1 states, “We review the EPP quarterly in our Quality Assurance and Performance Improvement [QAIP] meetings. Our last top table exercise was done in 2023, and our EPP for the patients is reviewed weekly by staff. The EPP Notebook has not been reviewed since 2021." An interview was conducted with Employee #1 on 2/14/24 at 12:25 p.m. Employee #1 states, “There has not been any training to the staff on the evacuation plan in this new building. I did not think of it until asked on 2/12/24 about the evacuation plan on the walls of this building." A review of the policy, titled “Emergency Management Plan” dated 10/2017. The policy states, “Purpose: To establish a plan which will allow for the continuation of services in the event of a disaster affecting the organization or the community … Policy … Planned evacuation routes will be known or identified and alternated means of transportation for personnel … Procedures … 9. An annual evaluation of the organization’s hazard vulnerability analysis and emergency management plan, including its objectives, scope, functionality, and effectiveness will be conducted. The annual evaluation may be based on the drill evaluation or actual implementation of the emergency management plan. 10. Organization leadership will provide for orientation and education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually.” A review of the policy, titled “Emergency Plan Policy” dated 5/1/2021. The policy states, “Policy: The agency develops and implements and emergency plan based on a risk assessment and using an “all hazard” approach, which provides an integrated system for emergency planning that focuses on capacities and capabilities. Purpose: To describe the Agency’s approach to responding to internal and external emergencies that would suddenly and significantly affect the need for services, plans for patients or the ability to provide such services. An emergency is defined as a natural or man-made disaster that significantly disrupts the Agency’s environment, disrupts care and service or results in sudden, significant change or increase in demand for Agency services. Procedure: 1. The emergency plan includes, but is not limited to, the following elements: The Agency has developed and maintains an emergency plan and policies that are reviewed and updated at least every two years.”

A recertification survey was conducted at Stonerise Home Health on February 12, 2024 through February 14, 2024. The agency provides the following services: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Social Worker, and Home Health Aide to residents in Kanawha, Putman, Lincoln, Boone, Fayette, Cabell, Wayne and Mason. The active patient census at the time of survey was three hundred and sixty-four (364) and the unduplicated census for past twelve (12) months were one thousand six hundred and thirty-two (1632) patients. It was determined the facility was in compliance with requirements of 42 CFR, Part 484-The Medicare Conditions of Participation for Home Health Agencies.