Every finding on record at Community Home Health Inc

A survey with CMS Appendix Z Emergency Preparedness Requirements, was conducted on June 21 through 24, 2021, during a recertification survey. The agency was NOT in compliance with the Appendix Z Emergency Preparedness Requirements.

EP Program Patient Population CFR(s): 484.102(a)(3) [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to address in their Emergency Preparedness Plan the patient population including, but not limited to, persons at-risk. This had the potential to effect all 128 current patients of the agency. Findings include: The agency's Emergency Preparedness Plan dated 2020, did not address population, including, but not limited to, persons at-risk; the type of services the agency had the ability to provide in an emergency; and continuity of operations. During interview on 6/24/21, at 12:32 p.m. the agency's administrator verified that plan did not address population, including, but not limited to, persons at-risk; the type of services the agency had the ability to provide in an emergency.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness communication plan included a procedure for sharing information on occupancy and the facility's ability to provide assistance to the authority having jurisdiction in the event of an emergency. This practice had the potential to affect all 128 patients currently receiving services from this agency. Findings include: During review of the agency's Emergency Preparedness Plan dated 2020, it was revealed, the plan lacked a policy and procedure that addressed how the agency would share occupancy needs and ability to provide assistance with outside resources during an emergency. On 6/24/21, at 12:32 p.m. the agency's administrator reviewed the plan with surveyors and confirmed the agency had not developed policies and procedures related to sharing occupancy needs or ability to provide assistance with outside resources during an emergency.

On June 21, 22, 23 and 24, 2021, a partial extended survey was conducted for Community Home Health Inc. The agency was found not in compliance with the requirements at 42 CFR. Part 484 for Home Health Agencies. Hours of Operation: Monday-Friday 8:00 a.m. to 5:00 p.m. Unduplicated census: 128 Total home visits conducted: 3 Branch office: Zero Total number of records reviewed: 7

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 interview, and document review, the agency failed to complete and electronically transmit a transfer to in-patient facility Outcome and Assessment Information Set (OASIS) data set for 1 of 1 patient (P3) who was on Medicare and received skilled nursing services. Findings include: P3's current plan of care (POC) for certification period 6/15/21 through 8/13/21, indicated P3 was admitted to home care agency on 4/16/21, with diagnoses of cutaneous abscess (commonly known as boils) of back, cellulitis (bacterial skin infection) of the back and type 2 diabetes and was receiving skilled nursing visits (SNV) daily for wound care. During review of the previous POC for certification period 4/16/21 through 6/14/21, it was revealed P3 was to receive SNV daily for wound care however a review of the SNV notes reviewed P3 had no visits completed from 5/24/21 through 6/1/21. The medical record lacked documentation of a transfer to in-patient facility OASIS being completed and transmitted. During further review of the hospital discharge summary dated 6/1/21, it was revealed P3 had been admitted to the hospital from 5/24/21 and was discharged on 6/1/21, related to sepsis (blood infection) due to the abscess on the back. On 6/23/21, at 10:01 a.m. registered nurse (RN)-A stated P3 had been seen by the primary physician on 5/22/21, and had been started on an antibiotic. However, two days later P3 was sent to the hospital via ambulance. RN-A stated, after that she was not certain if P3 was under observation or had been admitted to the hospital. RN-A stated, she had been informed on 6/1/21, P3 was being discharged to home and she had been out to resume the services. RN-A stated, being a new nurse she was still trying to figure out what was needed to be completed in terms of the paperwork. On 6/24/21, at 9:18 a.m. RN-B clinical manager stated, the transfer to in-patient OASIS was missed along the way and she had a system of what and who needed to do the required documentation, however this was missed. RN-B stated she was going to follow up with the staff moving forward as the transfer to in-patient OASIS was supposed to be completed within 24 to 48 hours after P3 was discharged to the hospital. On 6/24/21, at 12:41 p.m. the director of nursing (DON) stated she would have expected the transfer to in-patient OASIS to have been completed as required. The agency OASIS policy dated 2016, directed staff for a transfer OASIS "This must be filled out anytime a client with skilled care is transferred to an inpatient facility (hospital, nursing home, rehabilitation center) for more than 24 hours. The paperwork must be to data entry within six days of the assessment date ..."

