Every finding on record at Capital Home Health, Inc

Emergency Preparedness Survey The following deficiency is based on the emergency preparedness survey completed 02/18/21.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure emergency preparedness policies addressed the procedure to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.. This had the potential to affect all patients receiving services from the agency. The census was 41 patients. Findings include: Review of the agency's emergency preparedness plan was completed on 02/18/21 and revealed a facility and community based risk assessment that revealed the agency' patient population was at moderate risk for flooding. The review revealed an emergency triage classification in which to place the patients. The system was a numerical one, with 4 indicating the patient could have visits postponed 72 to 96 hours without adverse effects, to 1 indicating either life threatening or the potential for life threatening exists, and appropriate arrangements for evacuation to an acute care facility need to be made. The review did not reveal to what extent patient mobility determined to what triage classification the patient was placed. On 02/18/21 at 3:02 PM in an interview, Staff B explained the nurse assessed her patient and placed him/her into a triage classification by way of the agency's electronic charting. Staff B confirmed the electronic chart did not allow the patient's mobility to be a factor in triage classification. Staff B said the numbers were not always appropriate for the patient and "It doesn't fit well with our clients."

Standard Recertification Survey COVID-19 Focused Infection Control Survey Capital Home Health, Inc 368153, is in compliance with the requirements of 42 CFR Part 484, Subpart B, C for Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control.