Every finding on record at Warren County Home Health Agen

An onsite recertification survey was conducted March 11, 2024 - March 12, 2024. Standard level deficiencies to the Emergency Preparedness Program were identified.

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 agency policy, emergency preparedness review, and staff interview the agency failed to review and update their emergency plan every 2 years. Finding included: A policy, Emergency Operations Plan and Policies (revised 03/2019) was received on 03/12/2024 at 9:00 A.M. from the clinical director. The policy stated, "The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually." A review on the agency's emergency preparedness (EP) plan was conducted on 03/11/2024. The most recent review of the agency's EP plan and policies was completed 03/2019. An interview at 9:20 A.M. on 03/12/2024 with the clinical director revealed that they were not aware of the requirement to review and update the EP plan and policies.

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 agency policy, Emergency Preparedness Plan review, and staff interview the agency failed to conduct annual exercises or implement the emergency preparedness plan. Finding included: A policy, Emergency Operation Plan and Policies (revised 03/2019) was received on 03/12/2024 at 9:00 A.M. from the clinical director. The policy stated, "The Agency complies with all applicable federal, state and local emergency preparedness requirements." A review of the agencies emergency preparedness (EP) program was conducted on 03/12/2024. The review found 1 facility-based drill in 03/2024 and implementation of the EP plan in 2018. There was no evidence of annual exercises for the years 2019, 2020, 2021, 2022, or 2023. An interview at 9:20 A.M. on 03/12/2024 with the clinical director revealed that they were not aware of the requirement to test and evaluate the EP plan annually.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interview the agency failed to alert the physician of a low blood glucose level for 1 of 1 patient with low blood glucose. (patient #2) Finding included: A policy, Coordination of Patient Care (revised 02/2021) was received on 03/12/2024 at 10:30 A.M. from the clinical manager. The policy stated, "Staff provides the physician/practitioner with patient information on an on-going basis regarding: Current condition and changes of condition." A policy, Clinical Parameters for Physician Notification Policy (signed by physician 01/10/2002) was received on 03/12/2024 at 11:40 A.M. from the clinical director. The policy stated, "Below are the standards for this agency of signs and symptoms that all staff would report... RN [registered nurse] to report to the physician... Fingerstick blood sugars [glucose] less than 60 ..." Patient #2 was admitted on 08/17/2022 with diagnoses of pressure ulcer (wound), unstageable (with areas that cannot be visualized) and diabetes mellitus (chronic condition when the pancreas does not produce enough insulin). The plan of care for 10/11/2023-12/09/2023 included orders for SN (skilled nurse) visits 1 time a week for 1 week, 2 times a week for 8 weeks, and 3 prn (as needed) and assess diabetic regimen to include blood glucose monitoring..." The SN visit of 10/12/2023 was conducted by the clinical manager, the clinical manager stated, "Blood Sugar Log from 10/11/2023-10/12/2023: FBS [fasting blood sugar]: 42 to 54." There was no evidence in the clinical record physician notification. An interview was conducted on 03/11/24 at 1:53 P.M. “It’s a professional judgement kind of thing, the patient was in no harm we educated.” The interview revealed that the physician was not notified of abnormal blood glucose readings from 10/11/2023-12/09/2023.

An onsite recertification survey was conducted 08/30/21 to 09/02/21. No deficiencies to the Emergency Preparedness program were identified.

