Every finding on record at Act Home Health Services Inc

Based on the findings of an onsite unannounced medicare recertification survey conducted on April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

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), §485.625(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, 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 interview with the administrator, the review of the agency's emergency preparedness plan, the agency failed to include sufficient documentation for an unannounced drill, tabletop exercise, emergency drills or participate in a full-scale community-based exercise. Findings: A review of the agency emergency preparedness plan was conducted on 4/28/21 at approximately 11:00 A.M. There was documentation of an active shooter drill on 1/23/19 and a fire drill that was conducted on 12/10/19 . There was no documentation of exercises to test the emergency plan at least annually. Interview with the administrator on 4/29/21 at approximately 1:00 P.M confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted April 27, 2021 through April 29, 2021, Act Home Health Services, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on a review of personnel files (PF), interview with agency staff, and review of agency documentation of in-service education, the agency failed to provide documentation of annual number of in-service hours for two (2) of two (2) home health aide (HHA) PF reviewed (PFs # 1 & 2). Findings Include: Review of agency policy titled, "Staff Training Policy" on 4/29/21 at approximately 10:30 AM stated, "Home Health aides will receive twelve (12) in-service trainings as required by Federal/State/Joint Commission regulations and standards...Agency-wide meetings/in-service trainings will be scheduled one (1) in the springtime and another one (1) in the fall season yearly...Home Health aides will be required to complete at least three (3) or more in-services every quarter until twelve (12) in-services trainings are completed." Review of agency document titled "General Staff meeting topic receipt form 5/22/20" on 4/28/21 at approximately 10 AM contains the following topics "Covid-19 Info related to symptoms, caring for a person at home with covid-19, ACT organizational chart, MEGA HIPPA law, ACT Integrity program..., Abuse, Neglect and Exploitation, Incident Management, Emergency Preparedness plan, Patient's concerns and grievances, patients with hearing impairment/nursing responsibilities, patients with visual and speech impairment, policy on use of restraints, policy on reporting unauthorized restrictive interventions, policy and procedures on how to handle patients with behavior problems, safety in the home and infection control, Division of Intellectual Disability Services (ID) Beliefs/Values, ACT Quality Improvement, policy on transporting patients/family members, Documentation requirements- compliance with medication/treatment administration record, call out and cancellation policy, compliance with authorized hours and others" An interview with the administrator on 4/29/21 at approximatley 11 AM stated the topics in the General Staff meeting are not meant for the Home Health aides 12 hours of inservice, this is a meeting with all disciplines as a lot of the topics are meant for the nurses. It was also stated that this meeting is conducted in one day. Review of personnel files conducted on 4/28/21, at approximately 12:00 P.M. revealed the following: PF #1, Date of Hire: 2/7/19, revealed a document showing attendance at general staff meeting in 2019 and 2020 Document did not contain how many hours of in-services were conducted. PF #2, Date of Hire: 10/19/18, revealed a document showing attendance at general staff meeting in 2019 and 2020 Document did not contain how many hours of in-services were conducted. Interview with the administrator and human resources manager on 4/29/21, at approximately 1:00 P.M. confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PFs), review of policies and procedures, and an interview with the Administrator, the agency did not conduct testing for mycobacterium tuberculosis according to the Center for Disease Control guidelines for six (6) of nine (9) personnel files reviewed. (PFs # 1, 2, 3, 5, 6, 7 ) and the agency did not maintain current CPR certification for all clinical staff for two (2) of nine (9) PF reviewed of clinical staff (PFs # 1 & 7) and personnel files did not contain a signed job description on hire for five (5) of nine (9) personnel files reviewed (PFs #1, 2, 3, 5, 7) and agency did not obtain Child Abuse Clearance every five years for two (2) of nine (9) personnel files (PFs # 8 & 9). Findings include: The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) of a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screening annually. HCWs with a baseline positive or newly positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf. Review of Pennsylvania's Child Welfare Information Solution website on 4/29/21 at approxmiatley 3PM revealed that "Beginning July 1, 2015, certifications (child abuse clearances) must be obtained every 60 months.Any employee with current certification issued prior to July 1, 2015, that is older than 60 months must renew their certificate by December 31, 2015. If an individual or agency elects to renew all required employment certifications at the same time, the date of the oldest certification, rather than the most recent, is the date to be used for the renewal date" Review of Policies occurred on 4/29/21 at approximately 10:00 A.M. Policy titled, "Child Abuse Clearance" reviewed and does not mention the requirement to obtain an updated clearance every five (5) years. Job descriptions for Registered Nurse, Licensed Practical Nurse and Home Health aide revealed "Competency/skill requirement: CPR certified." Surveyor asked for TB testing policy and agency unable to obtain a copy to give to surveyor. A review of the personnel files was conducted on 4/28/21 at approximately 12 PM. PF#1, Date of Hire (DOH): 2/7/19. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed on 2/7/19. There was no documentation of a two-step TST and/or chest x-ray. In addition, there was no TB screening completed in 2020. File also did not contain CPR certification. PF#2, DOH: 10/19/18. File did not contain a copy of a signed job description on hire.. File did not contain TB screening completed in 2020. PF#3, DOH: 11/28/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018, a 1 step TST complied on 8/12/18 and a doctors note which stated history of positive testing. There was no documentation of a Chest X-ray completed. In addition, there was no TB screening completed in 2019 and 2020. PF#5, DOH: 7/27/18. File did not contain a copy of a signed job description on hire. File contained TB screening questionaire completed in 2018. There was no documentation of a two-step TST and/or chest x-ray completed. PF#6, DOH: 11/2/18. File did not contain documentation of TB screening completed in 2020. PF#7, DOH: 10/16/17. File did not contain a copy of a signed job description on hire. File did not contain documentation of TB screening completed in 2019 and 2020. PF#8, DOH: 2/14/05. File contained Child Abuse Clearance obtained in 2005 and was not renewed until 4/28/21. PF#9, DOH: 12/23/08. File contained Child Abuse Clearance obtained in 2008 and was not renewed until 4/29/21. Interview with the Administrator on 4/29/21 at approximately 1:00 PM confirmed the above findings.