Every finding on record at Mount Auburn Home Health

During the recertification survey conducted on 03/04/2024 to 03/06/2024 at Mount Auburn Home Health, a Home Health Agency, Emergency Preparedness was reviewed. Mount Auburn Home Health 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 03/04/2024 to 03/06/2024 at Mount Auburn Home Health. The home health agency was in non-compliance with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for home health agencies.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to have written service schedules provided to the patient in 1 out of 5 Sampled Patients (SP). SP#4 Findings include: The surveyor conducted closed record review on 03/02/2024 to 03/06/2024 for 1 out of 5 Sampled Patients (SP) SP#4. The surveyor's review of SP#4's clinical record revealed the agency failed to provide a written visit schedule to the patient that is consistent with the Plan of Care. The Surveyor conducted an interview with Director of Nursing and Administrator on 03/06/2024 from 12:30pm to 1:15pm. They acknowledged that SP#4's service agreement omitted the schedule of nursing visits as listed in the Plan of Care.

During the recertification survey conducted on 03/15/2021 to 03/17/2021 at Mount Auburn Home Health, a Home Health Agency, Emergency preparedness was reviewed. Mount Auburn Home Health 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:

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 reviews and interview, the Home Health Agency failed to document staff testing based on emergency plan on 6 out of 6 staff. Staff C, D, E, F, G, and H. Findings include: Personnel record review of Staff C, date hired 9/20/17; Staff D, date hired 11/21/2012; Staff E, date hired 10/10/13; Staff F, date hired 11/8/17; Staff G, date hired 12/9/12; and Staff G, date hired 11/16/15 showed no documentation that their knowledge on emergency preparedness were tested. On 3/17/2021 at 12:40 PM, the Director of Nursing stated about the testing portion of the emergency preparedness education and training: " we don't do a writing test. I do the training class to discuss the emergency preparedness." The Administrator stated on 3/17/2021 at 12:40 PM that: "Every employee is given a pamphlet regarding for example the pandemic. (name of the DON) talks to them. The employees will ask questions. Their answer is not written; not documented." There were no written testing completed by every employee. Record review of the Home Health Agency's 10/26/ 2018 Emergency/ Disaster Plan Training for Staff C, D, E, F, G, and H revealed Emergency Manual/ Plan reviewed only. There were no documentation showing their knowledge were tested.

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 reviews and interview, the Home Health Agency failed to document staff knowledge of emergency procedures on 6 out of 6 staff. Staff C, D, E, F, G, and H. Findings include: Personnel record review of Staff C, date hired 9/20/17; Staff D, date hired 11/21/2012; Staff E, date hired 10/10/13; Staff F, date hired 11/8/17; Staff G, date hired 12/9/12; and Staff G, date hired 11/16/15 showed no documentation that their knowledge on emergency preparedness were tested. On 3/17/2021 at 12:40 PM, the Director of Nursing stated about the testing portion of the emergency preparedness education and training: " we don't do a writing test. I do the training class to discuss the emergency preparedness." The Administrator stated on 3/17/2021 at 12:40 PM that: "Every employee is given a pamphlet regarding for example the pandemic. (name of the DON) talks to them. The employees will ask questions. Their answer is not written; not documented." There were no written testing completed by every employee. Record review of the Home Health Agency's 10/26/ 2018 Emergency/ Disaster Plan Training for Staff C, D, E, F, G, and H revealed Emergency Manual/ Plan reviewed only. There were no documentation showing their knowledge were tested.

A recertification survey was conducted on March 15, 2021 to March 17, 2021 at Mount Auburn Home Health. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that a Registered Nurse (RN) or other appropriate skilled professional made an annual on-site visit to the location where a patient is receiving care in order to observe and assess a Home Health Aide (HHA). Staff A Finding include: Review of Staff A's personnel file revealed the employee was hired on 06/29/2015 as an HHA. Further review of Staff A's file revealed a form titled "Annual Evaluation year 2017" which was completed on 07/03/2017. Additional review of Staff A's file revealed no documentation that a Registered Nurse (RN) or other appropriate skilled professional made an annual on-site visit to the location where a patient is receiving care in order to observe and assess the HHA subsequent to the annual evaluation which was completed on 07/03/2017. During an interview conducted on 03/16/2021 at 2:45 PM, the Administrator acknowledged that Staff A's file did not contain documentation showing that a Registered Nurse (RN) or other appropriate skilled professional made an annual on-site visit to the location where a patient is receiving care in order to observe and assess the HHA since 07/03/2017.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure 2 out of 10 Sampled Patients (SP)'s record contained all the clinical notes for the services rendered by the Physical Therapist (PT). SP#2 and SP#3 Findings include: 1) Review of SP#2's record revealed the patient was admitted on 02/23/2021. Further review of SP#2's record revealed the physician ordered Physical Therapy (PT) and Occupational Therapy (OT) evaluations on 02/22/2021. Additional review of SP#2's Plan of Care (POC) for the certification period of 02/23/2021 to 04/23/2021 revealed no documentation that the agency completed the PT evaluation nor that the SP#2 is receiving services from the agency. During an interview conducted on 03/15/2021 at 11:20 AM, the Administrator acknowledged that SP#2's record contained no documentation demonstrating that the PT evaluation was completed nor that the patient is receiving services from the agency. On 03/15/2021 at 11:22 AM, the Administrator stated the physical therapist has not brought the notes yet. 2) Review of SP#3's record revealed the patient was admitted on 02/05/2021. Further review of SP#3's Plan of Care (POC) for the certification period of 02/05/2021 to 04/05/2021 revealed the following order: "PT: 1 WK1, 2WK6, 1WK1". Additional record review revealed the initial PT evaluation was completed on 02/05/2021. Continued review of SP#3's record revealed no documentation showing that the agency provided PT services after 02/05/2021. During an interview conducted on 03/15/2021 at 12:44 PM, the Administrator acknowledged that SP#3's contained no documentation showing that the agency provided PT services after the initial PT evaluation on 02/05/2021.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to include in the patient's current assessment, including all of the assessments from the most recent home health clinical notes such as "Infusion/ IV site": IV site, IV tubing change, cap change, IV site dressing change infusion by, infusion med, infusion rate, and plans of care of patient for 1 out of 10 Sampled Patients (SP). (SP#7). Findings include: Review of "Skilled Nursing Progress Note" for SP # 7 on dates: 2/8/2021 through 2/13/2021 showed "Infusion/ IV site": IV site, IV tubing change, cap change, IV site dressing change infusion by, infusion med, infusion rate, infusion well tolerated by pt items were not marked. Review of patient's "Plan of Care"on page 5 of 8, showed patient has a double lumen PICC line in place on right arm and will be receiving IV (Intravenous) Vancomycin, Mycamine and Cefepime. Additional PICC line care included flushing and changing of caps. these were not indicated on "Infusion/ IV site". At around 2:00 PM on 3/17/2021, the Administrator, and the Director of Nursing acknowledged above findings and showed "Skilled Nursing Progress Note" for SP # 7 on dates: 2/8/2021 through 2/13/2021 with those items marked with "X". Review of the Home Health Agency's policy "Guidelines for Maintenance of Peripheral IV sites and Central Lines" showed site change by Registered Nurse only but does not include frequency of site care or site dressing change. Interview with the DON on 3/17/2021 at 2:10 PM revealed PICC (Peripheral Intravenous Central Catheter) site dressing change should be every 7 days. With these information, review of the "Skilled Nursing Progress Note" for SP # 7 on dates: 2/8/2021 through 2/20/2021 showed no documentation that PICC line site care or dressing change were done.