Every finding on record at Regency Home Health, LLC

Regency Home Health was Surveyed on 7/26/23 pursuant to the Emergency Preparedness regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual Appendix Z - 484.102 Rev 204, issued 4/16/21

A health recertification survey was conducted from 7/25/23 to 7/26/23 pursuant to 42 CFR Part 484 for Home Health Agencies with deficiencies cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to ensure that home visits were in conformance with physician orders for 1 patient in a survey sample of 13 patients (Patient Identifier is #2). Findings Include: Review on 7/25/23 of Patient #2's Home Health Certification and Plan of Care for the certification period of 12/28/23 to 3/27/23 revealed a physician's order for a Home Health Aide (HHA) / Licensed Nursing Assistant (LNA) 6 visits per week for 12 weeks for assistance with activities of daily living (ADLs). Review on 7/25/23 of Patient #2's schedule calendar revealed the following: -For the week of 2/17/23 through 2/25/23, there were 5 HHA visits. On 2/23/23 it was documented that the employee canceled and the visit was not made up on another day. -For the week of 2/26/23 through 3/4/23, there were 2 HHA visits (on 3/2/23 and 3/3/23). On 3/1/23 and 3/4/23 it was documented that the employee cancelled and was not made up another day. -For the week of 3/12/23 through 3/18/23, there were 5 HHA visits. On 3/14/23 it was documented that the employee canceled and the visit was not made up on another day. Review on 7/25/23 of Patient #2's medical record revealed no documentation that the physician had been notified of the above missed visits. Interview on 7/26/23 at 1:30 p.m. with Staff A (Administrator) and Staff B (Clinical Supervisor) confirmed that Patient #2 did not get the ordered visits and the physician was not notified. Review on 7/26/23 of the facility's policy "Notification to Physician Regarding Missed Visits" dated 2018, revealed, "... Policy: A missed visit is an alteration in the plan of care; therefore the physician must be notified... III. A missed visit which cannot be rescheduled shall be documented and communicated to the physician..."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the home health agency failed to ensure that Registered Nurse (RN) supervisory visits were performed no less frequently than every 14 days for 1 of 6 patient records reviewed for supervisory visits (Patient identifier is #2). Findings Include: Review on 7/25/23 of Patient #2's Home Health Certification and Plan of Care for the certification period of 12/28/23 to 3/27/23 revealed a physician's order for a Home Health Aide (HHA) / Licensed Nursing Assistant (LNA) 6 visits per week for 12 weeks for assistance with activities of daily living (ADLs). Further review revealed an order for a skilled nurse to visit weekly for 12 weeks. Review on 7/25/23 of Patient #2's schedule calendar revealed that on 1/24/23 the RN made a supervisory visit to observe and assess the HHA. Review on 7/25/23 of Patient #2's Home Health Certification and Plan of Care for the certification period of 3/28/23 to 6/25/23 revealed a physician's order for a HHA / LNA 6 visits per week for 12 weeks for assistance with ADLs. Further review revealed an order for a skilled nurse to visit weekly for 12 weeks. Review on 7/25/23 of Patient #2's medical record revealed no supervisory visits documented from 3/26/23 through 6/25/23. Review on 7/25/23 of Patient #2's Home Health Certification and Plan of Care for the certification period of 6/26/23 to 9/23/23 revealed a physician's order for a HHA / LNA 6 visits per week for 12 weeks for assistance with ADLs. Further review revealed an order for a skilled nurse to visit weekly for 12 weeks. Review on 7/25/23 of Patient #2's medical record revealed no supervisory visits were documented from 06/26/23 through 7/25/23. Interview on 7/26/23 at 1:20 p.m. with Staff A (Administrator) and Staff B (Clinical Supervisor) confirmed the above findings. Review on 7/26/23 of the facility's policy "Home Health Aide Supervision" revised March 2018, revealed, "...To assure the appropriateness of home health aide services and to maintain quality of care... 1. If Home Health Aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care and the written patient care instructions must make an onsite visit to the patient's home no less frequently than every 14 days. The Home Health Aide does not have to be present during the visit... 2. If Home Health Aide services are provided to a patient who is not receiving skilled nursing care... the registered nurse will make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care..."

Regency Home Health was surveyed 01/27/2021 pursuant to The Emergency Preparedness regulations as referenced in the Centers for Medicare and Medicaid State Operation Manual Appendix Z- Rev 186 Issued 03/04/19, with deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review of the E.P.P. (Emergency Preparedness Program) and interview, it was determined that the facility failed to update the E.P.P. to reflect the current location of the main office. Findings include: Review of the E.P.P. on 1/27/21 between 8:30 a.m. and 1:00 p.m. with Staff A (Administrator) and Staff B (CEO) revealed the facility failed to review and/or revise the E.P.P. to reflect the Londonderry office location for the continuity of operations (COOP). Facility documents provided in the existing E.P.P. specify the Continuity of Operations Plan Maintenance and states "The COOP plan should be reviewed, revised, and updated as necessary as a result of any of the following events: * A major incident * A change in operational resources (ex. policy, personnel, organizational structures, management processes, facilities, and/or equipment) * A formal update of planning guidance or standards * A change in elected officials * Each activation * Major exercises * A change in the demographics or threat/hazard profile for the jurisdiction in which Regency is located * A change in the acceptability of various laws, ordinances, policies, etc. at the federal, state, or local level * A change in CMS rules, regulations, Conditions of Participation The Facility's current location failed to be included and the Manchester location was confirmed as a training site. Interview on 1/27/21 with Staff A and Staff B confirmed the above findings and that the facilities recent relocation had not yet been updated in the E.P.P.

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 record review of the E.P.P. (Emergency Preparedness Plan) and interview, it was determined that the facility failed to incorporate a facility based and community based risk assessment for the new facility location. Findings include: Review of the E.P.P. on 1/27/21 between 8:30 a.m. and 1:00 p.m. with Staff A (Administrator) and Staff B (CEO) revealed the facility failed to conduct a facility specific risk assessment and review a community based risk assessment for the new facility location to identify potential; natural disasters, man-made disasters, or facility based disasters that have the ability to interfere with the normal supply of essential client service's. Interview on 1/27/21 with Staff A and Staff B confirmed the above findings and indicated the new facility location has only been in use 3-4 months.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review of the E.P.P. (Emergency Preparedness Program) and interview, it was determined that the facility failed to update the E.P.P. with any local emergency official's contact information to reflect the new facilities location. Findings include: Review of the E.P.P. on 1/27/21 between 8:30 a.m. and 1:00 p.m. with Staff A (Administrator) and Staff B (CEO) revealed that local emergency officials contact information was limited to the previous northern New Hampshire facility's location and failed to be currently updated. Interview on 1/27/21 with Staff A and Staff B confirmed the above findings and have not yet updated the E.P.P. to reflect the current facility's location.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review of the E.P.P. (Emergency Preparedness Program) and interview, it was determined that the facility failed to ensure that agreements with other health care services are arranged to ensure continuity of care in the communities served in southern New Hampshire. Findings include: Review of the E.P.P. on 1/27/21 between 8:30 a.m. and 1:00 p.m. with Staff A (Administrator) and Staff B (CEO) revealed that all the facility's agreements with other health care service's for the continuity of care are all located in northern New Hampshire and fail to reflect agreements for continuity of care within the southern New Hampshire communities being served. Interview on 1/27/21 with Staff A and Staff B confirmed the above findings and have not yet updated the E.P.P. to reflect the facility's current location.

A Health Recertification Survey was conducted on 1/26/21 through 1/27/21 pursuant to 42 CFR Part 484 for Home Health Agencies with no deficiencies cited.