Every finding on record at About Kids Home Care North LLC

A recertification survey was completed on 7/16/24. Two deficiencies were cited.

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 interviews and record reviews, the agency failed to comply with all applicable federal, state and local emergency preparedness requirements. Specifically, the agency's emergency preparedness plan, and risk assessment was not reviewed and updated at least every 2 years. Findings include: 1. An interview with the compliance manager on 7/16/24, at 9:49 a.m., revealed the emergency plan was reviewed by the agency on 1/1/20. She said the agency may have had an emergency plan that was reviewed more recently, then shared an emergency plan with a review date of 12/2/21. She went on to say the agency did not review the emergency preparedness plan in 2023 or 2024. During that same interview, the compliance manager stated the agency had completed a risk assessment, at the same time as the emergency preparedness plan, but the risk assessment did not contain a date of review. She further stated the agency did not have meeting minutes to show the agency reviewed the risk assessment in 2021, 2022, 2023, or 2024. Review of the agency's emergency preparedness plan revealed the plan and risk assessment had not been reviewed or updated since 12/2/21.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interviews and record review the agency failed to develop and implement policies and procedures based on the emergency plan and risk assessment. Findings include: 1. On 7/16/24 at 1:46 p.m., the compliance manager said she thought the agency had developed policies and procedures based on the emergency plan and risk assessment for fire and winter storms. a. The agency failed to develop and implement policies and procedures based on the emergency plan and risk assessment. A review of agency policies and procedures showed no evidence the agency had developed and implemented emergency plan and risk assessment policies and procedures. On 7/16/24 at 3:00 p.m., the agency manager said the agency was unable to provide policies and procedures based on the emergency plan and risk assessment. She acknowledged these findings and was going to start developing the policies based on the emergency plan and risk assessment.

A recertification survey was attempted on 8/10/21. The agency had no current patients to observe care and services. There were no open or closed patient records available for review. The recertification survey could not be completed. Based on the manner and degree of the standard level deficiencies referenced to the condition, it was determined the following conditions of participation were out of compliance: 484.65, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI); 484.110, CLINICAL RECORDS and 484.105 -ORGANIZATION AND ADMINISTRATION OF SERVICES Refer to CFR 484.80(f)(3) guidelines. An agency, which has a Condition of Participation out of compliance with any of the requirements, is precluded from conducting (if approved) or applying to conduct a Nurse Aide Training Program or Competency evaluation for two (2) years from the exit date.

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 interviews, the agency failed to implement a quality assessment and performance improvement (QAPI) plan which evaluated all agency services and complied with the requirements and standards set forth in CFR 484.65. 1. During an interview on 8/9/21begining at 8:02 a.m., the administrator stated that due to the change of ownership which occurred on 5/19/21, the agency did not have patients, had no patient records from the previous owner and no discharge records. The Administrator stated that no QAPI plan meetings had been held for the agency since the purchase. She stated that every patient of the agency was already discharged prior to the purchase of the agency and stated the new owner was only buying the license and the certification which did not include patients and/or patient records. She stated the purchase was not complete until CMS 855 was completed and the agency could enroll new patients. The agency failed to show it had a system in place to assess the agency's operational processes, services and mitigate areas of concerns. Specifically, the agency failed to show an operational documentation consisting of identification of issues/concerns, discussions of steps to take, collection of data and a show of measurable improvement in indicators as evidence of progress or lack of, and subsequent corrective actions for moving the agency forward. The agency failed to provide QAPI plan documentation to show the agency had a system which allowed the review of agency processes and operational decision tracks. Additionally, the agency failed to show they had considered performance improvement project (s) which reflected the scope or the complexity of the agency's services and operations. There was no evidence to show the agency had considered specific issues proactively, such as patient admissions, record keeping, quality of care, appropriateness of care, patient satisfaction surveys, and how information from the agency's complaint and occurrence logs could be incorporated as part of the agency's overall QAPI plan. There was no evidence to show the agency identified any concerns/issues, and had pulled all its concerns together in a unified manner.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on the interview, the administrator failed to adequately and effectively organize and direct the agency's day-to-day operations. Specifically; a. The administrator failed to provide oversight of the agency's quality improvement program inclusive of scope, data, activities, and performance improvement projects. The administrator failed to ensure the agency's quality improvement program was operational and included performance improvement activities to develop and implement a timely, comprehensive, and appropriate set of program activities that addressed the issues of the agency. The administrator failed to implement a quality assessment and performance improvement (QAPI) plan which evaluated all agency services and complied with the requirements and standards. Interview showed the administrator failed to develop and implement a QAPI plan as required by regulation and specifically failed to consider all areas of the agency's operations for improvement and failed to monitor, trend and identify significant outcomes that were essential to optimal and up-to-date running of the agency. (Cross Reference G640) b. The administrator failed to provide patient record access to the state inspectors when requested. On 8/9/21 at approximately 4:30 p.m. the administrator stated the agency was recently purchased and there were zero active patients. She further stated that clinical records were not received from the previous agency owner and stated patients were discharged prior to the sale of the agency and she had no additional information on the location of any of the clinical records. (Cross Reference G1008)

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interviews, the agency failed to maintain clinical records containing past and current information for every patient accepted by the agency in accordance with professional standards for clinical documentation. On 8/9/21 at approximately 4:30 p.m. the administrator stated the agency was recently purchased and there were zero active patients. She further stated that clinical records were not received from the previous agency owner. In addition, the Administrator stated patients were discharged prior to the sale of the agency and she had no additional information on the location of any of the clinical records. The agency failed to provide evidence it had maintained an effective, ongoing clinical documentation of patients' records and had failed to show patient records had been preserved as required. The agency failed to provide patient records inclusive of all required items in the clinical record, interventions and patient response, goals in the patient's plan of care, contact information for the patient, contact information for primary care provider, discharge and transfer summaries, protection of records, and retention of records.