Every finding on record at Upland Hills Health Inc.

An unannounced onsite recertification survey was conducted 01/23/2023 - 01/24/2023 at Upland Hills Home Care in Dodgeville, WI. Upland Hills Home Care was found to be in compliance with Medicare Conditions of Participation for Emergency Preparedness for Home Health agencies 42 CFR 484.102.

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 record review and interview, the agency failed to conduct and/or participate in an emergency exercise to test the agency's response to an emergency in coordination with the hospital health system's emergency preparedness plan annually in 1 of 1 Emergency Preparedness Programs reviewed. Findings include: Review of system-wide document titled “Upland Hills Health: All-Hazards Emergency Management & Operational Plan” (not dated) revealed “Scope: This is the all-hazards response portion of the organization’s Emergency Management Plan. The Emergency Management Plan applies to all members of the organization’s administration and employees. Preparation and Training: Semi-annual drills are conducted with Administration, physician, and employee participation. Drills will be critiqued; deficiencies identified, and corrected actions implemented. Reports are provided to the Environment of Care Council and Emergency Management Subcommittee." Review of agency policy and procedure titled “Upland Hills Home Care Emergency Preparedness” dated 07/13/2022 revealed “Procedures: Notification of Staff, Patients and Suppliers: 1. The emergency plan is implemented upon receipt of a call from the hospital or if an individual discovers a disaster situation and they contact the Director of Home Care or Home Care nurse on-call if after business hours. Recovery Strategies: 3. Department Director (or designee) will conduct after-action critique of the overall response and recovery efforts using the Upland Hills Health evaluation tool.” Review of agency Emergency Binder documents revealed no evidence that a drill or emergency test exercise had been conducted in calendar year 2022. During an interview with Director A on 01/23/2023 at 4:00 PM, when asked about an agency drill or test exercise to evaluate the agency's emergency preparedness plan and in coordination with hospital system emergency, Director A replied, “We did a drill in November of last year to test communications. We do that with the hospital system. I will get that for you.” Review of health system document titled “After Action Report” dated November 2022 and documented by health system Emergency Coordinator L revealed, “Exercise date: November 2022. Purpose of Exercise: Test all communication systems located in incident command storage area. Objective: Test all communication systems.” The document failed to provide evidence that the home health agency was involved in the emergency drill or test exercise. During an interview with Director A on 01/24/2023 at 8:35 AM, when reviewed the After-Action Report and if there was anything more to show the home health agency involvement in the system drill or an agency drill, Director A replied, “No, I will see if there is anything more.” During a follow-up interview with Director A on 01/24/2023 at 10:30 AM, when asked if any further information, Director A replied “The hospital incident command calls the emergency, notifies our Administrator, who notifies me. Then we follow our plan. These are the drills we did up through 2021 (revealing a drill conducted in calendar year 2021).” When asked about calendar year 2022 and if the agency had documented evidence of an emergency drill or test exercise that impacted their agency, Director A replied, “We have nothing.”

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.542(f), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on record review and interview, the agency and hospital health system in which it is integrated, failed to develop an emergency preparedness program that demonstrated the agency's involvement and coordination related to the unique circumstances and services offered in the event of a system-wide emergency in 1 of 1 Emergency Preparedness programs reviewed. Findings include: Review of system-wide document titled “Upland Hills Health: All-Hazards Emergency Management & Operational Plan” (not dated) revealed “Scope: This is the all-hazards response portion of the organization’s Emergency Management Plan. The Emergency Management Plan applies to all members of the organization’s administration and employees.” The organization system emergency preparedness plan revealed no documented evidence that the home health agency is integrated into the health system plan. Nowhere in this document, under plan activation, systems notification, activation organization chart, hospital incident management team, pre-designated incident command locations, assessment of response needs, operations and logistics, flow of communication, and hospital communication systems, does the system emergency preparedness plan delineate the home health agency’s role and integrate into the overall program. The above findings were reviewed 01/23/2023 at 3:50 PM regarding the health system emergency plan lacking detail of the home health agency's involvement and integration into the system plan. During an interview with Director A on 01/23/2023 at 4:00 PM, when discussed the findings and if there any evidence to support the home health integration, Director A replied "I will see if there is anything else." Review of health system document titled “After Action Report” dated November 2022 and documented by health system Emergency Coordinator L revealed, “Exercise date: November 2022. Purpose of Exercise: Test all communication systems located in incident command storage area. Objective: Test all communication systems.” The document failed to provide evidence that the home health agency was integrated into the hospital health system's activation of the emergency plan during an emergency drill or test exercise. During a follow-up interview with Director A on 01/24/2023 at 10:30 AM, when asked if there is anything further to show that the agency was integrated in the hospital health system emergency preparedness program, Director A replied “This is all Emergency Management Coordinator L gave me. This is what the system uses.”

