Madison Medical Center

The home health agency (HHA) failed to establish an emergency preparedness program to meet the federal, state, and local emergency preparedness program requirements.

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information.

The agency failed to: - Provide an individualized plan of care (POC) that included all the required components(G574); - Ensure drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner (G580); - Ensure the home health agency (HHA) staff promptly alerted…

The agency failed to : - Ensure there was evidence that the agency is measuring, analyzing, and tracking quality indicators (G642); - Ensure the agency used data collected to monitor the effectiveness and safety of the services and quality of care and identifying opportunities for improvement…

The agency failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.

The agency failed to meet the requirements for this condition of participation when the agency failed to: - Assume responsibility for ongoing interdisciplinary assessment of a patient (G706); - Provide services that were ordered by the physician in the plan of care (G710); and - Failed to ensure…

The agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to show adequate governing body, administrative, and clinical manager oversight to patients resulting in…

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements that is based on and includes a documented facility-based and community-based risk assessment, utilizing an all hazards approach and includes strategies for addressing emergency events…

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements that addressed the patient population including but not limited to the types of services the home health agency has the ability to provide in an emergency and continuity of operations…

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster…

The agency failed to comply with all federal, state, and local emergency preparedness (EP) requirements when the agency failed to establish and maintain a program that developed and implemented emergency preparedness policies and procedures based on risk assessment and a communication plan.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must include procedures to include procedures to follow up with on duty staff and patients to determine services needed if there is an interruption of services.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and includes the plan for use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health…

The agency failed to comply with all federal, state, and local emergency preparedness requirement when the agency failed to develop, establish, and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated every two…

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must include the names and contact information for staff, entities providing services under arrangement, patients physicians, and volunteers.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must include contact information for Federal, State, tribal, regional, or local emergency preparedness staff and other sources of assistance.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must include primary and alternate means for communicating with the agency staff, Federal, State, tribal, regional and local emergency management agencies.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements to include a method for sharing information and medical documentation for patients with other health care providers to maintain continuity of care; and a means of providing information…

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must include a means of providing information about the agency's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or…

The agency failed to develop an emergency preparedness training and testing program.

The agency failed to ensure/document if staff were provided initial and annual Emergency Preparedness (EP) training, in four (Employee #1, #2, #3, and #4) of five employee files reviewed.

The agency failed to establish and maintain an emergency preparedness program that meets federal requirements and must conduct exercises to test the emergency plan at least annually and must participate in a full scale exercise that is community based or an individual facility based functional…

Failed to assure this plan is an integrated emergency preparedness program as outlined in this regulation.

The agency failed to provide evidence that the agency was measuring, analyzing, and tracking quality indicators.

The agency failed to provide evidence that collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement.

The agency's Quality Assessment and Performance Improvement (QAPI) activities failed to show the agency conducted at least one performance improvement project to reflect the scope, complexity, and past performance of the agency's services/operations with measurable progress achieved.

The agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety.

The agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in three (Record/Patient #1, #2, and #3) of three home visit observations; failed to post signage on the entrance door related to COVID-19 recommendations, failed to check…

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Quality Assessment and Performance Improvement (QAPI) program.

The agency failed to maintain a coordinated agency-wide infection control program that included infection control education for a contracted staff which affected one (Employee #4) of five employee files reviewed.

The agency failed to ensure that the clinical manager/administrator/director of home health has effectively provided oversight of all patient care services and personnel.

The agency failed to ensure all documented entries included appropriate authentication that included, the time the plans of care were completed, the plan of care signed by the nurse, plans of care dated by the physician, and time the visits were completed in, but not limited to, two (Record/Patient…

The agency failed to update the written notice of patient rights to include that the agency must provide the patient/representative, the notice of rights during the initial evaluation visit, in advance of furnishing care to the patient.

The agency failed to update the written notice of patient rights to include: - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities.

The agency failed to update the written notice of patient rights to include the patient has the right to participate in, be informed about, and consent to or refuse care, in advance of and during treatment, where appropriate with respect to completion of all assessments and any changes in the care…

The agency failed to update the written notice of patient rights to be advised, orally and writing, of financial liability changes as soon as possible, in advance of the next home health visit of charges for services that may not be covered by Medicare, Medicaid, or any other Federally-funded or…

The agency failed to ensure staff provided the written notice of patient rights to include that the Missouri state toll free home health telephone hotline was available seven days a week.

The agency failed to update the written notice of patient rights to include that the patient and representative (if any) be advised of the name, addresses, and telephone number of the following Federally funded and state funded entities that serve the area where the patient resides to include the…

The agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, two (Records/Patients #2 and #3) of five full records reviewed.

The agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in two (Record/Patient #1 and #2) of five full records reviewed.

The agency failed to ensure staff obtained physician orders and obtained the physician signed plan of care (POC) for orders and treatments and verbal or telephone orders in a timely manner which affected two (Record/Patient #1 and #4) of five full records reviewed.

The agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Records/Patients #2 and #5) of five records reviewed.

The agency failed to ensure the plan of care was revised/updated to address patients' needs for two (Record/Patient #1 and #2) of five full records reviewed.

The agency failed to ensure coordination of care delivery to meet the patient's needs in one (Record/Patient #2) of five records reviewed.

