Every finding on record at Multicultural Community Services of Pioneer Valley

An Emergency Preparedness survey was conducted at Multicultural Community Services from 12/2/21 through 12/3/21 for compliance with § 484.22 Emergency Preparedness for Home Health Agencies (HHA's) and the following deficiency were cited:

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on policy review and interview, the agency did not ensure the emergency preparedness (EP) plan included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other healthcare providers to maintain the continuity of care during an emergency. Findings include: Review of the agency's EP plan indicated there were no procedures indicating how an individual patient's medical information would be communicated to entities receiving the patient evacuated during an emergency. During an interview on 12/3/21 at 2:00 P.M., the Executive Director said, after reviewing the EP plan, it did not specify the agency's procedures to communicate evacuated patients' medical information to entities receiving them.

A recertification survey was conducted at Multicultural Community Services from 12/2/21 through 12/3/21 for compliance with the Federal Conditions of Participation Governing Home Health Agencies and the following deficiencies were cited:

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document a clinical note related to physician notification for one Patient (#7) out of a total sample of seven patients reviewed. Findings include: Patient #7 was admitted to the agency in August 2020 with a diagnosis of Cerebral palsy (brain damage typically caused before or at birth). Review of the physician's order, certification period 10/21/2021 through 12/19/21, indicated an order to change the patient's Gastronomy Tube (G-tube, a tube surgically placed into the stomach for feeding and medication delivery) every three months. Record review indicated the last time the patient's G-tube was changed was 8/5/21. During a home visit on 12/3/21 at 10:00 A.M., the surveyor asked Nurse #1 when the last time the patient's G-tube was changed. Nurse #1 looked at a calendar that was in the patient's room and said 8/5/21. The surveyor asked if she was aware that there was a physician's order to change the G-tube every three months. Nurse #1 said she was aware, but she was not the Patient #7's primary nurse, and was told by the primary nurse that there was an insurance issue related to obtaining the G-tube. The surveyor asked if the physician was notified related to the G-tube not being changed as ordered. Nurse #1 said she did not know. During an interview on 12/3/21 at 1:05 P.M., the Executive Director (ED) said that the patient's primary nurse had notified the physician on two different occasions related to not being able to change the G-tube as ordered. The ED said that the discussions with the physician should have been documented in the clinical record but she was not able to find any documentation.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff communicated with the physician when unable to maintain the plan of care for one Patient (#2) out of total sample of seven patients. Findings include: Patient #2 was admitted into the agency in July 2020. Review of the plan of care dated 2/6/21 through 4/6/21, indicated the following physician order: Continuous Skilled Nursing: Total for 131 hours with up to 20 hours per week (provided by the home health agency). Review of the clinical record indicated the patient received nursing services on 2/8/21 for eight hours, 2/15/21 for eight hours, 2/22/21 for eight hours, 3/8/21 for eight hours, and 4/2/21 for one hour. Further review of the clinical indicated record nursing had not notified the patient's physician of missed skilled nursing services. During an interview on 12/3/21 at 1:05 P.M., the Clinical Manager and the Executive Director said the physician had not been notified by the agency's staff that the skilled nursing services were not provided as ordered from 2/6/21 through 4/6/21.