An unannounced onsite Recertification survey was conducted 01/23/2023 to 01/24/2023 at Upland Hills Home Care in Dodgeville, WI. Upland Hills Home Care was in compliance with Medicare Conditions of Participation 42 CFR 484 for Home Health Agencies. Citations are issued at a standard level or below.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, agency nursing staff failed to develop POC (Plans of Care) that were individualized to meet the patient needs based on diagnoses, including patient specific interventions and/or measurable goals in 7 out of 7 (Patients #1 - Patient # 7) patient records reviewed. Findings include: Review of agency policy and procedure titled “Admission Assessment, Reassessments" (dated 09/2017) revealed "POC: 1. The RN (Registered Nurse) or physical therapist admitting the patient develops an individualized POC with input from the patient/caregiver, any non-nursing disciplines involved, and the primary or referring physician within 72 hours of their assessment incorporating all aspects of care. 2. The individualized POC must include the following: Patient-specific interventions and education; measurable outcomes and goals identified by Upland Hills home care and the patient." Record review of Patient #1's home health record revealed Patient #1 was admitted to home health on 03/27/2020. Review of Patient #1's "Home Health Care Certification and POC" dated 01/11/2023-03/11/2023 revealed Patient #1 had the primary diagnosis of "Chronic Diastolic Congestive Heart Failure" and other pertinent diagnoses of "Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Pressure Ulcer right Ankle." The nursing POC failed to contain measurable goals for Patient #1's individualized needs for oxygen saturation, blood sugars, skin assessment, and heart failure. Record review of Patient #2's home health record revealed Patient #2 was admitted to home health on 01/09/2023. Review of Patient #2's "Home Health Care Certification and POC" dated 01/09/2023-03/109/2023 revealed Patient #2 had the primary diagnosis of "Non-pressure Chronic Ulcer Right Lower Leg" and other pertinent diagnoses of "Venous insufficiency, Muscle weakness, and Hypertensive Heart disease." The nursing POC failed to contain measurable goals for Patient #2's pain assessment related to the pressure ulcers/venous insufficiency, hypertension, mobility, and oxygen saturation. Record review of Patient #3's home health record revealed Patient #3 was admitted to home health on 01/19/2023. Review of Patient #3's "Home Health Care Certification and POC" dated 01/19/2023-03/19/2023 revealed Patient #3 had the primary diagnosis of "Bilateral Primary Osteoarthritis of Knee" and other pertinent diagnoses of "Aftercare following joint replacement surgery, Prediabetes, heart disease, shortness of breath, abnormalities of gait and mobility." The nursing POC failed to contain measurable goals for Patient #3's pain assessment related to the joint replacement, blood sugars, heart disease, and shortness of breath. Record review of Patient #4's home health record revealed Patient #4 was admitted to home health on 12/08/2022. Review of Patient #4's "Home Health Care Certification and POC" dated 12/08/2022-02/05/2023 revealed Patient #4 had the primary diagnosis of "Acute and Chronic Respiratory Failure with Hypoxia" and other pertinent diagnoses of "Heart and Kidney failure, and Type 2 diabetes." The nursing POC failed to contain measurable goals for Patient #4's oxygen needs, oxygen saturation assessment, blood sugars, pain assessment, urinary assessment related to Kidney failure. Record review of Patient #5's home health record revealed Patient #5 was admitted to home health on 11/17/2022. Review of Patient #5's "Home Health Care Certification and POC" dated 11/17/2022-01/15/2023 revealed Patient #5 had the primary diagnosis of "Encounter for Orthopedic aftercare following surgical amputation" and other pertinent diagnoses of Type 2 Diabetes with foot ulcer, Hypertension, Reduced Mobility." The nursing POC failed to contain measurable goals for Patient #5's pain assessment related to the surgical amputation, hypertension, mobility, wound care assessment, peripherally inserted central catheter (PICC) Line assessment and oxygen saturation. Record review of Patient #6's home health record revealed Patient #6 was admitted to home health on 11/25/2022. Review of Patient #6's "Home Health Care Certification and POC" dated 11/25/2022-01/22/2023 revealed Patient #6 had the primary diagnosis of "Pressure Ulcer right hip stage 4" and other pertinent diagnoses of "Pressure Ulcer Right heel, Pressure Ulcer Left Hip stage 4, Neuromuscular Dysfunction of bladder/bowel, Type 2 Diabetes, Hypertension, Muscle weakness, and Colostomy." The nursing POC failed to contain measurable goals for Patient #6's Pressure Ulcer to Left Hip, Right Heel, Dysfunction of