Every finding on record at Weston County Hospital District Dba/Weston County Health Services

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 10/9/23 through 10/12/23. Based upon the findings of the survey team, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 10/9/23 to 10/12/23.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on medical record review, staff interview and review of the agency's policy, the agency failed to review current medications for 3 of 8 (#1, #5, #7). The findings were: 1. Review of the medical record for patient #1 showed the last time the medications were reviewed was on 9/21/23. Oxycodone 5 milligrams (mg) immediate release every 4 hours as needed was ordered on 9/29/23 and there was no evidence the medication was reviewed as required. 2. Review of the medical record for patient #5 showed the last time medications were reviewed was on 6/16/23. Doxycycline 100 mg 2 times a day for 10 days was ordered on 6/21/23, amoxicillin 500 mg 3 times a day for 10 days was ordered on 6/22/23, a probiotic was ordered 1 time a day on 8/27/23, and empagliflozin 12.5 mg daily was ordered on 9/21/23 and there was no evidence the medications were reviewed as required. 3. Review of the medical record for patient #7 showed the last time the medications were reviewed was on 9/6/23. Jardiance 10 mg daily was ordered on 9/18/23 and Amaryl 1 mg daily after breakfast was ordered on 9/21/23 and there was no evidence the medications were reviewed as required. 4. Interview with RN #1 on 10/11/23 at 9:05 AM verified that patient medications should be reviewed when a new medication is ordered or the patients medications have been changed. 5. Review of the agency's policy "Medication Reconciliation" revised 09/2023 showed "The agency will reconcile patient's medications...on an ongoing basis in order to identify any potential adverse effects and drug interactions..."

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 medical record review and review of the agency's policy, the agency failed to ensure a registered nurse completed home health aide supervisory visits as required for 2 of 8 sample patients (#1, #4). The findings were: 1. Review of the physician orders for patients #1 and #4 showed each patient had received home health aide services. Review of the patients’ medical records showed gaps of greater than 14 days between supervisory visits. 2. Patient #1 was admitted to skilled care on 9/28/22. Review of the home health aide supervisory visits for the past 90 days showed a supervisory visit was conducted on 8/18/23 and again on 9/5/23 with a gap of 17 days between supervisory visits. 3. Patient #4 was admitted to skilled care on 7/1/23. Review of the home health aide supervisory visits for the past 90 days showed a supervisory visit was conducted on 8/11/23 and again on 8/29/23 with a gap of 17 days and again on 9/15/23 with a gap of 16 days between supervisory visits. 4. Review of the policy "Home Health Aide Supervision" revised 09/2023 showed "All home health aide supervisory visits will be made at least every 14 days."

An emergency preparedness survey was conducted by Healthcare Licensing and Surveys on 1/28/21. Based upon the findings of the survey team, it was determined the facility was in compliance with emergency preparedness requirements.

A recertification survey which included a COVID-19 focused infection control survey was conducted by Healthcare Licensing and Surveys on 1/25/21 through 1/28/21. The following common abbreviations are used throughout this document: DON: Director of Nursing ST: Speech Therapist .

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: . Based on employee record review, staff interview, and policy and procedure review the agency failed to complete employee in-service education according to agency policy for 1 of 7 employee records reviewed (ST #1). The findings were: 1. Review of the employee record for ST#1 hired as a contractor with an unknown hire date, showed no evidence of participation in in-service education. 2. Review of the policy and procedure titled "Home Health Aide Services and Training Program, 4.12.1," reviewed: 01/2018, showed: "...6. Documentation is maintained to demonstrate that the training requirements are met. ...10. Documentation is maintained to demonstrate that the competency evaluation, inservice and performance review requirements are met." 3. Interview with the DON on 1/28/21 at 11:00 AM confirmed the ST had not completed any in-services. Further, she revealed the ST was coming in that afternoon to get the required in-services needed to work at the agency. .