Every finding on record at Truett Enterprises, Inc.

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 and interview, the home health agency failed to maintain an emergency preparedness plan that must be reviewed and updated at least every 2 years as evidenced by failing to review the plan since year 2021. Findings: Review of the facility's emergency preparedness plan, presented by S1Administrator as current, revealed it had last been updated and reviewed on 05/17/21 (over three years ago). Further interview with S1Administrator revealed that the facility had moved into a new building in November 2023 and the emergency plan still had the facility's old address on it. S1Administrator confirmed the plan was in need of an update and a review.

Recertification Survey

Recertification Survey

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 record review and interview the agency failed to ensure the Home Health Aide (HHA) is supervised every 14 days by the registered nurse (RN) or appropriate skilled professional for 2 of 2 patients (#1, #2) receiving Home Health Aide services in a total sample of 7 patients. Findings: Patient #1 Review of the medical record for Patient #1 revealed an admission date of 03/18/21 with diagnosis of Hypertensive renal disease, chronic kidney failure, pancreas cancer and type 2 diabetes. Review of the plan of care for Patient #1's certification period 05/17/21-07/15/21 revealed an order for home health aide services two times a week for nine weeks and skilled nurse visits once a week. Review of the aide notes for Patient #1 revealed the patient received the aide visits as ordered. Further review of the medical record for Patient #1 revealed no documentation of HHA supervisory visits during the certification period 05/17/21 to 07/15/21. Interview on 07/20/21 at 1:45PM with S1 DON (Director of Nursing) confirmed there were no HHA supervisory visits for Patient #1 made during the certification period 05/17/21-07/15/21. Patient #2 Review of the medical record for Patient #2 revealed an admission date of 05/18/2020 with diagnosis of venous stasis ulcer to both legs and chronic deep vein thrombosis of peroneal vein. Review of the plan of care for Patient #2's certification period 05/13/2021-07/11/2021 revealed an order for home health aide services two times a week for eight weeks and skilled nurse visits once a week. Review of the aide notes for Patient #2 revealed the patient received the aide visits as ordered. Further review of the medical record for Patient #2 revealed no documentation of HHA supervisory visits during the certification period 05/13/2021 to 07/11/2021. Interview on 07/20/21 at 1:45PM with S1 DON (Director of Nursing) confirmed there were no HHA supervisory visits for Patient #2 made during the certification period 05/13/2021-07/11/2021.