Every finding on record at Care Plus Home Health Services, Inc

Based on the findings of an onsite unannounced state relicensure and Medicare re-certification survey completed May 14, 2021, Care Plus Home Health Services, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the agency Emergency Operations Plan and Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop and maintain an EPP that was reviewed and updated every two years. Findings Included: Review of the agency Emergency Preparedness Plan/Policies occurred on 5/12/2021 at approximately 1:15 PM. Documentation revealed that the plan was last revised on 8/16/2018. Discussion with EMP1 (Administrator) and EMP2 (Office Manager) occurred on 5/12/2021 at 1:30PM regarding Emergency Preparedness. EMP1 and EMP2 were unable to provide evidence of documentation that the emergency preparedness program was reviewed or updated for the period of 2020 or later. Findings were confirmed with EMP1 and EMP2 during an exit interview that was conducted on 5/14/2021 at approximately 1:40 PM.

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), §485.625(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 a review of the agency Emergency Operations Plan and Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to ensure documentation of a facility-based and community-based risk assessment for 2020. Findings include: Review of the agency Emergency Preparedness Plan/Policies occurred on 5/12/2021 at approximately 1:15 PM, including the agency hazard vulnerability assessment tool. Documentation revealed that the hazard vulnerability assessment tool was last revised on 10/25/2017. Discussion with EMP1 (Administrator) and EMP2 (Office Manager) occurred on 5/12/2021 at 1:30PM regarding Emergency Preparedness and the hazard vulnerability assessment tool. EMP1 and EMP2 were unable to provide evidence that the hazard vulnerability assessment tool was reviewed or updated for the period of 2020 or later. Findings were confirmed with EMP1 and EMP2 during an exit interview that was conducted on 5/14/2021 at approximately 1:40 PM.

Based on the findings of an unannounced onsite Medicare Recertification survey completed on May 14, 2021, Care Plus Home Health Services, Inc was found to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.