Every finding on record at Foundation for Senior Living Home Health Agency

Emergency Preparedness HHA 42 CFR 484.102 Home Health The facility must meet all applicable Federal, State and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. The following deficiencies were cited at the time of the survey conducted on August 30, 2022 through August 31, 2022.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] 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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of agency policy, patient information on emergency profile, and interview with the Programs Administrator, it was determined, the agency failed to address patient/client population, including, but not limited to, persons at risk. The failure to document and specify the unique vulnerabilities of patients at risk prior to an emergency or disaster increases the potential for adverse outcomes during an actual event . Findings Include: The agency policy entitled, Disaster Planning and Protocol Home Health (last documented to be reviewed 4/28/2021), contained "...Client Education: All clients admitted service are to be educated on need for Disaster Planning...(review at time of recertification for continued accuracy and/or need for update) Emergency Plan to be completed on admission by admitting clerk or professional staff: ...Responsible and Local Emergency Contact #(number) and relationship, location of where they will take in event of an emergency...hospital preference...specific comments or addtional information....Administrator will...identify patient's needing assistance by Acuity Codes...identify clinical need to determineif can go to shelter or needs hospitalization and or medical support...." Seven medical records were reviewed. Seven out of seven failed to contain the name of the hospital preferred by the patient. The Programs Administrator was interviewed on August 31, 2022 and confirmed the findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness documents, and staff interviews, it was determined that the facility failed to ensure that the communication plan was updated every two years per regulation requirements to include a list of the vital contacts and their contact information, as evidenced by names of employees and entities no longer working for the organization, and no volunteers which poses increased communication failure and a risk to patients during an actual emergency. Findings include: The review of the agency's emergency preparedness policy, plan and drills revealed that the agency had not updated the lists of contacts since August of 2019. The interview with the Programs Administrator conducted on August 31, 2022 confirmed this finding.

The following deficiencies were found at the time of the unannounced onsite Medicare Recertification survey conducted August 30, 2022 through August 31, 2022. One home visit was conducted. Emergency Preparedness- Appendix Z (E Tags) was also surveyed and Standard level deficiencies were found.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on the agency's policy, lack of quality data reporting after March of 2021 and interview with the agency's Programs Administrator, it was determined that the agency's Governing Body failed to maintain organizational managerment and direct the Quality Assurance data collection and reporting for the agency. Findings Include: The agency policy and procedure entitled "Quality Assurance and Performance Improvement-QAPI" contained "...The agency strives to provide quality health care services to all clients and ensures that these services are established and carried out by staff and that quality is a priority for the agency as a whole. The Governing Body will analyze and track quality indicators of performance to adequately assess its services and processes...Our governing body approves the frequency and level of detail to be used in data collection...The agency maintains documented evidence of the QAPI program...The agency will focus quality assessment efforts including data collection on high priority safety and health conditions and other goals as identified and identify opportunities for improvement...." The QAPI data and reports were requested for review on August 30, 2022. A report entitled Q3 (01/01/2021-03/31/2021) Report Home Health was presented on August 31, 2022 for review. There were no addtional reports presented for review. The quality data for the organization was requested and presented for review on August 30, 2022. The report was named Q3 (1/1/2021-3/31/2021) Report Home Health. The Healthcare Compliance Officer (HCO) was told that there were no addtional QAPI reports for viewing. The Programs Administrator (PA) stated during interview on August 31, 2022, that there were no additional QAPI reports and that the QAPI Coordinator had left in May of 2021, and that no comprehensive data, had been collected and evaluated since that time. The PA further stated that the agency had undergone reorganization in June of 2021 and that the governing body had not conducted an annual meeting since May 21, 2021. The agency transferred a total of 35 patients to other agencies in June of 2021 at the time of the reorganization, leaving the agency with 1 patient on service as of this writing.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on agency policy, lack of documentation submitted, and interview, it was determined that governing body failed to direct and ensure overall management of the agency's quality assessment and performance improvement program. The failure to direct and report on the agency's quality program increases potential risk for harm to patient's by not identifying potentially avoidable events. Findings Include: The agency policy and procedure entitiled "Quality Assurance and Perfomance Improvement-QAPI" contained "...The agency strives to provide quality helath care services to all clients and ensures that these services are established and carried out by staff and that quality is a priority for the agency as a whole. The Governing Body will analyze and track quality indicators of performance to adequately assess its services and processes...Our governing body approves the frequency and level of detail to be used in data collection...The agency maintains documented evidence of the QAPI program....The agency will focus quality assessment efforts including data collection on high priority safety and health conditions and other goals as identified and identify opportunities for improvement...." The QAPI data and reports were requested for review on 08/30/2022. On 08/31/2022, a report entitled Q3 (01/01/2021-03/31/2021) Report Home Health was presented for review. The Programs Administrator stated during interview that there was no additonal QAPI documentation.