bowel/bladder, diabetes, hypertension, muscle weakness/fall risk, and Colostomy. Record review of Patient #7's hospital record revealed Patient #7 was discharged from the hospital 11/30/2022 with a diagnoses of Esophageal Rupture. Review of hospital discharge orders titled "Discharge Packet" dated 11/30/2022 revealed "Nutrition Orders: Clear Liquid, you are being discharged on tube feeding to meet your nutritional needs. Other Orders: Measure weight-daily." Record review of Patient #7's home health record revealed Patient #7 was admitted to home health on 12/01/2022. Review of Patient #7's "Home Health Care Certification and POC" dated 12/01/2022 – 01/29/2023 revealed Patient #7 had the primary diagnosis of "Encounter for Surgical Aftercare Following Digestive System" and secondary diagnoses of "Perforation of Esophagus." The nursing POC failed to contain interventions for assessment of weights and nutrition and failed to contain measurable goals related to meeting Patient #7's individualized nutritional needs based on the primary and secondary diagnoses. During interview with Director A and Registered Nurse B on 1/24/2023 at 12:26 PM, when reviewing/confirming record review findings for the POC goals for patients #1-#7 as being either not measurable or not patient specific. Director A and Registered Nurse B were asked if the expectation is that staff should update the goal with individualized measurable information. Director A stated, "I think so" and Registered Nurse B stated, "the goals should be more individualized to the patients' needs/assessments." On 01/24/2023 at 12:30 PM, the above findings were confirmed regarding Patient #7's POC not being individualized to meet the patient's needs. Registered Nurse B stated "So some interventions should become goals. We can change that." When asked if the agency's expectations are for POC goals to be individualized, Director A replied "Yes."

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency nurse failed to assess the patient Peripherally inserted central catheter (PICC) Line per physician ordered plan of care (Patient #5) and failed to assess the patient weights per physician orders (Patient #7) in 2 of 7 patient records reviewed (Patient #5 and #7). Findings include: Review of agency policy and procedure titled “Admission Assessment, Reassessments" (dated 09/2017) revealed "Plan of Care: 1. Assessment, Reassessment, Education: 4. The comprehensive assessment must accurately reflect the patient's status and must include but not limited to: Specific assessments such as wound assessment are conducted when wounds are present. A diet, fall risk, pain assessment... that may affect care and any other relevant information that may affect the patient's goals." Review of agency policy titled “Peripherally Inserted Central Catheter (PICC)” not dated, revealed in part "Policy, All Registered Nurse's (RN) are responsible for assessing and maintaining long-term venous access devices." "Removing a PICC, 5. Measure and inspect the catheter. If any part has broken off during removal, notify the doctor immediately." Record review of Patient #5’s “Home Health Certification and Plan of Care” dated 11/17/2022-01/15/2023 revealed Patient #5 was admitted for primary diagnosis “Aftercare following Amputation” and secondary diagnosis “Encounter Adjustment and Management of Vascular Access Device.” Patient #5 had a PICC 4.5 French Single-lumen 41 Centimeters (CM)total and 39 cm internal measurements inserted central catheter in the right basilic and was receiving IV antibiotics. Per Patient #5's physician ordered plan of care, orders revealed in part “Orders and Treatments: Skilled Nursing: Assess IV." During an interview with Director A 1/24/2023 at 12:00 PM, when asked if the agency had a policy for skilled nursing PICC line assessment, Director A replied, "We have a PICC line policy that is used organizational wide (hospital and home health.) Record review of Patient #5’s Skilled Nurse visit for PICC Line Dressing Change revealed the following assessments omitted: 11/21/2022: No PICC site assessment, no PICC length assessment. 11/28/2022: No PICC site assessment, no PICC length assessment. 12/05/2022: No PICC site assessment, no PICC length assessment. 12/12/2022: No PICC site assessment, no PICC length assessment. 