Every finding on record at Dependable Home Health, Inc.

The following Standard Level Deficiencies were found at the time of the Medicare Recertification survey conducted November 15- November 17, 2022.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on the HHA’s s 2021 Emergency Preparedness plan, medical record review, and staff interviews, it was determined that the home health agency failed to develop individual plans for patients based on the comprehensive assessment. This poses an increased risk to the health and safety of the patients in the event of an emergency. Findings Include: A review of agency policy and procedures titled " Emergency Management Plan Policy No. 6-037.1" states "... 9. Individual plans for patients during a natural or man-made disaster will be included as part of the comprehensive patient assessment. The comprehensive assessment will be updated as frequently as the patient's condition warrants... 10. The organization educates patients and their families on emergency preparedness at the time of admission including where they can go to shelter..." A review of the HHA's policy under Provisions of Care and Record Management titled "Natural Disasters/Emergencies Policy No. 4-059.1" states "... 1. Upon admission, the patient and family/caregiver will be assessed regarding their emergency management plan for the home, and any special needs...3. The patient and family/caregiver will be assessed and instructed regarding the components of an emergency preparedness/natural disaster plan that will include, but not limited to: A. Emergency phone access, including ambulance, police, fire, gas, electric, and water B. Emergency supplies, including food, water, heat, light, day-to-day necessities, and needed medical supplies C. Disaster follow-up, including battery-powered access to local radio stations D. Procedures to follow if care is disrupted by a natural disaster E. Actions to take in preparation and during natural disasters, such as floods, storms, or earthquakes F. Actions to take in case of fire G. Evacuation plans for the home and how to access shelters if necessary... 4. Written information will be presented and reviewed, based on patient family/caregiver knowledge, skills, and identified needs...5. The Case Manager will document all patient and family/caregiver education information in the clinical notes. Noncompliance and/or lack of understanding will be documented, and a plan for instruction will be developed as part of the plan of care...". Seven patient medical records were reviewed for content and regulatory compliance. Seven of seven patient records revealed that no individual emergency preparedness plans were contained in the records. Eleven of eleven records revealed that the patients had only been assigned a "triage level" of 1, 2, or 3 (indicating a high, medium, or low priority) for delivery of service. In an interview conducted on November 16, 2022, with the Clinical Manager, the clinicians are to document in the narrative notes on the OASIS upon admission that an emergency plan was discussed with the patient and/or patient care representative. The clinical manager confirmed this was not being done upon admission. In an interview conducted on November 17, 2022, the Administrator confirmed that the agency did not currently have an emergency plan form or template that was to be completed upon admission and left in the patient home as well as a copy for the medical record.

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), §485.625(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, "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 a review of the facility's emergency policies and procedures, facility records, and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness policies and procedures. Failure to have staff review the emergency preparedness policies and procedures consistent with their expected roles may cause harm to the patients during an emergency. Findings include: A request was made to provide documentation of staff training and participation in the EP program. No staff training was provided. A review of HHA's policy titled "Personnel Administration ORIENTATION Policy No. 1-022-1" states "... Procedure 1. The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: A. General company orientation including the organization's mission/philosophy, policy and procedures, environmental safety program, etc... CC. Emergency Management Plan..." A review of the HHA's Policy No. 6-037.5 "Risk Management: Infection and Safety Control", states "... Training: ... The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable... 2. The training is provided at least every two (2) years and demonstrates staff knowledge of emergency procedures 3. Organization leadership will provide for orientation and annually thereafter of all personnel regarding participation in the emergency management plan. Education to include: A. Specifics of organization's emergency management plan B. Specific assigned emergency response role C. Information on developing their family's emergency response plan. D. Information regarding accessing housing and transportation for staff if necessary. 1. All training will be documented in the personnel record of staff, individuals under arrangement, and volunteers in applicable...". Six personnel files were reviewed. Six of the six files had no documentation of staff having received testing and training on emergency preparedness operations of the HHA from the date of hire through November 17, 2022. The Administrator and Clinical Manager confirmed during an interview conducted on November 17, 2022, that no training or testing had been provided to employees at orientation or annually.

Standard Level deficiencies for Emergency Preparedness were found at the time of the Medicare Recertification Survey conducted November 15- November 17, 2022. Three home visits were conducted. The home health program is in compliance with the Conditions of Participation contained under CFR 484.50 through 484.110, Subparts A, B, and C. Standard Level Emergency Preparedness- Appendix Z deficiencies were found and cited during the Recertification. Based on an acceptable Plan of Correction, State Agency recommends continued certification of this home health agency.