Every finding on record at Hedgemark Brentwood Medical Services, Inc.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted from 10/18/2021 to 10/21/2021. Based on observations, record reviews, interviews, and review of the HHA's EPP, it was determined the HHA’s EPP had one standard level deficiency.

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 record review and interview, the agency failed to provide documentation of staff knowledge for emergency procedures in eight out of eight employee records reviewed [Administrator, Physical Therapist (PT)#1, PT#2, Medical Social Worker (MSW), Occupational Therapist (OT), RN#1, RN#2, and Speech Therapist (ST)]. On 10/21/2021 from 9:24 AM to 9:36 AM, a review of personnel files revealed no documentation of staff knowledge for Emergency Preparedness Training for the Administrator, PT#1, PT#2, MSW, the OT, RN#1, RN#2, and the Speech Therapist. This finding is verified by the Office Manager on 10/21/2021 at 9:36 AM and the Administrator on 10/21/2021 at 10:58 AM.

A survey of the Home Health Agency (HHA) in conjunction with a COVID-19 focused Infection Control Survey was conducted from 10/18/2021 to 10/21/2021. Based on observations, record reviews, interviews, and review of the HHA’s policy and procedures, it was determined the HHA had a standard level deficiency from the Recertification Survey but was in compliance with the COVID - 19 focused Infection Control requirements.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency staff failed to document measurable goals for all goals listed on the plan of care in 8 out of 13 records reviewed (Patient #1, #2, #4, #7, #9, #11, #12, and #13). Patient #7 On 10/18/2021 at 3:04 PM, a review of Patient #7’s chart reveals the plan of care does not have all goals measurable (physical therapy evaluation will be performed and occupational evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 9:04 AM. Patient #9 On 10/19/2021 at 9:02 AM, a review of Patient #9’s chart reveals the plan of care does not have all goals measurable (demonstrate measures to prevent skin breakdown, physical therapy evaluation will be performed, and occupational evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 8:59 AM. Patient #11 On 10/20/2021 at 1:34 PM, a review of Patient #11’s chart reveals the plan of care does not have all goals measurable (demonstrate measures to prevent skin breakdown). This finding is verified by the Administrator on 10/21/2021 at 8:53 AM. Patient #12 On 10/20/2021 at 2:01 PM, a review of Patient #12’s chart reveals the plan of care does not have all goals measurable (occupational therapy evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 8:51 AM. Patient #13 On 10/20/2021 at 2:17 PM, a review of Patient #13’s chart reveals the plan of care does not have all goals measurable (physical therapy evaluation will be performed and occupational therapy evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 8:40 AM. Patient #4 On 10/20/2021 at 3:00 PM, a review of Patient #4’s chart reveals the plan of care does not have all goals measurable (physical therapy evaluation will be performed and occupational evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 9:14 AM. Patient #2 On 10/20/2021 at 3:37 PM, a review of Patient #2’s chart reveals the plan of care does not have all goals measurable (physician therapy evaluation will be performed and occupational therapy evaluation will be performed). This finding is verified by the Administrator on 10/21/2021 at 9:11 AM. Patient #1 On 10/20/2021 at 3:51 PM, a review of Patient #1’s chart reveals the plan of care does not have all goals measurable (demonstrate measures to prevent skin breakdown). This finding is verified by the Administrator on 10/21/2021 at 9:17 AM.