An onsite recertification survey was conducted 08/30/21 to 09/02/21. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 policy review, clinical record review, and staff interview, the agency failed to include a description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors for 6 of 10 (Patients #1, 2, 4, 5, 8, 9) and failed to include all required components for medications and treatments for 4 of 10 (Patients #4, 6, 7, 9) clinical records reviewed. 1. Policy Plan of Care – CMS#485 and Physician/Practitioners Orders, revised February 2021, was received from the Office Manager on 08/31/21 at 12:25 PM. This policy revealed “The individualized plan of care must include the following…A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.” Patient #1 was admitted to the agency on 06/02/20 with a principal diagnosis of type 1 diabetes mellitus with hyperglycemia (high blood glucose levels). Plan of Care from 06/02/20 to 07/13/20 revealed orders for skilled nursing services 2 times per week for 2 weeks and 1 time per week for 2 weeks. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. Patient #2 was admitted to the agency on 01/23/21 with a principal diagnosis of urinary tract infection. Plan of Care from 01/23/21 to 03/23/21 revealed orders for physical therapy services 1 time per week for 1 week and 2 times per week for 4 weeks with an add-on request for skilled nursing, occupational therapy and home health aide services. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. Patient #4 was admitted to the agency on 08/07/21with a diagnosis of displaced oblique fracture of the right femur. Plan of Care from 08/07/21 to 10/05/21 revealed orders for skilled nursing 1 time per week for 1 week, 2 times per week for 1 week and 1 time per week for 2 weeks. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. Patient #5 was admitted to the agency on 07/28/21 with a principal diagnosis of multiple fractures of the ribs and right side after multiple falls. Plan of Care from 07/28/21 to 09/25/21 revealed orders for physical therapy services 2 times per week for 4 weeks. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. Patient #8 was admitted to the agency on 01/24/19 with a principal diagnosis of chronic obstructive pulmonary disease. Plan of Care from 07/12/21 to 09/09/21 revealed orders for skilled nursing services every other week for 9 weeks. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. Patient #9 was admitted to the agency on 06/03/21 with a principal diagnosis of sepsis, unspecified organism. Plan of Care from 08/02/21 to 09/30/21 revealed orders for skilled nursing services 3 times per week for 9 weeks. There is no evidence of a description of the patient’s risk for emergency department visits or hospital admission and all necessary interventions to address the underlying risk factors in the Plan of Care. In a telephone interview with Employee B, the Administrator, on 09/02/21 at approximately 11:00 AM, Employee B stated, “For recertifications, the questions (related to the risk for emergent care or hospitalization) get dropped. Usually we will answer…in the summary note. We can add that to make sure it does not get missed.” 2. Policy Medication Orders, revised February 2021, was received from the Office Manager on 09/01/21 at approximately 3:00 PM. This policy revealed “Medications and treatments are administered by Agency staff only as ordered,” and “…indication for use must be included in PRN medication orders…” and “PRN orders must specify dose, route, frequency and indication for use, if more than one indication.” Patient #4 was admitted to the agency on 08/07/21with a diagnosis of displaced oblique fracture of the right femur. Plan of Care from 08/07/21 to 10/05/21 revealed orders for skilled nursing 1 time per week for 1 week, 2 times per week for 1 week and 1 time per week for 2 weeks. Orders for discipline and treatments revealed, “Monitor trauma wound on LLE (left lower extremity) and may assist primary caregiver with dressing change: Clean with NS(normal saline)/saline, pat dry and apply Xeroform gauze and cover with dry dressing every 2-3 days and prn (as needed).” The skilled nursing visit of 08/12/21 revealed, “…pt (patient) has dressing intact on left arm, SN (skilled nurse) removed it. Pt states she stuck herself with her fingernail. Pt has reddened noted [sic] with serosanguinous drainage (thin liquid that is red tinged or pink), SN cleaned with NS, applied xeroform gauze, dry gauze & gauze wrap & secured with tape. Pts cg (patient’s caregiver) will change it daily & PRN.” There was no evidence of an order for treatment to the left arm in the Plan of Care. Patient #6 was admitted to the agency on 03/14/19 with a principal diagnosis of pressure ulcer of the sacral region, stage 2. Plan of Care from 08/20/21-10/18/21 revealed “Lasix, 20 mg (milligrams) 1 tablet daily po (by mouth), prn (as needed)…polyethylene glycol, mix and drink 1 pack daily po PRN…ranitidine, 150 mg PO bid, po, prn…” There is no evidence of an indication for these medications on the Plan of Care. Patient #7 was admitted to the agency on 07/31/20 with a principal diagnosis of Type 2 diabetes mellitus. Plan of Care from 07/26/21-09/23/21 revealed “Tylenol, 325 mgs po every 4 hrs (hours) PRN…” There is no evidence of an indication for this medication on the Plan of Care. Patient #9 was admitted to the agency on 06/03/21 with a principal diagnosis of sepsis, unspecified organism. Plan of Care from 08/02/21-09/30/21 revealed “Mineral oil, 1 tablespoon daily prn…” There is no evidence of a route or indication for this medication on the Plan of Care. In an interview with Employee D on 09/02/21 at 9:30 am, Employee D stated, “…when we go out to admit we profile everything that the doctor sends, even over the counter medications.” Employee D verified verbally that PRN medications should include an indication for use when listed on the medication profile. In an interview on 09/02/21 at 10:25 am, Employee E stated, “I’m not seeing a specific order for that but I’m seeing an order on the 485 to monitor trauma wounds and I followed the same order for that one as I did the other trauma wound.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to document wound measurements for 1 of 6 (Patient #2) clinical records reviewed of patients with wounds. Policy Wound Documentation Process, revised 11/01/20, was received from the Office Manager on 09/02/21 at 10:55 AM. This policy revealed “Document the type of wound and location. ALWAYS [sic] document Length x Width x Depth.” Patient #2 was admitted to the agency on 01/23/21 with diagnoses including urinary tract infection, Stage I pressure ulcers to the right and left heels, chronic obstructive pulmonary disease and bed confinement status. Plan of Care from 01/23/21 to 03/23/21 revealed orders for physical therapy services 1 time per week for 1 week and 2 times per week for 4 weeks with an add-on request for skilled nursing, occupational therapy and home health aide services. Skilled nursing services were initiated on 01/30/21 with visits ordered 1 time per week for 1 week and 2 times per week for 3 weeks. In a skilled nursing visit note made on 02/11/21, Employee E, the nurse case manager, revealed “…new wound on right lower leg…pt (patient) has Vaseline gauze on leg, underneath there appears to be a trauma wound. There is no evidence of wound measurements for the wound to the right lower leg in the clinical record. In an interview on 09/02/21 at 10:25 am, Employee E stated, “We don’t normally do measurements for a trauma wound because there really isn’t anything there or distinct enough to measure…If it covers the whole area and it’s not distinct enough then we don’t do measurements.” There was no evidence of a different requirement for measurements of trauma wounds in the agency’s policy.