Every finding on record at Sumner County Home Health Agency

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (ASPEN #61163-H1) conducted at the above-named Home Health Agency (HHA) from 09/27/23 to 09/29/23 resulted in the following deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan (EPP) that is based on and includes a documented, facility-based and community-based risk assessment; utilizing an all-hazards approach that included strategies for addressing emergency events identified by the risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA failed to develop the EPP based on a facility-based and community-based risk assessment. During interview on 09/27/23 between the hours of 2:00 PM and 5:00 PM, Staff A confirmed that the EPP folder provided was the most recent available EPP onsite. The staff member responsible for the development and management of the EPP was not available onsite. The provided EPP was not up to date nor based on a facility-based and community-based risk assessment.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to review, revise, and update policies and procedures at least every 2 years and failed to develop EPP policies and procedures for all hazards identified within the facility's risk assessment. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of all EPP policies and procedures revealed the HHA last reviewed and/or revised the policies and procedures in 2017 and/or 2018. Review of all EPP policies and procedures revealed the EPP policies and procedures were not inclusive of all hazards identified within the HHA risk assessment. Further review of the EPP policies and procedures revealed the HHA failed to include a policy and procedure for the following: 1. use of other healthcare entities, contracted service providers, or memorandum of agreements (MOAs), 2. initial communication and follow-up communication for staff and patients in the event of an emergency, 3. alternative communication methods, and 4. transfer of patient information and medical documents relevant to care should a transfer of care be required during 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 the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to provide procedures to follow up with on-duty staff and patients to determine services that are need, in the event that there is an interruption in services during or due to an emergency. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA failed to have written policies or procedures in place to facilitate following-up with on-duty staff and patients to determine services that are needed, in the event of an emergency.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to develop and maintain a written emergency communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA failed to include a written emergency communication plan.

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), §485.542(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 interview and review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to maintain an emergency preparedness communication plan. The facility failed to review and update the emergency preparedness communication plan at the required frequency. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation due to a delay or inability to communicate with staff, entities providing services under arrangement or contract, patients' physicians, and volunteers in the event of an emergency. Based on interview and review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to maintain an emergency preparedness communication plan. The facility failed to review and update the emergency preparedness communication plan at the required frequency. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation due to a delay or inability to communicate with staff, entities providing services under arrangement or contract, patients' physicians, and volunteers in the event of an emergency. Findings Include: Review of the EPP revealed that the HHA failed to have a written communication plan that was maintained and updated at least every 2 years or as needed to include contact information for staff, entities providing services under arrangement or contract, patients' physicians, and volunteers. Review of the EPP revealed that the HHA failed to have a written communication plan that coordinated communication with staff and patients via a call tree or similar design. Alternative methods of communication with staff were not detailed in the communication plan. During interview on 09/27/23 between the hours of 2:00 PM and 5:00 PM Staff A confirmed the EPP communication plan did not contain contact information for some current staff and contained staff who were no longer employed by the HHA.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP) Communication Plan, the Home Health Agency (HHA) failed to develop a written policy and procedure for alternate means of communication with staff within the emergency communication plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Included: Review of the EPP revealed that the HHA did not have a written policy and procedure for alternate means of communication with staff within the emergency communication plan. During interview on 09/27/23 between the hours of 2:00 PM and 5:00 PM, Staff A confirmed the EPP communication plan did not have a documented policy for an alternative method of communication.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness (EPP) training and testing program that is based on the emergency plan, risk assessment, policies and procedures and the communication plan that is reviewed and updated at least every 2 years. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA failed to show a developed and implemented training and testing program for all staff that incorporates all risks identified in the facility's risk assessment.

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), §485.542(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, REHs at §485.542, "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: Based on interview and review of the Emergency Preparedness Plan (EPP), the HHA failed to develop and provide the following: 1. initial training in emergency preparedness (EPP) policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. 2. provide emergency preparedness training at least every 2 years. 3. maintain documentation of all emergency preparedness training, 4. demonstrate staff knowledge of emergency procedures. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA failed to show a developed and implemented initial and continuing training program for all staff, volunteers, and contracted staff on the EPP.

