Every finding on record at Wetzel Enteprises, LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (4F26F-H1) conducted at the above-named Home Health Agency (HHA) from 10/31/22 to 11/02/22 resulted in the following deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR Part 484.22.

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), §485.625(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, 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 interview and review of the agency’s “Emergency Preparedness Plan Training Program”, it was determined the agency failed to implement the emergency preparedness training program to ensure staff were prepared and knowledgeable regarding the emergency plan. Findings Included: A review of the agency’s “Emergency Preparedness Plan Training Program” revealed no evidence the training program had been implemented. During an interview on 11/01/2022 at 2:30 PM, the Administrator stated the agency had developed a training program, but the program had not been implemented.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (#2F26F-H1) conducted at the above-named Home Health Agency (HHA) from 10/31/22 to 11/02/22 resulted in noncompliance with 484.65 Condition of Participation (CoP) (Quality Assurance and Performance Improvement) respective to applicable CoP under 42 CFR 484, Subpart A through C and the following standard-level deficiencies cited.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview, document review, and facility policy review, it was determined the agency failed to develop and implement a quality assessment and performance improvement (QAPI) program. This failure placed the agency’s patients at risk for potential harm and adverse outcomes related to patient care. Findings Included: A review of the agency’s policies and procedures revealed the agency did not have a QAPI Program as required. During an interview on 11/01/2022 at 2:30 PM, the Administrator stated the agency did not currently have a QAPI program established.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and review of the agency’s policies and procedures, it was determined the agency failed to develop and implement a quality assessment and performance improvement (QAPI) program that included measurement, analysis, and tracking of quality indicators to improve health outcomes, patient safety, and quality of care. This failure placed the agency’s patients at risk for potential harm and adverse outcomes related to patient care. Findings Included: A review of the agency’s policies and procedures revealed the agency did not have a QAPI Program as required. During an interview on 11/01/2022 at 2:30 PM, the Administrator stated the agency did not currently have a QAPI program established.