Every finding on record at Cp Humboldt N - Ca Hh, LLC

The following reflects the findings of the California Department of Public Health, during standard Recertification Survey. The findings are in accordance with 42 Code of Federal Regulations with 484.102 Emergency Preparedness for Home Health Agencies. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN) #36790. The agency reported 610 unduplicated admissions in the last 12 months. The facility was not in compliance with 42 CFR 484.102 Emergency Preparedness for Home Health Agencies. (Refer to E 0037 and E 0042)

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 interview and record review the facility did not document the training of the staff in preparation of an emergency or disaster and did not have a process to assess the staff's knowledge of Emergency Preparedness. This has the potential for the staff to not know their role in relation to the agency should a emergency or disaster hit the community. During an interview on 9/20/23 at 1:45 p.m., the Clinical Manager stated Emergency Preparedness Training was done annually. The Clinical Manager stated updates to the Emergency Plan was provided as needed during clinical case conferences. During an interview on 9/22/23 at 2:30 p.m., the Clinical Manager stated she did not document the Emergency Preparedness Training completed by the staff. The Clinical Manager stated they did not have knowledge checks or competencies documented concerning the Emergency Preparedness Training of staff. The Corporation's Policy on Emergency Preparedness Plan, revised 9/2021, for a different facility type, indicated, "All employees receive training and testing on emergency preparedness upon hire and annually thereafter." No documentation was available for record review for Emergency Preparedness Training.

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.542(f), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on interview and record review the facility does not have a written emergency policy and procedure specific to the Home Health Agency in Eureka California. This has the potential for the staff and patients do not get the help needed in a disaster. During an interview on 9/20/23 at 1:30 p.m., the Clinical Manager stated she did not have a copy of the emergency procedure at the office. The Clinical Manager stated the copy of the Emergency Plan was on the Corporation's electronic system. The Clinical Manager stated this was what she found and handed the Surveyor a copy pulled from the Cooperation web site. During the interview, two components required for the Emergency Plan were not known by the Clinical Manager: How to communicate with Federal, State and Tribal governments and what the alternate communication plan would be if phones and electronics were down. During a review of the agency's Emergency Preparedness Plan, last revised 09/2021, documented, "Purpose: to develop …Emergency Preparedness Plan for Providence ElderPlace (PACE) staff to follow in the event of emergencies that will be reviewed and updated at least annually." The procedure indicated, “Each PACE center will follow the PACE emergency policies and procedures applicable to the emergency and follow the polices and procedures of the location in which the PACE center exists if applicable." The document heading indicated the authors of this Emergency Preparedness Plan was PACE WA (Washington) Ministries.

The following represents the findings of the California Department of Public Health during a Home Health Agency Standard Survey conducted 9/20/23 to 9/22/23.Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) # 36790.There were 610 Unduplicated Admissions in the previous 12 months.There were five home visit observations with clinical record reviews, and eight clinical record reviews without home visit observations. One deficiency was cited for the survey. Refer to G 718.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to follow physician's orders according to the Plan of Care (POC), when three of thirteen sampled patients (Patient 2, Patient 5, and Patient 6) did not get the visits by staff as ordered by the physician. This failure resulted in Patient 2, Patient 5, and Patient 6 not receiving services as ordered by the physician and had the potential for Patient 2's, Patient 5’s, and Patient 6’s care needs to be unmet. During a review of Patient 2's, "Home Health Certification and Plan of Care," for the period of 7/16/23 to 9/13/23, a visit was scheduled for 7/22/23. The visit was not completed. Explanation for the missed visit and whether the MD was notified, was not found. During an interview with the Clinical Manager (CM) on 9/20/23 at 2:20 p.m., the CM stated she expected to see some documentation to explain the missed visit but was not able to find documentation in the electronic records. During a review of Patient 5's, "Home Health Certification and Plan of Care,” for the period of 7/20/23 to 9/26/23, indicated visits by a Home Health Aide (HHA) were ordered by the Physician. Starting from 8/6/23, the HHA was to make a visit one time a week for eight weeks. No visits by a HHA were documented for the week of 8/20/23 to 8/26/23. Documentation for the missed visit and whether the MD was notified, was not found. During an interview with the CM on 9/21/23 at 9:50 a.m., the CM stated she did not find documentation of the missed visit nor notification of the Physician. The CM stated it was a staffing complication. The CM stated, usually notes about missed appointments were in the medical records. A review of Patient 6's, "Home Health Certification and Plan of Care," for the period of 8/6/23 to 9/23/23, indicated HHA visits were ordered for one visit a week for seven weeks. A visit by the HHA was scheduled for 8/20/23, but was not completed. Documentation about the missed visit and whether the MD was notified, was not found. During an interview with the CM on 9/21/23 at 3:10 a.m., the CM stated she did not find documentation of the missed visit nor notification of the Physician. The CM stated it was a staffing complication.