Every finding on record at Stonerise Reliable Healthcare, LLC

An emergency preparedness survey was conducted Stonerise Home Health, New Martinsville July 15, 2024 through July 17, 2024, as part of a recertification survey conducted during the same survey period. It was determined the agency was not in compliance with the requirement of 42 CFR, Part 484- The Medicare Conditions of Participation for Home Health Agencies with citation E0039.

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 staff interview, the facility failed to participate in a tabletop disaster drill that is community based to address potential hazards within the community at least every two years. This failure has the potential to adversely affect all patients when there is an emergency in the community. FINDINGS INCLUDE: The policy titled, “Testing Program for Emergency Operation Plan (EOP)” reviewed: undated and stated in part: Policy: Agency will ensure that the Emergency Operation Plan (EOP) is functional through testing and evaluation. Procedures: 1. Agencies will conduct exercises to test the EOP at least annually. Agencies will do the following: … (ii) Conduct an additional exercise every two [2] years, opposite the year the full-scale or functional exercise is conducted, that may include, but not limited to the following: … (C) A tabletop exercise or workshop that is led by a facilitator. A document review of the “Emergency Preparedness Notebook;” last update 01/18/2024 revealed that there were no tabletop exercise completed in 2023 or 2024. An interview was conducted on 07/15/24 at 2:15 p.m. with Employee #1, who confirmed, “We have not participated in a tabletop exercise with the local healthcare coalition in 2023 or 2024. If it is not in the book, we have not participated in one.”

A recertification survey was conducted at Stonerise Home Health, New Martinsville on July 15,2024 through July 17, 2024. It was determined the facility was in compliance with requirements of 42 CFR, Part 484-The Medicare Conditions of Participation for Home Health Agencies.

An emergency preparedness survey was conducted at Stonerise at Home from 1/10/22 to 1/12/22 as part of a recertification survey conducted during the same survey period. One (1) standard level deficiency was cited at E 0017.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on document review, medical record review and staff interview it was determined the facility failed to ensure the emergency preparedness plan was complete and individualized in the comprehensive assessment for five (5) of eight (8) patients (patients #4, 5, 6, 7 and 8). The failure to include all information regarding the emergency plans for the patient in the comprehensive assessment has the potential to adversely affect all patients in the event of an emergency. Findings include: A review of the facility policy entitled “Emergency Plan Policy,” implemented 5/1/21, revealed in part: "Mitigation activities … The plans for patients during a natural or man-made disaster. Individual plans for each patient must be developed as part of the comprehensive patient assessment …” A review of the facility document entitled “Chart Review Quick Reference Guide,” dated 1/11/22, revealed in part: “Ensure patient EP plan is complete and is individualized …" A review of the facility document entitled “Individualized EP Plan,” dated 2/19/21, revealed in part: “Under ‘Does patient have any special needs?’ respond with yes or no. If yes, describe the needs and include information that would need to be quickly identified for the patient in the event of an emergency. (Ex. Mr. ___ can evacuate to sister’s house, contact info and address) …” A review of patient #4’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #5’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #6’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #7’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #8’s medical record revealed the question regarding special needs was answered with a ‘yes” and patient would evacuate to the “daughter’s house” but did not contain the daughter’s contact information or address. An interview with the home health administrator was conducted on 1/11/22 at 12:50 p.m. and they agreed with the above findings.

A recertification survey was conducted at Stonerise at Home from 1/10/22 to 1/12/22. The agency provides skilled nursing, physical therapy, occupational therapy, speech therapy and home health aide services to Pleasants, Tyler, Wetzel, Marshall and Ohio counties. At the time of the survey the agency reported an active census of fifty-four (54) and an unduplicated census of two hundred and thirty-five (235) patients. A total of eight (8) medical records were reviewed and three (3) home visits were made. One (1) standard level deficiency was cited at G 526.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on document review, medical record review and staff interview it was determined the facility failed to ensure the emergency preparedness plan was complete and individualized in the comprehensive assessment for five (5) of eight (8) patients (patients #4, 5, 6, 7 and 8). The failure to include all information regarding the emergency plans for the patient in the comprehensive assessment has the potential to adversely affect all patients in the event of an emergency. Findings include: A review of the facility policy entitled “Emergency Plan Policy,” implemented 5/1/21, revealed in part: "Mitigation activities … The plans for patients during a natural or man-made disaster. Individual plans for each patient must be developed as part of the comprehensive patient assessment …” A review of the facility document entitled “Chart Review Quick Reference Guide,” dated 1/11/22, revealed in part: “Ensure patient EP plan is complete and is individualized …" A review of the facility document entitled “Individualized EP Plan,” dated 2/19/21, revealed in part: “Under ‘Does patient have any special needs?’ respond with yes or no. If yes, describe the needs and include information that would need to be quickly identified for the patient in the event of an emergency. (Ex. Mr. ___ can evacuate to sister’s house, contact info and address) …” A review of patient #4’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #5’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #6’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #7’s medical record revealed the question regarding special needs was answered with a “no” and the individualized emergency preparedness plan did not contain evacuation or contact information. A review of patient #8’s medical record revealed the question regarding special needs was answered with a ‘yes” and patient would evacuate to the “daughter’s house” but did not contain the daughter’s contact information or address. An interview with the home health administrator was conducted on 1/11/22 at 12:50 p.m. and they agreed with the above findings.