Every finding on record at Buckeye Health Agency LLC

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 05/11/22, Buckeye Health Agency LLC is in compliance with the provisions of 42 CFR Part 484.105, Conditions of Participation for Home Health Agencies.

Extended Recertification Survey An entrance conference was conducted with administrative staff on 05/09/22, and an exit conference was conducted with administrative staff on 05/11/22. The following deficiencies are based on the extended recertification survey completed on 05/11/22. Buckeye Health Agency LLC 368255, is not in compliance with the requirements of 42 CFR, Part 484 Subpart B,C for Home Health Agencies as a result of the extended recertification survey completed on 05/11/22. Buckeye Health Agency 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 Revised, Attachment G, review of facility COVID-19 vaccination records, staff interview, and review of the facility policy, the facility failed to implement a process for tracking and securely documenting the COVID-19 vaccination status of all staff, failed to implement 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, and failed to ensure 100% of staff have received at least one dose of COVID-19 vaccine, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the Center for Disease Control (CDC). The cumulative effect of these systemic practices resulted in the agency’s inability to prevent the potential spread of infectious disease. (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 Revised, Attachment G, review of facility COVID-19 vaccination records, staff interview, and review of the facility policy, the facility failed to implement a process for tracking and securely documenting the COVID-19 vaccination status of all staff, failed to implement 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, and failed to ensure 100% of staff have received at least one dose of COVID-19 vaccine, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the Center for Disease Control (CDC). The facility's percentage of vaccinated staff for COVID-19 was 75.9%. This affected 20 of 83 staff members. The active census was 98. Findings include: Review of QSO memo 22-09-ALL Revised, Attachment G, dated 01/14/22, revealed within 90 days of issuance of this memorandum, 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC). The agency must have a process for tracking and securely documenting the COVID-19 vaccination status employees as recommended by the (CDC). The must have 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 Review of the undated facility policy titled, “Covid Policy Number 001” revealed that all employees and health care providers are required to receive a Covid-19 vaccination, and any subsequent booster vaccinations, unless there is a verifiable approved exemption for either a medical contradiction or religious accommodation. All employees who are not eligible for an exemption and who have not completed at least the first dose of the Moderna or Pfizer-BioNtech or the one-time dose of Johnson & Johnson by 05/28/22 will be terminated. All employees will be vaccinated by 06/01/22 and/or have an exemption on file in order to work at the establishment. The policy also revealed all employees will be required to submit his/her vaccination card upon each dose of the vaccination and subsequent booster. Copies of vaccination cards will be kept for tracking vaccinations and boosters. All vaccinations and subsequent boosters will be tracked using an approved organization form. Review of staff vaccination records on 05/10/22 at 9:45 AM revealed there were no COVID-19 vaccinations or exemptions on file for twenty of eighty three employees who provided direct patient care. This affected 18 Home Health Aides and 2 Licensed Practical Nurses. The facility's percentage of vaccinated staff for COVID-19 was 75.9%. Interview with Staff A on 05/10/22 at 3:16 PM confirmed the employees identified above had not received the COVID-19 vaccination or had an exemption on file. Staff A also confirmed the agency did not implement the process for tracking employee COVID-19 vaccination and/or exemption status until after the surveyor started the survey.