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 interview and review of the Emergency Preparedness Plan (EPP), the Home Health agency (HHA) failed to conduct or participate in exercises to test the Emergency Preparedness Plan (EPP). This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP revealed that the HHA conducted an annual Flu Clinic mock event. However, there was no documented evidence to show the HHA conducted varying exercises to test the emergency plan based on the hazards identified in the risk assessment. During interview on 09/27/23 between the hours of 2:00 PM and 5:00 PM, Staff A confirmed the annual flu clinic as the facility’s annual mock event testing the EPP.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site (Recertification) survey (#61163-H1) was conducted at the above-named Home Health Agency (HHA) from 09/27/23 to 09/29/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 418, Subpart C through E with the following standard-level deficiencies cited.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review, and staff interview the home health agency skilled staff failed to ensure the patient's right to participate in, be informed about, and consent or refuse care in advance of and during treatment with respect to the disciplines that will furnish the care and the frequency of visits for 6 of 7 sample patients (Patients 1, 2, and 4-7). The home health agency's failure to ensure the patient's right to consent to frequency of services placed all patients currently on services, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1's Admission Consent dated 12/10/22 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Patient 2 Review of Patient 2's Admission Consent dated 09/13/22 showed Skilled Nurse (SN) to "eval" patient however, there was no evidence of the frequency of visits listed on the signed consent form. Patient 4 Review of Patient 4's Admission Consent dated 08/29/23 showed Skilled Nurse (SN), Physical Therapy (PT), were both marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Patient 5 Review of Patient 5's Admission Consent dated 06/09/23 showed Skilled Nurse (SN), Physical Therapy (PT), were both marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Patient 6 Review of Patient 6's Admission Consent dated 07/24/23 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. Patient 7 Review of Patient 7's Admission Consent dated 08/04/23 showed Skilled Nurse (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health Aide (HHA) were all marked with an X however, there was no evidence of the frequency of visits for each discipline listed on the signed consent form. During an interview on 09/28/23 at 4:15 PM, Staff B, Clinical Manager confirmed there was no evidence of the frequency of visits for each discipline listed on the signed consent form for Patients 1, 2, 4, 5, 6 or 7.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and staff interview, the agency failed to provide 7 of 7 patients (Patient 1-7) with medication administration instructions written in plain language that they could understand and did not use medical abbreviations. The failure to provide patient with an accurate and understandable medication list had the potential to contribute to medication errors for all patients receiving home health services. Findings Include: Patient 1 Review of Patient 1's current Plan of Care (POC) showed a Start of Care date of 12/10/22 with the listed medications containing abbreviations, "po" (by mouth), "prn" (as needed), "BID" (twice a day), "TID" (three times a day), "HS" (at bedtime), and "IM" (intermuscular). Review of a document titled, "Medication Profile" indicated a review date of 04/19/23 and contained the following handwritten abbreviations: "po","qd" (everyday), "BID", "TID", "prn", "HS", and "IM". During a home visit on 09/28/23 at 9:30 AM, the written medication instructions left in the home for the Patient 1 and the caregiver was the same handwritten "Medication Profile" that was in the medical record. Patient 2 Review of Patient 2's current Plan of Care (POC) showed a Start of Care date of 09/13/22 with the listed medications containing abbreviations, "po", "prn", "BID", "TID", "HS", and "IM". Review of a document titled, "Medication Profile" indicated a review date of 05/08/23 and contained the following handwritten abbreviations: "po","qd", "BID", "TID", "prn", and "HS". During a home visit on 09/28/23 at 10:30 AM, the written medication instructions left in the home for the Patient 2 and the caregiver was the same handwritten "Medication Profile" that