Every finding on record at Ameristar Homehealthcare LLC

Extended Substantial Allegation Survey Substantial Allegation 62110 An entrance conference was conducted with administrative staff on 03/30/22, and an exit conference was completed with the administrative staff on 04/05/22. The following deficiencies are based on the Federal Vaccine Mandate QSO 22-09- All review, completed on 04/05/22 at Ameristar Home Healthcare LLC 369129. No deficiencies were issued in regard to allegations contained in substantial allegation 62110 investigated concurrently. On 03/30/22 at 4:41 P.M. the Administrator and Director of Nursing, were informed a determination of Immediate Jeopardy was made under Infection Control. On 03/30/22 the facility had 30% of staff vaccinated against COVID-19 creating a likelihood of serious harm. An action plan was received on 04/05/22 and approved on 04/05/22 at 10:23 AM. On 04/05/22 at 10:25 AM, the DON was informed the Immediate Jeopardy was removed. Ameristar Home Healthcare LLC is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on review of QSO memo 22-09-ALL Attachment G, review of facility COVID-19 vaccination records, and staff interview, the home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' infection control needs would be met. G687

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on review of QSO memo 22-09-ALL Attachment G, review of facility COVID-19 vaccination records, and staff interview, the facility failed to ensure all staff were fully vaccinated against COVID-19 at 100% compliance within 60 days of issuance of the memorandum. The home health agency had a total of 19 of 63 staff that were vaccinated for a total vaccination rate of 30%. Additionally, the agency failed to develop any COVID-19 vaccination policies and procedures, the agency failed to develop a process to track and document vaccine status of all staff and staff with boosters per the Centers for Disease Control and Prevention (CDC), failed to develop a process to track and document information provided by staff requesting exemptions and who agency has granted, failed to develop a process to ensure all documentation confirms clinical contraindications, supports staff request for medical exemptions and must be signed and dated by the Physician, failed to develop a process to document and evaluate religious exemptions, and failed to develop a process to track and document staff where vaccine is delayed, as recommended by the CDC. The agency census was 57. Findings include: Findings include: Review of QSO memo 22-09-ALL Attachment D, dated 01/14/22, revealed within 60 days of issuance of this memorandum, 100% of staff have received at least one dose of COVID-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the CDC. Review of the employee vaccination list received on 03/30/22 at 3:00 PM revealed the home health agency had a total of 19 of 63 staff that were vaccinated for COVID-19 with a total of 30% vaccinated and 70% unvaccinated. There was no documented evidence of any approved exemptions. Review of agency documentation revealed no evidence the agency developed any COVID-19 vaccination policies and procedures, developed a process to track and document vaccine status of all staff and staff with boosters per the Centers for Disease Control and Prevention (CDC), developed a process to track and document information provided by staff requesting exemptions and who agency has granted, developed a process to ensure all documentation confirmed clinical contraindications, supported staff request for medical exemptions and must be signed and dated by the Physician, developed a process to document and evaluate religious exemptions, and failed to develop a process to track and document staff where vaccine was delayed, as recommended by the CDC. Interview with the DON on 03/30/22 at 10:14 AM revealed the agency was not tracking the vaccination status of their employees. The DON revealed he/she did not know anything about the vaccine mandate and the agency did not have a policy in place for the vaccination requirement. The DON revealed he/she had a meeting with the staff in January and none of the employees wanted to be vaccinated. The DON revealed he/she had no record of who was vaccinated and who was not. Interview with Staff D on 03/31/22 at 9:45 AM revealed he/she had been educated on vaccination and the ability to receive a vaccination. Staff D revealed he/she was still thinking about getting the vaccine but was unaware of the need to have an exemption if choosing not to be vaccinated.