Every finding on record at Community Healthcare System Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (5FE77-H1) at the above-named Home Health Agency (HHA) from 06/06/23 to 06/08/23 resulted in the following deficiency respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 the agency’s Emergency Preparedness Plan (EPP) the above-named home health agency (HHA) failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency. This failure has the potential to place patients at risk for unmet needs during an emergency. On 6/7/2023 between 8:30 am and 12:00 pm, while reviewing the Emergency Preparedness Program, it was observed that the agency failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey (iQIES 5F994-H1) at the above-named Home Health Agency from 06/06/23 to 06/08/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to be free from mental and sexual abuse, including injuries of unknown source, neglect, and misappropriation of property. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patients’ Bill of Rights, dated as “Reviewed 7/2018," showed during the admission visit the patient and the family/caregivers/patient representative present would receive a clear, concise explanation that the development of the patient plan of care was provided under the Patient’s bill of rights. Review of agency document in the patient admission packet, titled "Patients’ Bill of Rights, updated 5/20/2022" showed each patient shall have the right to be free from verbal, physical and psychological abuse. The Bill of Rights did not include the right to be free from mental and sexual abuse, including injuries of unknown source, neglect, and misappropriation of property. During an interview on 06/08/23 at 10:10 AM, Staff A, Administrator confirmed the agency’s written notice of patient's rights provided to the surveyor for review, was the version of the patient’s rights provided to all agency patients on admission. During a subsequent interview on 06/08/23 at 12:40 PM Staff A, Administrator and Staff B, Director of Ancillary Services, confirmed the agency’s Patients’ Bill of Rights, did not contain all required rights and was being revised.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to make complaints to the HHA regarding the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patients’ Bill of Rights, dated as “Reviewed 7/2018," showed during the admission visit the patient and the family/caregivers/patient representative present would receive a clear, concise explanation that the development of the patient plan of care was provided under the Patient’s bill of rights. Review of agency document in the patient admission packet, titled "Patients’ Bill of Rights, updated 5/20/2022" showed the written notice of Rights did not include the right to make complaints to the HHA regarding “treatment of care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA.” During an interview on 06/08/23 at 10:10 AM, Staff A, Administrator confirmed the agency written notice of patient's rights, provided to the surveyor for review was the version of the patient’s rights provided to all agency patients on admission. During a subsequent interview on 06/08/23 at 12:40 PM Staff A, Administrator and Staff B, Director of Ancillary Services, confirmed the agency’s Patients’ Bill of Rights, did not contain all required rights and was being revised.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; the disciplines furnishing the care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and Any factors that could impact treatment effectiveness. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patients’ Bill of Rights, dated as “Reviewed 7/2018," showed during the admission visit the patient and the family/caregivers/patient representative present would receive a clear, concise explanation that the development of the patient plan of care was provided under the Patient’s bill of rights. Review of agency document in the patient admission packet, titled "Patients’ Bill of Rights, updated 5/20/2022" showed the written notice of Rights did not include the right to participate in, be informed about, and consent or refuse care during treatment, where appropriate, with respect to; Completion of all assessments; The care to be furnished, based on the comprehensive assessment; Establishing and revising the plan of care; The disciplines furnishing the care; Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits and any factors that could impact treatment effectiveness. During an interview on 06/08/23 at 10:10 AM, Staff A, Administrator confirmed the agency written notice of patient's rights, provided to the surveyor for review, was the version of the patient’s rights provided to all agency patients on admission. During a subsequent interview on 06/08/23 at 12:40 PM Staff A, Administrator and Staff B, Director of Ancillary Services, confirmed the agency’s Patients’ Bill of Rights, did not contain all required rights and was being revised.

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 document review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the written notice of patient's rights and responsibilities included the right to 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 HHA’s. The home health agency's failure to ensure patients received a comprehensive written Bill of Rights has the potential to place all patients at risk for compromised understanding and preservation of individual patient rights. Findings Include: Review of a policy titled, "Patients’ Bill of Rights, dated as “Reviewed 7/2018," showed during the admission visit the patient and the family/caregivers/patient representative present would receive a clear, concise explanation that the development of the patient plan of care was provided under the Patient’s bill of rights. Review of agency document in the patient admission packet, titled Patients’ Bill of Rights, updated 5/20/2022" showed the written notice of Rights did not include the right to be advised of the state toll free home health telephone hot line and included “its contact information, its hours of operation and that its purpose is to receive complaints or questions about local HHA’s.” During an interview on 06/08/23 at 10:10 AM, Staff A, Administrator confirmed the agency written notice of patient's rights, provided to the surveyor for review, was the version of the patient’s rights provided to all agency patients on admission. During a subsequent interview on 06/08/23 at 12:40 PM, Staff A, Administrator and Staff B, Director of Ancillary Services, confirmed the agency’s Patients’ Bill of Rights, did not contain all required rights and was being revised.