12/14/2022 PICC Line Removed no documented PICC line length that was removed. During an interview with Director A, Registered Nurse B, and President C on 01/24/2023 from 12:00 PM to 12:26 PM, the above findings were confirmed and discussed. When asked about Patient #5's plan of care orders which revealed “Assess PICC line,” and what the agency’s expectation for nurses to assess and document PICC line, Director A replied, “We would expect the nurses to follow the PICC line policy and follow the training they had." Director A was further asked if it would it be the expectation upon PICC line removal for the nurse to measure the removed PICC line and compare to the length inserted. Director A replied, "That should be documented." President C confirmed this would be best practice. Record review of Patient #7's hospital record revealed Patient #7 was discharged from the hospital 11/30/2022 with a diagnoses of Esophageal Rupture. Review of hospital discharge orders titled "Discharge Packet" dated 11/30/2022 revealed "Nutrition Orders: Clear Liquid, you are being discharged on tube feeding to meet your nutritional needs. Other Orders: Measure weight-daily." Record review of Patient #7's home health record revealed Patient #7 was admitted to home health on 12/01/2022. Review of Patient #7's "Home Health Care Certification and Plan of Care" dated 12/01/2022 – 01/29/2023 revealed Patient #7 had the primary diagnosis of "Encounter for Surgical Aftercare Following Digestive System" and secondary diagnoses of "Perforation of Esophagus. Nurse 1 time per week." Review of skilled nurse visits revealed a weight was assessed upon admission on 12/01/2022, and no weights were assessed on the skilled nurse visits dated 12/07/2022, 12/13/2022, and 12/27/2022. During an interview with Director A on 01/24/2023 at 12:10 PM, the above findings were confirmed regarding missing weight assessment in Patient #7's record.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program utilized program quality indicator data in monitoring effectiveness, identifying improvement opportunities, and outlining detail and frequency of data collection in 1 of 1 QAPI programs reviewed. Findings include: Review of this agency’s health system quality program policy titled “Performance Improvement (PI) Plan” not dated, revealed in part “The goals of the PI Program are: To facilitate a planned, systematic, organization-wide approach to process design and performance measurement, assessment, and improvement. To provide the structure and framework for PI activities to become a part of day-to-day operations across the continuum of care." Review of this agency’s QAPI binder and QAPI file folders revealed the binder and folders contained data collection from various sources of quality outcomes, patient satisfaction, falls safety data, and quality resources. There was no documented evidence that the agency analyzed the data to develop, monitor effectiveness and identify and evaluate for opportunties of improvement at the agency level. During an interview on 01/23/2023 at 4:05 PM with Director A, the QAPI binder and folders content were reviewed, and it was discussed that the agency binder and folders contained evidence of quality data collection, such as quality outcomes, patient satisfaction, and fall safety data, but failed to reveal documented evidence that the agency acted upon this data to monitor the effectiveness of the agency QAPI program. A request was made for QAPI committee documented activity or meeting minutes that revealed a focus on quality indicators and actions taken by agency staff to monitor the effectiveness of the program. During an interview with Director A on 01/24/2023 at 8:30 AM, a follow-up request was made for documented evidence of the the agency’s QAPI committee in terms of how often they meet, who makes up the agency QAPI committee and how the QAPI data is monitored and evaluated for effectiveness, Director A replied “We have no specific meetings. Our quality nurse left their role in September 2022. I (Director A) have two employees, one nurse and one office person that meet monthly. No other disciplines meet.” When asked if there is any documented proof of an agency quality program, Director A replied “No, we don’t have that. This has been our challenge. We simply need to have someone take over the QAPI role. Someone needs to take it and run with it. We all do different pieces but don’t really have a full program. We talk in our IDT (Interdisciplinary Team) meetings about patient specific issues or meet one-on-one with staff if quality issues and share the data.” When asked how the data is analyzed for performance improvement, Director A replied “We report all data up (to the hospital), but back to home health, I don’t know. How would you do that?” Director A was asked about the governing body and proof of the oversight per policy, Director A replied, “I have an extensive quality PowerPoint of data that I presented to the Board. The Quality Council at the hospital with President C meets monthly and looks at our data. While we report it up, it’s bringing it down to the home health level that we are weak. I struggle with how to incorporate it to the agency level especially without a QAPI nurse.” When asked, so would you say that you don’t have a home health agency quality team that takes action to involve all services and disciplines to discuss the quality, safety and outcomes data, Director A replied “Yes, we do not have that.”

