Every finding on record at Community Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/09/24. Standard level deficiencies cited.

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), §485.542(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 review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure that the Emergency Preparedness Plan was established based on a risk assessment using an all-hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 08/08/24. The Emergency Preparedness Plan contained an undated Hazard Vulnerability Assessment. The Plan lacked documentation that a facility-based and/or community-based risk assessment was completed for 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 08/08/24 at 10:00 AM, the Director of Nursing confirmed that the Agency lacked an all hazards risk assessment after 2020.

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 review of Agency’s Emergency Preparedness Plan, review of In-service binder and Staff interview, it was determined that in 1 of 7 (Employee #2) Employees, the Agency failed to conduct staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and In-service binder were reviewed on 08/08/24. The Agency’s In-service binder lacked documentation that the Agency conducted Emergency Preparedness training for Employee #2 (Home Health Aide/Date of Hire 09/06/17) in 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 08/08/24 at 11:40 AM, the Director of Nursing confirmed the above findings.

Recertification survey was conducted on 08/09/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning SN = Skilled Nurse POC/PsOC = Plan of Care / Plans of Care SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and Staff interview, it was determined that in 5 of 73 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 05/2023 to 04/2024 (12 months), was reviewed on 08/08/24. The report included a warning for Error # -3330. The Error included 5 (6.85 %) of 73 assessments that were submitted late. 2. During an interview with the Director of Nursing on 08/07/24 at 2:00 PM, the Director of Nursing stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Director of Nursing confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy review and Staff interview, it was determined that in 5 of 7 (Pts. #1, 4, 5, 6 and 7), the Agency failed to ensure Pts. were assessed for the Influenza and/or Pneumonia vaccination status per Agency policy. Findings include: 1. The following clinical records were reviewed from 08/06/24 at 11:30 AM to 08/07/24 at 12:30 PM: Pt. #1 SOC 06/14/24 Lacked Pneumonia vaccination assessment Pt. #4 SOC 06/09/24 Lacked Influenza vaccination assessment Pt. #5 SOC 02/28/24 Lacked Influenza and Pneumonia vaccination assessment Pt. #6 SOC 01/22/24 Lacked Influenza and Pneumonia vaccination assessment Pt. #7 SOC 09/28/23 Lacked Influenza and Pneumonia vaccination assessment The records lacked documentation that the Pts. were assessed for Influenza and/ or Pneumonia vaccine. 2. The Agency’s policy titled: “Influenza/ Pneumonia Vaccine”, required Agency to: “….will obtain information from the patient in reference to influenza and pneumonia vaccination from the month of October to March….1. SN is to complete INFLUENZA/PNEUMONIA QUESTIONAIRE….5. SN is to have follow up documentation within 30 days if vaccine not given by SN or patient was referred to other site….” The policy did not address the Patient’s Pneumonia vaccination assessment outside months of October to March. 3. During interviews with the Director of Nursing on 08/07/24 from 11:00 AM to 2:00 PM, the Director of Nursing confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical records and Staff interview, it was determined that in 2 of 7 (Pts. #4 and 6) clinical records reviewed, the Agency failed to ensure the staff provided services ordered by the Physician in the plan of care. 2. Pt. #6 was admitted for to Home Health Services on 1/22/24 with the Diagnosis of Bilateral Primary General Osteoarthritis of knee. The clinical record was reviewed on 8/6/24. The record included a POC for the certification period of 3/22/24 to 5/20/24 which required SN Frequency of 1 week 9. The record lacked an SN visit for the weeks of 4/28/24 to 5/4/24 and 5/5/24 to 5/11/24 and lacked documentation of why these SN visits were missed. 3. During an interview with the Director of Nursing on 8/7/24 at 11:15 AM and 2:00 PM, the above findings were confirmed. Findings include: 1. Pt. #4 was admitted to Home Health Services on 06/09/24 with Diagnosis of Autistic Disorder. The clinical record was reviewed on 08/07/24. The clinical record contained a POC for certification period The clinical record contained a POC for certification period 05/16/24 to 07/14/24 that required SN frequency of 1 time a week for 9 weeks. The clinical record lacked an SN visit for the week of 07/14/24 to 07/20/24 and lacked documentation of why these SN visits were missed.