Every finding on record at Northeast Professional Home Care, Inc

EMERGENCY PREPAREDNESS SURVEY The following deficiencies are based on the Emergency Preparedness survey completed 03/23/23.

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), §485.542(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 a review of the Emergency Preparedness Plan, review of the Hazard Risk and Vulnerabilities Assessment, and staff interview, the agency failed to ensure the risk assessment was updated as required. This had the potential to affect all patients receiving services. The agency census was 234. Review of Emergency Preparedness Plan and Administrative Policy and Procedures revealed the Hazard Vulnerability Analysis will be evaluated annually Review of the Hazard Risk and Vulnerabilities Assessment revealed it was dated 11/14/2017. Per interview on 03/22/23 at 2:10 PM, the Administrator confirmed the last dated Hazard Risk and Vulnerabilities Assessment was completed on 11/14/2017.

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), §485.542(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, REHs at §485.542, "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 a review of staff training and staff interview the agency failed to ensure all staff had training on the emergency preparedness plan. This affected 103 of 138 staff members (Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O, Staff P, Staff Q, Staff R, Staff S, Staff T, Staff U, Staff V, Staff W, Staff X, Staff Y, Staff Z, Staff AA, Staff BB, Staff CC, Staff DD, Staff EE, Staff FF, Staff GG, Staff HH, Staff II, Staff JJ, Staff KK, Staff LL, Staff MM, Staff NN, Staff OO, Staff PP, Staff QQ, Staff RR, Staff SS, Staff TT, Staff UU, Staff VV, Staff WW, Staff XX, Staff YY, Staff ZZ, Staff AAA, Staff BBB, Staff CCC, Staff DDD, Staff EEE, Staff FFF, Staff GGG, Staff HHH, Staff III, Staff JJJ, Staff KKK, Staff LLL, Staff MMM, Staff NNN, Staff OOO, Staff PPP, Staff QQQ, Staff RRR, Staff SSS, Staff TTT, Staff UUU, Staff VVV, Staff WWW, Staff XXX, Staff YYY, Staff ZZZ, Staff AAAA, Staff BBBB, Staff CCCC, Staff DDDD, Staff EEEE, Staff FFFF, Staff GGGG, Staff HHHH, Staff IIII, Staff JJJJ, Staff KKKK, Staff LLLL, Staff MMMM, Staff NNNN, Staff OOOO, Staff PPPP, Staff QQQQ, Staff RRRR, Staff SSSS, Staff TTTT, Staff UUUU, Staff VVVV, Staff WWWW, Staff XXXX, Staff YYYY, Staff ZZZZ, Staff AAAAA, and Staff BBBBB). This had the potential to affect all patients receiving services. The agency’s census was 234. Review of the Emergency Preparedness Plan and Administrative Policy and Procedures revealed ongoing staff education and training will occur as part of an exercise or in response to an actual emergency. Review of the NEPHC Annual Competency Self Learning Packet revealed 103 (Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O, Staff P, Staff Q, Staff R, Staff S, Staff T, Staff U, Staff V, Staff W, Staff X, Staff Y, Staff Z, Staff AA, Staff BB, Staff CC, Staff DD, Staff EE, Staff FF, Staff GG, Staff HH, Staff II, Staff JJ, Staff KK, Staff LL, Staff MM, Staff NN, Staff OO, Staff PP, Staff QQ, Staff RR, Staff SS, Staff TT, Staff UU, Staff VV, Staff WW, Staff XX, Staff YY, Staff ZZ, Staff AAA, Staff BBB, Staff CCC, Staff DDD, Staff EEE, Staff FFF, Staff GGG, Staff HHH, Staff III, Staff JJJ, Staff KKK, Staff LLL, Staff MMM, Staff NNN, Staff OOO, Staff PPP, Staff QQQ, Staff RRR, Staff SSS, Staff TTT, Staff UUU, Staff VVV, Staff WWW, Staff XXX, Staff YYY, Staff ZZZ, Staff AAAA, Staff BBBB, Staff CCCC, Staff DDDD, Staff EEEE, Staff FFFF, Staff GGGG, Staff HHHH, Staff IIII, Staff JJJJ, Staff KKKK, Staff LLLL, Staff MMMM, Staff NNNN, Staff OOOO, Staff PPPP, Staff QQQQ, Staff RRRR, Staff SSSS, Staff TTTT, Staff UUUU, Staff VVVV, Staff WWWW, Staff XXXX, Staff YYYY, Staff ZZZZ, Staff AAAAA, and Staff BBBBB) out of 138 staff members had not been trained on their emergency preparedness plan. An interview on 03/22/23 at 2:22 PM with the Director of Nursing confirmed 103 staff had not been trained on the emergency preparedness plan.

Partial Extended Recertification Survey Substantial Allegation Survey Substantial Allegation 95825 The following deficiencies are based on the partial extended standard recertification survey completed on 03/23/23. No deficiencies were cited in regard to the allegations contained in substantial allegation 95825, completed on 03/23/23.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observation, policy review, patient interview, and staff interview, the agency failed to ensure the medications taken by the patient matched the current medication profile. This affected two (#11 and #12) out of five patients reviewed with home visits. The census was 234. 1) Review of the record revealed Patient #11 had a start of care (SOC) of 02/23/23 with a primary diagnosis of cerebral infarct (stroke). A skilled nurse completed the SOC assessment and medication profile on 02/23/23. Listed on the plan of care (POC) and medication profile was atorvastatin calcium 40 milligrams (mg) oral. Observations during a home visit with Staff B on 03/21/23 at 9:30 AM revealed the atorvastatin calcium was not found in the home. Interview with Patient #11 on 03/21/23 at 9:40 AM revealed she has not taken this medication since her stroke and was not taking it with the start of care (02/23/23). Staff B was present during this conversation. 2) Review of the medical record revealed Patient #12 had a SOC of 03/14/23 with a primary diagnosis of congestive heart failure (CHF). Review of the medication profile and POC for Patient #12 revealed Trusopt 2 % (glaucoma medication) ophthalmic drops one drop three times per day. Observations during a home visit on 3/21/23 at 11:30 AM revealed the prescription in the home indicated the Trusopt was only administered twice a day. A second ophthalmic solution of Rocklaton (glaucoma medication) labeled give one drop to each eye once per day was present in the home. Interview with the caregiver (Patient #12's son) at the time of the home visit revealed the Trusopt drops are only given twice per day. Patient #12's son verified the Rocklaton eye drops have been given since the SOC. Staff C was present during this verification. Review of the agency policy titled “Medication, Regimen Review Comprehensive,” Revision date 08/2022, revealed at the time of admission an accurate, current and complete list of all prescriptions and over the counter medications, taken by the patient will be maintained on the medication profile. The findings of not having an accurate list of medications for Patient #11 and Patient #12 on the POC and medication profile was verified with the Director of Nursing on 03/21/23 at 3:00 PM.