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure 3 of 3 patients (P2, P3, P1) plans of care included a list of durable medical equipment (DME) used to meet patients needs, reviewed during home visits. Findings include: P2's plan of care (POC) for certification period 5/8/21 to 7/6/21, included diagnoses of acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), type 2 diabetes, peripheral vascular disease and chronic diastolic congestive heart failure. A home visit was conducted on 6/22/21, at 10:30 a.m. to 11:25 a.m. with physical therapist (PT). Upon entering P2's home PT stated P2's room was located in the basement of the house. As PT and surveyor(s) took the stairs, a stairway lift chair was observed to the left hand side going down to where P2 was. P2 was then observed seated on the recliner and a white Life Alert pendant was lying on top of the table. During the home visit PT was observed instructing and assisting P2 getting on and off the stairway lift chair to the wheelchair at the top of the first level of the home. In addition, during the home visit, a nebulizer machine and 4 urinals were observed lying on the beside table next to the recliner chair which both were not listed in the POC. On 6/22/21, at 11:27 a.m. PT verified the DME's, nebulizer machine, urinals, Life Alert pendant and the stairway lift chair were not included in the plan of care. P3's current POC for certification period 6/15/21 through 8/13/21, included diagnoses of cutaneous abscess (commonly known as a boil) of back, cellulitis (bacteria infection of the skin) of the back and type 2 diabetes. The POC indicated P3 received skilled nursing visits five days for wound care per week. A home visit was conducted on 6/23/21, at 9:15 a.m. to 10:00 a.m. with registered nurse (RN)-A. Upon entering the home RN-A stated P3's room was located in the basement of the house and because of weakness and shortness of breath, P2 used the stairway lift chair for mobility in the home. P3 was then observed lying in bed watching television when both the surveyor and RN-A approached her. During the home visit RN-A was observed assessing P3, checked vital signs and provided wound care to a wound on P3's back. During the home visit, the following DME's and supplies were observed in P3's environment: Bi-Pap machine, a nebulizer machine, diabetic supplies, wound supplies (Vashe wound solution, gauze, wound cleanser, packing strips), oxygen concentrator, portable oxygen tank, toilet raiser, shower chair, grab bars, stairway lift chair and an incentive spirometer by P3's bedside. During the visit, P3 stated she used the DME's and RN-A verified the DME's were not listed in the POC. On 6/24/21, at 9:20 a.m. RN-B the clinical manager reviewed the POC's for all the patients and verified the DME's were not included in the POC's. P1's POC for certification period 6/16/21 to 8/14/21, included diagnoses of amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), unspecified osteoarthritis and unsteadiness on feet. A home visit was conducted on 6/22/21, at 10:15 a.m. to 11:10 a.m. with home health aide (HHA)-B. Upon entering P1's home, HHA-B stated P1's room was located in the basement of the house. As HHA-B and surveyor took the stairs, P1 used the stairway lift chair to get down to the basement. When surveyor got to the basement, there was a hospital bed in the living room area. HHA-B and P1 verified that it was his hospital bed. P1 then sat down in his electric wheelchair at the dining room table. P1 was observed to be using oxygen via nasal cannula and verified that he uses it continuously throughout the day. HHA-B assisted P1 to take a shower. P1 was observed to have a shower chair in his bathroom which he used to sit on while taking a shower. On 6/24/21, at 9:52 a.m. clinical manager verified the DME's chair lift, hospital bed, electric wheelchair, and oxygen were not listed in the POC. She stated, "he has a chair lift and we should have added that. It looks like we've got some work to do on that." On 6/24/21, at 12:40 p.m. the director of nursing stated all medical equipment and medical supplies ordered by the physician for the patient to use not luxury items were supposed to be listed in the POC's. The agency Comprehensive Client Assessment policy dated 2016, indicated in addition to the general health status/system assessment, the agency comprehensive assessments tool would include "Equipment needs and ability to manage the equipment..."