Every finding on record at Caring Touch Home Care, LLC

The facility must meet all applicable Federal, State and local 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. The following deficiency was found at the time of the survey conducted on August 14 through August 17, 2023.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on agency policy and procedure, personnel file documentation and interview, it was determined that the agency failed to ensure that all employees received an orientation to and training on the agency's emergency preparedness program. The failure to provide emergency preparedness training to employees, potentially increases the risk of harm to homebound patients during an actual event. The agency policy entitled "Emergency Management Plan" contained "...1.The training includes: Initial Training in emergency preparedness policies and procedures to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable, 2.The training is provided annually and demonstrates staff knowledge of emergency procedures, 3.Organization leadership will provide orientation and annually thereafter of all personnel regarding participation in the emergency management plan. Education to include: A. Specifics of organization's emergency management plan...1.All training will be documented in the personnel record of staff, individuals under arrangement and volunteers, if applicable...." The agency policy entitled "Orientation" revealed, "...The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided...S. Emergency Preparedness...4. During the orientation process, the supervisor will be responsible for evaluating the knowledge and skills of the personnel being oriented...." Eight personnel files were reviewed. Four of eight failed to contain documentation of orientation to the agency's Emergency Management Plan. The Administrator confirmed during interview conducted on 08/17/2023 at approximately 10:30 am that there was no additional documentation to demonstrate the Employee #2 through #5 had received orientation and training on the agency's Emergency Preparedness Plan. The failure to orient staff to the Emergency Preparedness Plan and Procedures increases likelihood of activity mismanagement during an actual disaster and increases potential for adverse outcomes for patients and staff.

The following Standard Level deficiency was found at the time of the Medicare Recertification Survey conducted August 15, 2023 through August 17, 2023. Seven home visits were conducted. The home health program is in compliance with the Conditions of Participation contained under CFR 484.10-484.115, Subpart A, B and C. Emergency Preparedness- Appendix Z (E Tags) was surveyed as part of this survey.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on the findings contained in four personnel files, the agency policy and procedure entitled, "Orientation Policy No. C-3-020.1 and Administrator interview, it was determined that staff were not advised of the state toll free home health hot line telephone number and its purpose to receive complaints. The failure to provide and inform employees on the state hot line and website subtracts from resources for available for assistance to employees, patients and caregivers when problematic issues arise. Eight personnel files were reviewed. Four of the eight files failed to contain documentation that personnel received orientation to operations of the state home health hot line and its purpose to receive complaints or questions about local home health agencies on behalf of employees, patients and caregivers. The agency policy entitled "Orientation Policy No. C-3-020.1 was reviewed. Findings revealed that the policy failed to contain verbiage or any mention of state hot line or how to report a complaint or concern on behalf of a patient. The Administrator confirmed these findings on August 17, 2023 at approximately 11:00 am. The orientation to the state hot line is a valuable resource to deter risks of adverse outcomes and be aware of in aiding patients.