Every finding on record at Pernet Family Heatlh Services

A Recertification survey was conducted at Pernet Family Health Services, located at 237 Millbury Street, Worcester, MA, 01610 on 6/11/24 and 6/12/24 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance. Deficiencies were cited.

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 document review and staff interview, the agency failed to ensure the Emergency Preparedness (EP) plan that included a facility-based and community-based risk assessment, utilizing an all-hazards approach and strategies for addressing emergency events identified by the risk assessment, had been updated every two years as required. Findings include: A review of the agency's EP plan indicated an undated All-Hazards Risk Assessment. During an interview on 6/11/24 at 11:25 A.M., the Executive Director said the All-Hazards Risk Assessment was developed in May 2022, but had not been updated since, as required.

A recertification survey was conducted at Pernet Family Services, located at 237 Millbury Street, Worcester, MA 01610, on 6/11/24 and 6/12/24 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the initial assessment visit was completed either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner ordered start of care date for 5 Patients (#1, #4, #5, #6, and #7), out of a total sample of 7 patients. Findings include 5. Patient #5 was admitted to the agency in August 2023 due to poor growth, height and oral intake. Review of the clinical record indicated a referral was received by the agency on 7/20/23. Further review of the clinical record indicated an initial assessment visit was completed on 8/2/23, and not within the required 48 hours. During an interview on 6/12/24 at 12:45 P.M., Nurse #1 said the initial assessment visit was completed on 8/2/23 and not within 48 hours, as required. 1. Patient #1 was admitted to the agency in June 2024. Review of the clinical record indicated the patient was referred to the agency on 6/3/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 6/11/24, not within 48 hours of the referral, as required. 2. Patient #5 was admitted to the agency in April 2024. Review of the clinical record indicated the patient was referred to the agency on 4/16/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 5/10/24, not within 48 hours of the referral, as required. 3. Patient #6 was admitted to the agency in February 2024. Review of the clinical record indicated the patient was referred to the agency on 2/7/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 2/15/24, not within 48 hours of the referral, as required. 4. Patient #7 was admitted to the agency in March 2024. Review of the clinical record indicated the patient was referred to the agency on 3/7/24. Further review of the clinical record indicated the initial assessment was completed by the RN on 3/25/24, not within 48 hours of the referral, as required. During an interview on 6/12/24 at 11:20 A.M., the Executive Director (ED) said she was aware the initial assessments were not being done timely, and they should have attempted to do them within the required 48 hours.,

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to ensure the comprehensive assessment was updated within the last 5 days of the last 60 certification period for one Patient (#6), out of total sample of 7 patients. Findings include: Patient #6 was admitted to the agency in February 2024 for skilled nursing services. Review of the clinical record indicated an initial comprehensive assessment was completed on 2/15/24 and a physician's order was obtained on 2/15/24, for skilled nursing services once a week for 6 weeks, then once every other week, through 4/15/24. Review of the clinical record indicated the patient was seen by a nurse on 5/3/24. Further review of the clinical record indicated the comprehensive assessment had not been updated during the last 5 days of the certification period of 2/15/24 through 4/15/24. During an interview on 6/12/24 at 12:05 P.M., the Executive Director said the comprehensive assessment for Patient #6 had not been updated, as required.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care for two Patients (#4 and #6), out of a total sample of 7 patients. Findings include: 2. Patient #4 was admitted to the agency in August 2023 due to poor growth, height and oral intake. Review of the clinical record indicated a signed Physician order for weekly skilled nursing home visit for weight check for 60 days, from 8/2/23 through 10/25/23. Review of the weekly home visits indicated there was no weekly home visit provided from 10/1/23 through 10/7/23 and 10/8/23 through 10/14/23. During an interview on 6/11/24 at 3:40 P.M., Nurse #1 said she received an email from the physician on 9/27/23 to change the weekly home visits to monthly visits, but she failed to write the order and send it to the physician for signature, as required. 1. For Patient #6, the agency failed to obtain a new physician's order for skilled nursing services, after the initial physician's order plan of care. Patient #6 was admitted to the agency in February 2024 for skilled nursing services. Review of the clinical record indicated an initial comprehensive assessment was completed on 2/15/24 and a physician's order was obtained on 2/15/24, for skilled nursing services once a week for 6 weeks, then once every other week, through 4/15/24. Review of the clinical record indicated the patient was seen by a nurse on 5/3/24. Further review of the clinical record indicated no additional physician orders for skilled nursing visits after 4/15/24. During an interview on 6/12/24 at 12:05 P.M., the Executive Director said the skilled nursing visit on 5/3/24 should not have been provided as there was not a physician's order allowing the visit.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure complete and appropriately authenticated, dated, and timed documentation for one Patient (#6), out a total sample of 7 patients. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. Findings include: Patient #6 was admitted to the agency in February 2024 requiring skilled nursing services. Review of a nursing Request for Discharge order, dated 4/24/24, indicated a planned discharge from the agency for 5/3/24. Further review of this order indicated it had not been signed and dated by the physician. During an interview on 6/12/24 at 12:20 P.M., Nurse #1 said the discharge order for Patient #6 was faxed to the physician for a signature as required, but the agency did not ensure a signed and dated order was returned.

An Emergency Preparedness Survey was conducted during the recertification survey at Pernet Family Health Services, Inc, from 10/5/21 through 10/6/21. The agency did not meet the Conditions of Participation for Emergency Preparedness, and the following deficiencies were cited.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on staff interview, the agency failed to meet the §483.475 (Emergency Preparedness) requirements for Home Health Agencies and did not establish and maintain a comprehensive Emergency Preparedness (EP) program that met all of the standards specified within the Conditions of Participation for the EP program. Findings include: During an interview on 10/6/21 at 1:30 P.M., the ED said the agency had not developed any EP program including the following required elements: -Written policies and procedures based on the agency's and community-based risk assessment, utilizing an all-hazards approach. -A process for collaboration with local, tribal, regional, State and Federal emergency preparedness officials. -A process for providing care to patients during an emergency. -Documentation of individualized emergency plans for each patient. -A communication plan including critical contact information and processes to share clinical information. -An EP training program including initial and yearly staff training and participation in emergency preparedness drills. During an interview on 10/6/21 at 2:00 P.M., the ED said the agency had not developed any policies and procedures for emergencies that are required in the Condition of Participation of the EP program.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure that seven Patients (#1, #2, #3, #4, #5, #6 and #7) out of a total sample of seven patients, had individualized emergency preparedness plans included in the clinical record. Findings include: Review of Patients' #1, #2, #3, #4, #5, #6 and #7 clinical records indicated there was no documented evidence that an individual emergency preparedness plan was part of each record. During an interview on 10/5/21 at 2:45 P.M., the Clinical Nurse Manager said she verbally reviewed emergency preparedness, but it was not individualized and documented in each patient's clinical record. During an interview on 10/6/21 at 1:30 P.M., the Executive Director said the agency did not develop individualized emergency plans for any of the patients.

A recertification survey was conducted at Pernet Family Health Services, Inc. from 10/5/21 through 10/6/21. At this time, the Agency was found to be in substantial compliance with the Federal Conditions of Participation Governing Home Health Agencies.