Every finding on record at Faith Health Care Inc

During the recertification survey conducted on 05/09/2023 to 05/11/2023 at Faith Health Care Inc., a Home Health Agency, Emergency Preparedness was reviewed. Faith Health Care Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

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 record review and interview, the provider failed to demonstrate that an initial training in emergency preparedness policies and procedures was provided to all new and existing staff consistent with their expected roles and provide emergency preparedness training at least every 2 years thereafter for 6 out of 10 sample active staff. (Staff D, Staff E, Staff F, Staff G, Staff H, and Staff I) Findings include: On 05/10/23 the Director of Nursing was informed to provide the documentation for the most recent staff training to be presented on 05/11/23 for review. On 05/11/23 personnel files were reviewed for 10 samples of active staff. Review of the personnel files revealed no documentation of receiving initial training upon hire for Staff F and further review revealed established staffs’ personnel files omitted documentation of receiving emergency preparedness training at least every 2 years thereafter for Staff D, Staff E, Staff G, Staff H, and Staff I. Interview with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM. The Intake Coordinator acknowledged the provider was not able to demonstrate Staff D, Staff E, Staff F, Staff G, Staff H, and Staff I received emergency plan training as required.

A recertification survey was conducted on 05/09/2023 to 05/11/2023 at Faith Health Care Inc. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the provider failed to ensure that a review of all medications the patient is taking in 2 out of 3 Sampled Patients (SP) with home visits done. (SP#1 and SP#2) Findings include: During a home visit made to SP#1 on 05/10/23 at 11:24 AM the surveyor reviewed medications taken by SP#1 in presence of the Director of Nursing. The Medication Profile and Plan of Care (POC) for certification period 03/22/23 to 05/20/23 had the following discrepancies found: -Rosuvastatin Calcium Oral 5 mg 1 tablet daily (as per POC). The label on the bottle stated 20 mg as of 03/30/23. -Metformin oral 1000 mg 1 tablet daily (as per POC). The label on the bottle stated morning and afternoon as of 03/30/23. During a home visit made to SP#2 on 05/11/23 the surveyor reviewed medications taken by SP#2 in presence of the Registered Nurse (Staff B) and Intake Coordinator. The Medication Profile and Plan of Care for certification period 03/07/23 to 05/05/23 omitted the medications Benadryl, Acetaminophen and Percocet. Interview conducted with the SP#2 on 05/11/23 at 9:06 AM stated that she takes over the counter medications Benadryl as needed, Acetaminophen for headache as needed and Percocet for severe pain when needed. Interview with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM confirmed findings that there was failure of the provider to document all the medications the patients are taking.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the provider’s staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 2 out of 3 Sampled Patients (SP) with home visits made. (SP#1 and SP#2) Findings include: During a home visit made to SP#1 on 05/10/23 at 11:11 AM with Director of Nursing (DON) present, surveyor observed the Licensed Practical Nurse (Staff A) donned on clean gloves to remove old dressing from the right foot plantar aspect ulcer wound. Using the same pair of dirty gloves, surveyor observed at 11:13 am Staff A entered nursing bag to obtain individualized gauze pack, then at 11:14 am using same dirty pair of gloves the Staff A cleansed the wound with normal saline and pat dry using the individualized gauze packed. Review of the clinical record of SP#2 contained a Plan of Care that reads "SN (skilled nurse) check preparation and administration insulin inject subcutaneous. Following infection control measures, aseptic technique, universal precautions always rotating the site where is injected and proper disposal of sharps into a sharp’s container". During home visit made to SP#2 with Intake Coordinator present on 05/11/23 at 8:55 AM the surveyor observed the Registered Nurse (Staff B) administer insulin to SP#2’s abdomen area. At 8:58 AM the surveyor observed Staff B recapped the tip of the insulin pen, removed it, and placed in sharp container. Interview conducted with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM acknowledged that Staff A and Staff B failed to maintain infection control.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that 5 (Staff A, Staff B, Staff F, Staff G, and Staff K) out of 13 active staff received annual in-service on infection control. Findings include: Record review revealed the home health agency provided infection control education in-service on 01/16/23 to 01/18/23 to its employees. Further record review revealed no documentation to show that 5 out of 13 active staff (Staff A, Staff B, Staff F, Staff G and Staff K) participated in the infection control education in-service. Interview with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM acknowledged the provider is not able to demonstrate Staff A, Staff B, Staff F, Staff G and Staff K received infection control education in-service from the provider.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of a Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 5 personnel file review. (Staff H) Findings include: Personnel files review conducted on 05/11/23 revealed Staff H is a Home Health Aide with a Date of Hire of 03/15/2022. Further review of the Staff H personnel record contained a titled document "Home Health Aide Competency Test" undated that omitted documentation distinguishing between skills evaluated during patient care and those in a laboratory/office setting. Interview conducted with the Human Resource Staff on 05/11/23 at 12:54 PM. Human Resource Staff reviewed the undated form in Staff H personnel record and stated the form is the initial competency. Further observation made by the Human Resource Staff confirmed the document has no date of completing the form.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 7 Sample Patients (SP). (SP#2) Findings include: Clinical record review of active SP#2 conducted on 05/09/23 to 05/11/23 revealed the patient receives Skilled Nursing (SN) and Home Health Aide (HHA) services provided by the Home Health Agency. The provider failed to demonstrate that HHA supervisions were conducted every 14 days from last documented supervision(s) dated 03/20/23 and 04/17/23 which is an interval of 28 days. Interview with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM confirmed findings that provider is unable to demonstrate that aide supervisions were conducted every 14 days for the SP#2.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to have skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are provided directly through agency employees. Findings include: A review of the provider's most recent licensure application dated 12/19/22 revealed that Nursing service would be provided by direct employees. A review of the last paycheck information provided by the Director of Nursing revealed that all the nurses were not direct employees, federal taxes were not withheld from (1) Licensed Practical Nurse and (1) Registered Nurse. On 05/10/23 at 1:20 PM, the Director of Nursing and Human Resource Staff acknowledged the findings and stated that the (2) nurses do not have federal taxes withheld and are independent contractors.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed discharge summary for 2 out of 7 Sampled Patients (SP). (SP#6 and SP#7) Findings include: Closed record reviews of SP#6 and SP#7 were conducted on 05/11/23. The SP#6 contained a discharge summary from the agency with a discharge date 02/27/23; and SP#7 contained a discharge summary from the agency with a discharge date 03/09/23. The discharge summaries for SP#6 and SP#7 omitted information such as listing the reason for admission to home health; omits the type of services provided and frequency of services; omits any Lab data (as applicable); and omits a complete summary of care/outcomes in meeting the goals in the Plan of Care. Interview with the Intake Coordinator on 05/11/23 from 1:55 PM to 2:27 PM acknowledged the provider is not able to demonstrate a completed discharge summaries for SP#6 and SP#7.