The agency failed to ensure staff provided a written visit schedule to patients that included what discipline was visiting, when the discipline would visit, and the frequency of visits in three (Record/Patient #1, #2, and #3) of three home visits.

The agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Record/Patients #2, and #3) of three home visits.

The agency failed to ensure each patient received written information related to the name and contact information of the agency's clinical manager in the admission packet during the initial assessment in three (Record/Patient #1, #2, and #3) of three home visit observations.

The agency failed to provide evidence of any performance improvement activities that were focused on high risk, high volume, or problem prone areas.

The agency failed to complete an ongoing interdisciplinary assessment of the patient in one (Record/Patient #2) of five records.

The agency failed to provide skilled nursing services as ordered by the physician on the plan of care (POC) in one (Record/Patient #1) of five full records reviewed.

The agency failed to ensure staff were provided with agency in-service training in one (Employee #4) of five employee files reviewed.

Based on the results of this extended level survey, resulting in noncompliance with seven Conditions of Participation: Patient rights; Care Planning, Coordination of Services and Quality of Care; Quality Assessment and Performance; Organization and Administration of Services; Emergency…

The agency failed to ensure the administrator (who was the clinical manager) made patient and personnel assignments.

The clinical manager (director of home health and administrator) failed to: - Assure complete and accurate medication review completed by the registered nurse; - Assure a complete and accurate plan of care; and - Assure physical therapy services were provided in a manner to assure that the needs of…

The agency failed to ensure contract agreements between the home health agency and the agencies contracted for services, contain all the information required by this regulation.

The agency failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire for four (Employee #1, #2, #3, and #4) of five employee files reviewed, failed to ensure the Criminal Disclosure Statement was obtained prior to hire for four (Employee #1, #2, #3, and #4) of…

The agency failed to ensure the medication list was sent with the transfer summary within five business days of a planned transfer to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge in one…

The agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information based on the new home health regulations effective 01/13/18. The agency failed to provide in writing, in advance of furnishing care, the…

Madison Medical Center Home Health Agency failed to: - Ensure an organizational chart was set forth, in writing, including lines of authority and services furnished by the home health agency (G940, G942)); - Ensure an effective QAPI (Quality Assessment Performance Improvement) program (G942); -…

The agency failed to ensure each patient had an individualized emergency plan documented as part of the patient's comprehensive assessment in, but not limited to, three (Records/Patients #1, #2, and #3) of five cases reviewed.

The agency failed to develop an emergency preparedness plan training program that included initial training in emergency preparedness policies and procedures to all new and existing staff, maintained documentation of all emergency preparedness training, and demonstrated staff knowledge of emergency…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the notice that if the state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities…

The agency failed to ensure performance improvement activities tracked adverse patient events, analyzed the causes, and implemented preventive actions as part of the quality assessment and performance improvement (QAPI) program.

The agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program.

The agency failed to ensure that the home health aide competency evaluation was completed and that the home health aide was competent to perform services before the aide performed personal care to patients in three (Employees/Aides: E 6, E 7, and E 8) of three home health aide employee files…

The agency failed to ensure effective management and oversight of the provision of all home health services and the performance improvement program.

The agency failed to ensure all documented entries were clear, complete, and included appropriate dates and authentication that included a signature and title (occupation) of the author of the documented entry in, but not limited to, one (Record/Patient #2) of five cases reviewed.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the administrator's name and contact information in order to receive patient complaints.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include verbal notice of the patient's rights and responsibilities in the individual's language, free of charge, no later than the completion of…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the written notice to the patient about their right to have a copy of the patient's rights and responsibilities provided to a…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit and…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of the state hotline hours (7:00 AM to midnight).

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must make efforts to resolve the problem.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause.

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that the agency must investigate mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown…

The agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include that any agency staff in the normal course of providing services to patients, who identifies, notices, or recognizes incidences of…

The agency failed to ensure the registered nurse (RN) performed an accurate and complete review/update of all medications the patient was currently using in, but not limited to, four (Records/Patients #1, #2, #3, and #5) of five cases reviewed.

The agency failed to ensure the plan of care included the required description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors in, but not limited to, three (Records/Patients #1, #2, and #3) of…

The agency failed to alert the physician to 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 in, but not limited to, one (Record/Patient #2) of five cases reviewed.

The agency failed to provide the name and contact information for the agency's clinical manager to all patients admitted to service after January 13, 2018 when this regulation became effective.

The agency failed to ensure a registered nurse (RN) made an annual onsite visit to observe and assess the home health aide while performing care on a patient in three (Employees: E 6, E 7, and E 8) of three applicable personnel files reviewed.

The agency failed to ensure the administrator provided responsible oversight for the day-to-day operations of the home health agency.

The agency failed to ensure that when the administrator was not available, a qualified, pre-designated person was authorized in writing by the administrator and the governing body to assume the same responsibilities and obligations as the administrator.

The agency failed to ensure that the administrator or a pre-designated person was available during all operating hours.

The agency failed to ensure that all employees met the requirements for Alzheimer's and related dementia training in eight (Employees: E1, E2, E3, E4, E5, E6, E7, and E8) of eight employee files reviewed.

The agency failed to ensure the discharge summary was completed and sent to the physician within five business days of discharge in one (Records/Patient #5) of one applicable case reviewed where a discharge occurred after 1/13/18 when the new federal regulations became effective.