Every finding on record at Anmed Home Health Agency

An onsite unannounced Emergency Preparedness Survey and a COVID - 19 Staff Vaccination Survey were conducted at AnMed Home Health from 04/24/2023 to 04/27/2023. The Home Health Agency was not in compliance with the Conditions for Coverage (CFC) at 42 CFR PART 484.102 (Establishment of the Emergency Program) with the following standards. The Home Health Agency is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 30 staff members fully vaccinated and 9 approved religious exemptions.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Home Health Agency (HHA) Emergency Preparedness Program (EPP) and interview, the HHA failed to ensure that its EPP policy/procedure included all the emergency officials for both counties in which the HHA operates. The findings are: Review of the HHA's license revealed the HHA operated in Anderson and Pickens counties in South Carolina. Review of the HHA's EPP data revealed there were no listings for Emergency Preparedness (EP) officials in Pickens County. Although the HHA is licensed to operate in Anderson and Pickens counties, the HHA's EPP policy/procedure only addressed/lists EP officials in Anderson County. There was no listing for EP officials in Pickens County. In an interview with Administrator #1 on April 27, 2023 at 11:00 AM, Administrator #1 verified there were no listings for Pickens County emergency officials.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency (HHA) Emergency Preparedness Program (EPP) and interview, the HHA failed to ensure that the HHA's EPP policy/procedure included all the EPP contractors for both counties in which the HHA operates. The findings are: Review of the HHA's licensed revealed the HHA was licensed to operate in Anderson and Pickens counties in South Carolina. Review of the HHA's EPP revealed there were no listings for EPP contractors in Pickens County. Although the HHA is licensed to operate in Anderson and Pickens counties, the HHA's EPP policy/procedure only addresses/lists the EPP contractors in Anderson County. There was no listing of EPP contractors in Pickens County. In an interview with Administrator #1 on April 27, 2023 at 11:00 am, Administrator #1 confirmed there were no Pickens County EPP contractors listed in the HHA's EPP policy/procedure.

An onsite unannounced Recertification Survey was conducted at AnMed Home Health from 04/24/2023 to 04/27/2023. The Home Health Agency (HHA) is in substantial compliance with the Medicare Conditions of Participation at 42 CFR PART 484. Standard level deficiencies existed.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record reviews and interview, the Home Health Agency (HHA) failed to ensure 1 of 1 patient's Plan of Care was updated when a Home Health Aide was added to the service. (Patient #8) The findings are: On 04/26/2023 at 1:00 PM, review of Patient #8's chart revealed a Start of Care (SOC) date of 4/4/2023 with physician orders for nursing and physical therapy. On 4/13/2023, a physician order was obtained for a Home Health Aide to assist the patient twice a week. The Home Health Aide saw Patient #8 twice a week, but the Patient's Plan of Care was not updated to reflect the addition of the aide service. In an interview with the Clinical Manager on 4/26/2023 at 1:30 PM, The Clinical Manager confirmed Patient #8's Plan of care was not updated with the aide service.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on patient record review and interview, the Home Health Agency (HHA) failed to ensure the Home Health Aide (HHA) assignments were added to the patient's Plan of Care for one of one patient receiving aide services. (Patient #8) The findings are: On 04/25/2023 at 10:00 AM, review of Patient # 8's chart revealed a Start of Care on 4/4/23. Review of the patient's Plan of Care revealed there were any aide task assignments for the Home Health Aide. In an interview with the Clinical Manager on 4/25/23 at 11:00 AM, the Clinical Manager confirmed there were no instructions for tasks for the HHA in the Plan of Care.