Every finding on record at Exclusive Home Health and Hospice Inc

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 01/24/23 at 01:00 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Administrator. Census: Licensed and Certified: 147 An exit conference was conducted on 01/27/2023 at 01:00 p.m. with the Adm. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Administrator - Adm Alternate Administrator – Alt Adm HAM- Hertz, Armstrong, Marconi. CB- Citizen Band EPRP- Emergency Preparedness Response Plan

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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 facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it had on-hand, HAM radios, CB Radios nor a satellite phone as described in their EPRP for use as their alternate mode of communication in the event of telephone or power failure This failure has the potential to negatively impact the agency's active patients if the agency is unable to function and meet its communication needs during a disaster. Findings Include: Review of the agency's Emergency Preparedness and Response Plan page 6 and 7, with revision date 06/30/2021 revealed in part: “COMMUNICATION System: The primary method of communication is by cellular phone… In the event of a power outage or telephone/cell phone disruption, other methods may be utilized. Acceptable methods are electronic mail, via the electronic medical record platform (s), Internet technologies, fax, satellite phone, HAM Radios, CB Radios...” Further review of the Emergency Preparedness Manual and Emergency Preparedness and Response Plan revealed the agency's Emergency Preparedness and Response Plan failed to describe available, alternate forms of communication or alert systems for telephone or power failure if the cell phone service was unavailable. During an interview on 01/27/23 at 11:30 p.m. with the Disaster Coordinator, the Surveyor asked to see the HAM radios fully charged, docked and ready to go in the event of an emergency, CB Radios or Satellite phone as described in the communication section of the Agency’s Emergency Preparedness and Response Plan. Disaster Coordinator confirmed that the Agency did not have CB radios, HAM Radios or a satellite phone, and therefore failed to describe an alternate form of communication in the event of an emergency in its Emergency Preparedness and Response Plan.

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 01/24/23 at 01:00 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Alternate Administrator. Census: Licensed and Certified: 147 An exit conference was conducted on 01/27/2023 at 01:00 p.m. with the Adm. The preliminary findings were discussed. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 418.64, Conditions of Participation for Hospice Agencies.