Every finding on record at Morrow County Health District

An unannounced Federal recertification survey was completed at this agency on 8/21/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health, Part 484.102 Emergency Preparedness. An entrance conference was held on 8/12/2024 beginning at 1:40 PM with the Director and Interim Director. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and Abbreviations: CEO - Chief Executive Officer CFR - Code of Federal Regulations MSW - Medical Social Worker RN - Registered Nurse

An unannounced Federal recertification survey was completed at this agency on 08/21/2024. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director and Interim Director on 08/12/2024 at 1:40 PM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CEO - Chief Executive Officer CFR - Code of Federal Regulations HCW - Health Care Worker HHA - Home Health Agency MSW - Medical Social Worker RN - Registered Nurse TB - Tuberculosis

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on employee file review and interview, it was determined the agency failed to maintain documentation of communicable disease prevention for agency employees in its infection control program. Findings: Review of 15 employee records revealed 7 employee records (Employees #2 and #8-13) lacked documentation of a Hepatitis B vaccine offered by the Agency upon hire. During interview with the Director and Interim Director on 08/14/2024 beginning at 4:00 PM, the above findings were discussed. The Interim Director acknowledged the findings and then presented a document titled "Hepatitis B Virus Vaccine Consent/Declination" stating, "We have the form and we should be using it."

An unannounced Federal recertification survey was completed at this agency on 7/21/2021. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held with the Director on 7/13/2021 at 10:50 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CEO - Chief Executive Officer CFR - Code of Federal Regulations CNA - Certified Nursing Assistant

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(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 Hospices at §418.113(a):] 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. *[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 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):] 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. This STANDARD is not met as evidenced by: Based on interview and policy review, it was determined the agency emergency plan failed to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings: Review of the policy titled "Community Emergency/Preparedness Plan," with "PolicyStat ID: 5330238," dated "Last Revised: 02/2019," revealed under "A. Management Responsibilities:...7. Director will create, maintain, review and update annually, a community-based risk assessment, utilizing an all-hazards approach." Review of Emergency Preparedness documentation revealed the information failed to include a community-based risk assessment, utilizing an all-hazards approach. During an interview on 7/21/2021 beginning at 2:00 PM, Employee #1 confirmed the agency did not have a community-based risk assessment, utilizing an all-hazards approach specific to home health. Employee #1 stated "The hospital has one, but it is very hospital based."

An unannounced Federal recertification survey was completed at this agency on 7/21/2021. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held with the Director on 7/13/2021 at 10:50 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CEO - Chief Executive Officer CFR - Code of Federal Regulations CNA - Certified Nursing Assistant

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and policy review, it was determined the agency failed to pre-designate, in writing, a qualified person, who is authorized by the administrator and the governing body, to assume the same responsibilities and obligations as the administrator when the administrator is not available. Findings: During interview with Employee #1 on 7/13/2021, beginning at approximately 1:45 PM, Employee #1 was asked to provide information regarding who was pre-designated, in writing, to assume the responsibilities of the administrator when the administrator is not available. Employee #1 stated "I don't have that." Employee #1 indicated that he/she designates an alternate when he/she takes vacation; but the agency did not have a qualified person, approved by the administrator and governing body, pre-designated in writing to assume the administrator responsibilities if the administrator should become unavailable unexpectedly.