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, this agency failed to ensure the QAPI (Quality Assessment Performance Improvement) program focused on high risk, high volume, or problem-prone areas based on agency risk assessment in 1 of 1 QAPI programs reviewed. Findings include: Review of agency’s health system quality program policy titled “Performance Improvement (PI) Plan” not dated, revealed in part, “The goals of the PI Program are: To facilitate proactive risk assessments. PI Priorities: 2. PI Data and organizational priorities are used to establish PI priorities for the coming year. Assessment priority setting is based on departmental and organizational data. Priorities are determined based on high risk, high volume, and problem prone areas." Key Procedures for Directors and Managers: 2. Multidisciplinary PI project requests will be submitted…The role of the Quality Council is to prioritize improvement activities and assure appropriate resources are deployed to support the activities. Pro-Active Risk Assessment: 2. The pro-active risk assessment should be used to evaluate a process to see how it could fail, to understand consequences of the failure, and to identify parts of the process that need improvement. 3. The processes that have the greatest potential for affecting patient safety should be the primary focus for risk assessments. 9. A minimum of one pro-active risk assessment will be done every 18 months." Review of this agency’s QAPI (Quality Assurance Performance Improvement) binder and QAPI file folders revealed no documented evidence that the agency had a quality program that identified this high risk or problem-prone areas based on agency risk assessment. There was no agency pro-active risk assessment on file. On 01/23/2023 at 4:05 PM, findings of the QAPI binder and folders content regarding no documented evidence of an agency pro-active risk assessment of data to set priorities were reviewed with Director A. A request was made to provide documented evidence of the agency QAPI program to include the agency’s pro-active risk assessment. During an interview with Director A on 01/24/2023 at 8:30 AM, a follow-up request was made for the documented pro-active risk assessment. Director A stated "I will see if we have that." As of 01/24/2023 at 12:15 PM, there was no further documented evidence that a pro-active risk assessment was conducted to identify focus on high risk, high-volume or problem prone areas.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to incorporate infection control data into the agency QAPI (Quality Assessment Performance Improvement) program in 1 of 1 infection programs reviewed. Findings include: Review of agency’s health system quality program policy titled “Performance Improvement (PI) Plan” not dated, revealed “Purpose of the PI Plan: Upland Hills Health leaders are committed to a collaborative effort to achieve excellence and continuous PI. The goals of the PI Program are: To facilitate a planned, systematic, organization-wide approach to process design and performance measurement, assessment, and improvement. To facilitate and communicate continuous PI activities throughout the organization and community. To provide the structure and framework for PI activities to become a part of day-to-day operations across the continuum of care." Review of this agency’s Infection Control Binder revealed monthly agency data collection of patient infection sources through May of 2022. There was no documented evidence in this agency's Infection Control Binder and/or QAPI Binder that the agency imbedded infection control data into the QAPI program. During an interview with Director A on 01/23/2023 at 1:30 PM, when asked about the infection data that is collected and how it is incorporated into the agency QAPI program, Director A replied “Our hospice nurse does the infection control for home care since our quality nurse left. The nurse collects the data and shares it with infection prevention at the hospital.” A request was made to provide documented evidence on how the agency utilized and incorporated infection control data into the agency QAPI program. During an interview with Director A on 01/24/2023 at 8:30 AM, a follow-up request was made to show evidence of the infection data incorporated into the agency QAPI program. Director A stated "We report all data up (to the hospital), but back to home health, I don’t know. How would you do that?” As of 01/24/2023 at 12:30 PM, there was no documented evidence that infection data was incorporated into the agency QAPI.