Every finding on record at Florida Nurses Home Health Agency Inc

During the recertification survey conducted on 02/27/2024 to 02/29/2024 at Florida Nurses Home Health Agency Inc., a Home Health Agency, Emergency Preparedness was reviewed. Florida Nurses Home Health Agency Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 02/27/2024 to 02/29/2024 at Florida Nurses Home Health Agency Inc. The home health agency was in non-compliance with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

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 provider is unable to demonstrate a completed discharge summary for 2 out of 5 Sampled Patients (SP). Sp#4 and SP#5. Findings include: The surveyor performed closed record reviews of Sample Patient (SP) #4 and SP#5 on 02/27/2024 to 02/29/2024. SP#4 contained a discharge summary for the agency with a discharge date of 12/07/2023; and SP#5 contained a discharge summary from the agency with a discharge date of 02/16/2024. The discharge summaries omitted the admission and discharge dates, physician responsible for care, reason for admission to home health, type of services provided and the frequency, laboratory data (if applicable), medications on at the time of discharge, discharge condition, patient outcomes in meeting the goals in the plan of care and patient and family post-discharge instructions. The surveyor conducted an interview with the Director of nursing and administrator on 02/29/2024 at 12:30pm and they acknowledged that the summaries for SP#4 and SP#5 were incomplete, missing the required notations as previously mentioned.

During the recertification survey conducted on 02/23/2021 to 02/25/2021 at Florida Nurses Home Health Agency Inc., a Home Health Agency, Emergency preparedness was reviewed. Florida Nurses Home Health Agency Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies. The following is a description of the non-compliance:

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to develop and maintain an emergency preparedness plan that is based on and include a documented, facility-based and community-based risk assessment, utilizing an all hazards approach and that include strategies for addressing the emergency events identified by the risk assessment. Findings include: Record review conducted on 02/25/2021 at 10:00 AM revealed no documentation showing that the agency had developed and maintained an emergency preparedness plan that is based on and include a documented, facility-based and community-based risk assessment, utilizing an all hazards approach and that include strategies for addressing all the emergency events identified by the risk assessment. During a telephone interview conducted on 02/25/2021 at 1:26 PM, the Alternate Administrator/owner acknowledged that the agency did not develop a federal emergency preparedness plan utilizing an all hazards approach and that include strategies for addressing all the emergency events identified by the risk assessment.

Development of EP Policies and Procedures CFR(s): 484.102(b) (b) Policies and procedures. [Facilities] 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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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 These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to develop and implement federal emergency preparedness policies and procedures. Findings include: Record review conducted on 02/25/2021 at 10:00 AM revealed no documentation showing that the agency had developed and implemented policies and procedures based on its federal emergency preparedness plan. During a telephone interview conducted on 02/25/2021 at 1:27 PM, the Alternate administrator/owner acknowledged that the agency did not develop and implement emergency preparedness policies and procedures based on its emergency plan.

EP Training and Testing CFR(s): 484.102(d) *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to develop an emergency preparedness training and testing program that is based on its emergency preparedness, that included strategies and procedures on the identified risks. Findings include: Review of Staff A, Staff B, Staff C and Staff D's personnel files conducted on 02/24/2021 revealed the agency did not develop a federal emergency preparedness training and testing program that is based on its emergency plan that included strategies and procedures on the identified risks. During a telephone interview conducted on 02/25/2021 at 1:30 PM, the Alternate Administrator/owner acknowledged the above findings.

EP Training Program CFR(s): 484.102(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 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 Home Health Agency failed to conduct training on its emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement consistent with their expected roles. Findings include: Review of Staff A, Staff B, Staff C and Staff D's personnel files conducted on 02/24/2021 revealed no documentation that the agency tested the employees' knowledge of its federal emergency preparedness plan based on their expected/respective roles during an emergency. During a telephone interview conducted on 02/25/2021 at 1:32 PM, the Alternate Administrator/owner acknowledged that Staff A, Staff B, Staff C and Staff D's records contained no documentation that the agency tested the employees' knowledge of its federal emergency plan based on their expected/respective roles during an emergency.

An extended recertification survey was conducted on February 23, 2021 to February 25, 2021 at Florida Nurses Home Health Agency Inc. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency failed to organize, manage, and provide Skilled Nursing (SN) services as required; the Home Health Agency failed to provide 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) directly. Refer to (G982).

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 interview and record review, the Home Health Agency failed to provide 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) directly. Findings include: Record review conducted on 02/22/2021 revealed the agency documented the following direct services on its most recent licensure application: skilled nursing, physical therapy, medical social services, home health aide and certified nursing assistant. During a telephone interview conducted on 02/23/2021 at 10:15 AM, the office manager stated that they did not have any active patients. During an interview conducted on 02/23/2021 at 11:30 AM, the Alternate Administrator/owner stated they don't have any active patients currently and that the last time the agency provided patient care was in July of 2020. Review of Sampled Patient (SP)#1 revealed the patient was admitted on 01/08/2020 and discharged on 07/20/2020. Review of SP#2's record revealed the patient was admitted on 01/18/2020 and discharged on 07/24/2020. Review of SP#3's record revealed the patient was admitted on 02/12/2020 and discharged/transferred to the hospital on 07/21/2020. During a second interview conducted on 02/25/2021 at 12:19 PM, the Alternate Administrator/owner stated "We don't have any patients since July 24th, 2020. I am putting everything together to do a grand opening. I just started with integrate, we should have patients soon. The patients are refusing the nurses, they don't want anybody in their homes."