Every finding on record at Azhomehealth, LLC

42 CFR Part 484 Home Health Care The facility must meet all local, Federal and state emergency preparedness requirements as outlined in the Medicare and Medicaid programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. Deficiencies were noted at the time the survey was conducted on January 21-January 24, 2025.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to execute and maintain an emergency preparedness plan based on an all-hazards facility-based risk assessment. Failure to complete, maintain and regularly update a facility based all-hazards risk assessment and then develop and regularly update an emergency preparedness plan to reflect the risks identified within the assessment can result in a facility not being prepared to address the hazards most likely to affect a patient and staff population. Findings include: Facility Policy No. 7-001.1 titled, "...Emergency Preparedness Plan...."reviewed January 23, 2025 revealed,"...Communication Plan, The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws...3. Specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities will be developed for each priority emergency...." Facility policy addendum titled, "7-001.E PLANS FOR PRIORITY EVENTS..." revealed no documentation to support specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities developed for each priority emergency. A review was conducted of all materials presented related to the emergency preparedness communication. Materials did not reveal written process or procedure address strategies for addressing emergency events identified by the facility based risk assessment. In an interview conducted with Employee #2, Employee #2 confirmed that copies of all materials related to emergency preparedness had been provided. Per employee #2 the emergency plan and procedures will be updated to include written policy and procedure to formalize plan to address strategies for addressing emergency events identified by the facility based risk assessment.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of facility policies and procedures, review of facility documentation and interview, it has been determined the facility failed to develop a policy regarding the use of volunteers during an emergency. Failure to develop a policy regarding the use of volunteers during an emergency event can result in being unprepared for employees who wish to volunteer during a surge event or for the need to accept volunteer staff to address surge needs during an emergency event. Findings include: Facility Policy No. 7-001.1 titled, "...Emergency Management Plan...." did not reveal written process or procedure address use of volunteers or other staffing strategy to address surge needs during an emergency. A review was conducted of all materials presented related to the emergency preparedness communication. Materials did not reveal written process or procedure address use of volunteers or other staffing strategy to address surge needs during an emergency. In an interview conducted with Employee #2, Employee #2 confirmed that copies of all materials related to emergency preparedness had been provided. Per employee #2 the emergency plan and procedures will be updated to include written policy and procedure to formalize plan on the use of volunteers or other staffing strategy to address surge needs during an emergency.

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 facility policy, review of facility documentation and interview, it was determined the facility failed to include names and contact information for staff and entities providing services under arrangement in the facility communications plan. Failure to provide contact information that could be needed during an emergency event the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients. Findings include: Facility Policy No. 7-001.1 titled, "...Emergency Management Plan...." reviewed January 23, 2025 revealed,"...Communication Plan, The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws...The plan includes the following: 1. Names and contact information for the following: A. Staff B. Entities providing services under arrangement...." A review was conducted of all materials related to the emergency preparedness communications plan. Contact information for the following staff and entities providing services under arrangement could not be found. In an interview conducted with Employee #2, Employee #2 confirmed that all hard copy materials related to emergency preparedness had been provided. Per employee #2 the emergency plan and procedures will be updated to include contact information for the following staff and entities providing services under arrangement.

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 facility policies and procedures, review of facility documentation and interview, it has been determined the facility failed to include contact information for Federal, State, tribal, regional, and local emergency preparedness staff in the Communication Plan. Findings include: Facility Policy No. 7-001.1 titled, "...Emergency Management Plan...." reviewed January 23, 2025 revealed,"...Communication Plan, The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws...The plan includes the following: ...2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff B. Other sources of assistance...." A review was conducted of all materials related to the emergency preparedness communications plan. Contact information for Federal, state, tribal, regional and/or local emergency preparedness staff and other sources of assistance could not be found. In an interview conducted with Employee #2, Employee #2 confirmed that all hard copy materials related to emergency preparedness had been provided.

There were deficiencies noted during the unannounced onsite Medicare Recertification survey conducted January 21, 2024 through January 24, 2024. The facility is in compliance with 42 CFR Part 484 subparts A, B, and C requirements for a Home Health Agency. State Agency recommends continued certification of this home health program. Five (5) home visits were conducted during the survey. Appendix Z, Emergency Preparedness was surveyed at the time of the Medicare Recertification, deficiencies were noted.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. Facility staff staff should know and be able to verbalize upon interview who the pre-designated administrator designee. This deficient practice has the potential to result in confusing, disorganization, communication issues ultimate negatively impacting patient care. Review of Governing body minutes failed to reveal alternate administrator. In an interview conducted with Employee #2, Employee #2 was unable to verify the alternate administrator. In an interview conducted with Employee #1, Employee #1 confirmed most recent alternate administrator had resigned this month. The organization has just identified replacement and the governing body will be confirming the appointment in the near future.