Every finding on record at At Homehealth, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/10/23. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number AM = morning SOC = Start of care Pt./Pts. = Patient/Patients PM = afternoon/evening

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records, policy review and staff interviews, it was determined the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines for 5 of 7 (Pts. #1, 2, 4, 6 and 7) clinical records reviewed. Findings include: 1. As of 08/09/23, the following clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry: Pt. #1. SOC 07/05/23. Pt. #2. SOC 07/06/23. Pt. #4. SOC 04/21/23. Pt. #6. SOC 12/27/22. Pt. #7. SOC 04/10/23. 2. The policies titled, “Policy on Flu Vaccination” and “Policy on Pneumonia Vaccination” effective 05/31/22, were reviewed and required, “Procedure: 1. Our clinicians upon Start of Care will obtain patient information regarding the patient’s (flu/pneumonia) vaccination status, will document where and when patient obtained their vaccination…The following will be considered to be documentation approaches that meet the requirements…Individual patient record entries identifying the assessment for the need of vaccination, date of offer or referral, patient response, administration, contraindication or refusal or any follow-up activities…Standardized check off form recording patient specific information, including the assessment for the need of the vaccination, date of offer or referral, patient response, administration, contraindication, or refusal and any follow-up activities." 3. During an interview with the Administrator, the Clinical Manager, and the Alternate Clinical Manager on 08/09/23 at 2:30 PM, it was stated that during the SOC, the patient’s Influenza and Pneumococcal Pneumonia vaccination status is assessed, and this information is documented in the clinical record under “Immunization Status” and could also be documented on the “Influenza/Pneumonia Vaccine Consent Form.” During the same interview, the above finding was confirmed.