was in the medical record. Patient 3 Review of Patient 3's current Plan of Care (POC) showed a Start of Care date of 09/15/23 with the listed medications containing abbreviations, "po", "prn", "BID", "QID", and "Q 4-6 HRS PRN". Review of a document titled, "Medication Profile" indicated a review date of 05/08/23 and contained the following handwritten abbreviations: "po","qd", "BID", "TID", "prn", "HS", and "Q 4-6 HRS PRN" (every 4-6 hours as needed). During a home visit on 09/28/23 at 11:15 AM, the written medication instructions left in the home for the Patient 3 and the caregiver was the same handwritten "Medication Profile" that was in the medical record. Patient 4 Review of Patient 4's current Plan of Care (POC) showed a Start of Care date of 08/29/23 with the listed medications containing abbreviations, "po", "SL" (sublingual-under the tongue), "BID", "prn", and "Q4 HRS PRN". Review of a document titled, "Medication Profile" indicated a review date of 08/29/23 and contained the following handwritten abbreviations: "po", "qd", "SL", "BID", and "Q4 HRS PRN". Patient 5 Review of Patient 5's current Plan of Care (POC) showed a Start of Care date of 06/09/23 with the listed medications containing abbreviations, "po", "SOA" (shortness of air), "BID", "prn", "QID", and "0.6% oph (ophthalmic-eye) 1 drop ou (right eye)". Review of a document titled, "Medication Profile" indicated a review date of 08/29/23 and contained the following handwritten abbreviations: "po", "SOA", "BID", "prn", "QID", and "0.6% oph 1 drop ou". Patient 6 Review of Patient 6's current Plan of Care (POC) showed a Start of Care date of 07/24/23 with the listed medications containing abbreviations, "po", "BID", "TID", "PRN", and "Q4hrs prn". Review of a document titled, "Medication Profile" indicated a review date of 07/24/23 and contained the following handwritten abbreviations: "po", "BID", "TID", "PRN", and "Q4hrs prn". Patient 7 Review of Patient 7's current Plan of Care (POC) showed a Start of Care date of 08/04/23 with the listed medications containing abbreviations, "po", "BID", and "per SVN (small volume nebulizer-device that delivers medication to the lungs) QID (four times a day) for SOA". Review of a document titled, "Medication Profile" indicated a review date of 08/04/23 by the RN and contained the following handwritten abbreviations: "po", "qd", "QID", "BID", and "per SVN QID for SOA". During an interview on 09/27/23 at 3:50 PM, Staff B, Clinical Manager explained that the Start of Care Comprehensive Assessment is done on paper while in the home. She also stated that the nurses hand writes out the medication instructions for the patient from the hospital discharge list. She also confirmed the above findings of the medication instructions not being provided to the patients in a language they can understand without medical abbreviations. This surveyor requested a policy regarding the use of abbreviations and Staff B, Clinical Manager stated that they did not have one.

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: Based on interview and record review, it was determined the home health agency (HHA) failed to ensure the completion of supervisory visits for 1 (Patient 1) of 2 patients receiving home health aide services. This failure has the potential for patients to not receive the appropriate services and delay the patient's progress toward meeting established goals. Findings Include: Patient 1 Review of Patient 1's Plan of Care (POC) for the certification period dated 08/07/23-10/05/23, showed there was an order for home health aide services for "assistance with personal care and all aspects of personal hygiene". The order indicated the home health aide service was effective on 080/7/23 and visit frequency to be two times per week for four weeks. The previous certification period (06/04/23-08/06/23), showed home health aide services were provided and the most recent aide supervisory visit to be on 08/04/23. The next required aide supervisory visit would then be due on or before 08/18/23 however, the next documented aide supervisory visit was on 08/24/23, which was six days late. The next required aide supervisory visit would then be due on or before 09/07/23 however, the next documented aide supervisory visit by an RN, was on 09/14/23, which was seven days late. The visit on 09/07/23 was performed by an LPN who documented aide supervision. During an interview on 9/28/23 at 3:55 PM, the Clinical Manager and Administrator both stated that they were unaware that an LPN could not perform supervisory visits of the home health aide.