Every finding on record at Aj Home Health Services Inc

A recertification inspection was conducted on 08/08/2024. Licensed and certified home health services census was 0. Abbreviations and Acronyms: Admin-Administrator Alt. Admin-Alternate Administrator Office Mgr.-Office Manager EP-Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019

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 record review and interview the agency failed to comply with all applicable Federal and State emergency preparedness requirements, in that: The agency failed to complete a review of the EP plan at least annually (state requirement) and at least every two years (federal requirement) to evaluate its effectiveness and to update the plan for two (2022 and 2023) of three years reviewed. The failure placed the agency's patients at risk of harm due to the agency not having a reviewed and updated plan to ensure patient safety in the event of a disaster/emergency. Findings included: On 08/08/2024 during the entrance conference (with the Admin by phone) and the Office Mgr. at 9:32 a.m., the Admin self-identified as the administrator. The Admin identified (Alt Admin) as the alternate administrator. The surveyor requested all agency emergency preparedness (EP) and response records/documents/reports/manuals. On 08/09/2024 the agency’s undated “Emergency Preparedness and Response Guide [and] Emergency Preparedness and Response Plan Manual” was on a table at the agency when the surveyor arrived. Review of the agency’s undated business profile binders and undated emergency preparedness and response plan binders did not reveal that the agency completed a review of the EP plan at least annually (state requirement) and at least every two years (federal requirement) to evaluate its effectiveness and to update the plan for 2022 and 2023. Continued review of agency’s EP and business profile binders revealed the following: A sample form titled, “Emergency Preparedness Plan Review Check list” with a revised date of 06/11/2011.The last completed EP plan review checklist was dated 02/08/2017. An Emergency preparedness policy titled, “Emergency Preparedness EC.8” dated 09/12/2011. An employee management report (employee contact information) with a print date of 06/03/2015. A “Disaster Co-Ordination Designation” Letter dated 01/05/2024 that was signed by the Admin and the Supervising Nurse. The designation letter listed the Admin as the disaster coordinator and the Supervising Nurse as the alternate disaster coordinator. An emergency preparedness drill/activation evaluation form for a severe weather event that was dated 02/15/2021 and signed by the Admin on 02/15/2024 (sic). An emergency preparedness mock fire drill dated and signed by the Admin on 03/06/2021. Board of Directors meeting minutes for review of the agency’s emergency preparedness plan related to the COVID-19 pandemic dated and signed by the Admin and Supervising Nurse on 02/11/2020 and 04/21/2021. During an interview with the Admin on 08/14/2024 at 10:09 a.m., the surveyor asked who at the agency was responsible for the agency’s emergency and response plan. The Admin stated that (the Admin) was responsible for the plan. The surveyor asked what the agency’s processes were for implementing the EP plan. The Admin stated: that the agency gave and reviewed the agency’s EP plan with agency’s clients at admission; that the agency held a mock drill in the office; and that during an emergency event the agency called staff, agency clients, and clients families. The surveyor reviewed the findings and asked why the agency’s EP program (annual internal reviews with drills or actual events for 2022 and 2023 per state requirements) had not been reviewed and revised per agency policy and regulations. The Admin stated that “honestly,” the agency was not expecting the surveyor. The Admin stated that the Alt Admin was out of the country, the Office Mgr. had a family emergency, and the Admin and Supervising nurse were taking educational classes. Review of agency policy titled, “Emergency Preparedness EC.8” dated 09/12/2011 read in part: "...POLICY...The effectiveness of the [EP] Plan will be evaluated at least annually and after each actual disaster/emergency response. The annual internal review will consist of testing the response phase of the [EP] and response plan in a planned drill, if not tested during an actual emergency response... Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual…Procedure…J…As part of the annual review, an Agency must test the emergency response phase of the emergency preparedness and response plan in a planned drill if not tested during an actual emergency response…” Continued review of agency policy revealed that it was not updated to include federal regulatory requirements for EP Plan reviews.

A recertification inspection was conducted on 08/08/2024. Licensed and certified home health services census was 0. Abbreviations and Acronyms: Admin-Administrator Alt. Admin-Alternate Administrator Office Mgr.-Office Manager PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s), for three (2021, 2022, and 2023) of three years reviewed, that reflected the scope, complexity and past performance of the agency's services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings included: On 08/08/2024 during the entrance conference (with the Admin by phone) and the Office Mgr. at 9:32 a.m., the surveyor requested all agency QAPI documents/reports/manuals. On 08/09/2024 the agency’s undated “QAPI Manual” was on a table at the agency when the surveyor arrived. Review of agency’s QAPI records revealed the following: The agency's last written QAPI plan for the year 2015. A printout form Medicare.gov for Home Health Compare dated 06/24/2015. A 4th Quarterly report for 2012 dated 03/29/2013. Review of the agency’s QAPI records (including the agency’s undated business profile binders) did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, (in development, ongoing, or completed) the reason for conducting the projects, and the measurable progress achieved on the projects for each calendar year of 2021, 2022, and 2023. During an interview on 08/14/2024 approximately 9:45 a.m. with the Admin, the surveyor asked who was responsible for the agency’s QAPI program. The Admin stated that (the Admin) was responsible for the program. The surveyor asked what the agency’s processes were for its QAPI program. The Admin stated that when the agency had Medicare patients, they had a compliance committee. The Admin stated that because the agency had not admitted Medicare patients for a while the agency had “not done it (conducted PIPs).” The surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2021, 2022, and 2023. The Admin stated that (the Admin) did not think it was needed because the agency did not have Medicare patients. The surveyor asked how the failure could adversely affect the agency’s patients. The Admin stated that the agency would have difficulty in improving quality of care and services due to no assessments and reviews of client care and services. Review of agency policies titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN QAPI.1" revised 02/27/10, QAPI.3 revised 12/11/08, QAPI .4 revised 02/26//10, and QAPI.5 revised 02/26/10 revealed that the policies were not revised to include the federal regulatory requirement beginning July 13, 2018, for conducting performance improvement projects annually.