Every finding on record at Community Home Health Services LLC

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 2/26/24 to 2/29/24. Unless otherwise indicated, the general use of the terms "facility" or "facilities" refers to all providers and suppliers affected by this regulation. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey was conducted by Healthcare Licensing and Surveys from 2/26/24 to 2/29/24. The findings were:

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure the individualized care plans were signed by a provider for 4 of 7 records reviewed (#1, #2, #4, #6). The findings were: Review of the medical record for patient #1 showed a referral date of 2/7/24 and an admission date of 2/8/24 for nursing services. Further review showed the patient received services per a verbal order by the physician on 2/8/24 but the orders had not been signed by a physician and returned to the agency by the date of survey. Review of the medical record for patient #2 showed a referral date of 2/8/24 and an admission date of 2/9/24 for nursing services, assistance with activities of daily living (ADL's), and physical therapy. Further review showed the patient received services per a verbal order on 2/9/24 but the orders had not been signed by a physician and returned to the agency by the date of survey. Review of the medical record for patient #4 showed a referral date of 2/1/24 and an admission date of 2/2/24 for nursing services, physical therapy and occupational therapy. Further review showed the patient received services per a verbal order on 2/2/24 but the orders had not been signed by a physician and returned to the agency by the date of survey. Review of the medical record for patient #6 showed a referral date of 2/7/24 and a start of care date planned for 12/11/23 for nursing services and physical therapy. Further review showed the patient received services and was discharged on 2/8/24 but the orders had not been signed by a physician and returned to the agency by the date of survey. Interview with the administrator and assistant administrator on 2/29/24 at 8:30 AM verified they had not received the signed plan of care back from the ordering physicians for patients #1, #2, #4 and #6.

An Emergency Preparedness survey was conducted by Healthcare Licensing and Surveys from 3/22/21 through 3/24/21. Based upon the findings of the survey, it was determined that no deficiencies were identified pertaining to the Emergency Preparedness Rule.

A recertification survey, which included a COVID-19 focused infection control survey was conducted by Healthcare Licensing and Surveys from 3/22/21 to 3/24/21. The following abbreviations were used throughout the document: CMS- Centers for Medicare & Medicaid DON- Director of Nursing PT- Physical Therapist RN- Registered Nurse

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, staff interview, policy and procedure review and review of CMS guidance, the facility failed to ensure clients were screened for COVID-19 during 1 of 3 home visits (patient #1). The findings were: Review of the 3/10/20 CMS memorandum titled "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs) showed "...HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel and visitors..." The following concerns were identified: 1. Observation of a home visit on 3/24/2021 at 11 AM showed PT #1 failed to screen patient #1 for signs or symptoms of COVID-19. Interview with PT #1 by telephone on 3/24/21 at 1:20 pm, confirmed she did not screen the patient for COVID-19. 2. Interview on 3/24/21 at 2:30 PM with the DON and RN #3 at 2:30 pm revealed all patients should be screened for signs and symptoms of COVID-19 immediately upon arrival for a home visit. 3. Review of "COVID-19 Patient Policy" titled," Our Commitment to your health and safety", not dated, showed: "...Community Home Health Services, its employees and contractors will practice all CDC recommended best practices to help prevent spreading the COVID-19 viral infection to you ..."