Every finding on record at Select Home Care LLC

42 CFR Part 484 Home Health Care The facility must meet all local, Federal and state emergency preparedness requirements as outlined in the Medicare and Medicaid programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) September 16, 2016. Deficiencies were noted at the time the survey was conducted on August 13, 2024-August 15, 2024. Megan Foster, LCSW, Compliance Officer

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, §485.542, §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 interview, review of facility policies and procedures and review of facility documentation, the Department has determined the Administrator failed to ensure the facility's emergency preparedness plan complied with all applicable local, state, and Federal emergency preparedness requirements. Failure to ensure the facility has a comprehensive emergency preparedness plan that is completely updated, trained and tested can result in staff and patient injury and/or death in the event of a facility or community emergency event. Findings include: Facility policy and document titled, "...Emergency Operations Plan and Policies...." approved December 2, 2023 revealed, "...The Agency primarily serves elderly, homebound patients. Vulnerabilities for patients may include no caregivers to provide assistance and/or no way to evacuate home safely...The Agency complies with all applicable federal, state and local emergency preparedness requirements...The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. The plan...Is based on and includes a documented, facility-based (Agency) and community-based risk assessment, utilizing an all-hazards approach...Includes strategies for addressing emergency events identified by the risk assessment...Addresses patient population...the type of services the Agency has the ability to provide in an emergency and the continuity of operations, including the delegation of authority and succession plans...Includes a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials...Mitigation activities will be undertaken...Such activities will include...The plans for patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment...Individual patient preparation...prioritizing patients who might require care/service during emergency and advanced planning for extra supplies, equipment, medications, food and home evacuation...Communication systems, including back-up systems...Conducting the Hazard Vulnerability Analysis...Assisting patients and families to develop a home emergency plan, including patients identified as having limited mobility...Educating patients and families about self-care, sources of alternate care in the community and Agency role during an emergency...Providing staff with information about developing their family's emergency response plan before an emergency...Working closely with other home health agencies and hospitals in referral areas to plan for disasters and emergency situations...preparation activities include...Staff orientation and annual training...The local community command structure is located at [this line is blank]...The agency will maintain at all times a current list of patients who evacuation...On an ongoing basis, staff will evaluate/assess such factors as transportation, evacuation and patient's medical and/or psychiatric condition, home environment and relevant healthcare information assessed in patients' individual emergency plan...At the time of admission, each patient's acuity or priority level is determined...Level 1 patients are high priority patients and include patients who require daily or more frequent skilled nursing visits. Patients with very limited mobility who live alone will also be considered high priority patients. The Agency will maintain a list of patients with acuity level established. The list will be updated weekly. Administrative person on-call maintains the current list...Patients will be responsible for replenishing their own medications and related supplies. If communication systems are in operation, nursing staff will assist patients by telephone and work with patients' retail pharmacies and/or infusion to get needed medications dispensed in order that patient/family can obtain...Agency will track patients and staff by telephone or in person during an emergency...." Attached to the referenced "Emergency Operations Plan and Policy" was a document titled, "...Individual Patient Emergency Preparedness Plan...." approved December 2, 2023. Facility policy titled, "...Agency Facility-Based and Community-Based Risk Assessment Policy...." approved December 2, 2023 revealed: "...Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually...The Hazard Vulnerability Analysis...focuses on Agency capacities and capabilities that are critical to preparedness planning...in Agency's location, considering the particular types of hazards which may most likely occur in the Agency's area...." Facility policy titled, "...Communication Plan and Policy for Emergency Operations Plan (EOP)...." approved December 2, 2023 revealed: "...The communication plan includes the following...Name and contact information for...Staff...Entities providing services under arrangement or contract...Patients' physicians (available in a printed list or computer system)...Volunteers, if applicable...Contact information for the following...Federal, state, tribal, regional or local emergency preparedness staff...A means of providing information about the general condition and location of patients under the Agency's care...The Administrator...will provide such information by telephone or in person...A means of providing information about the agency needs...to the authority having jurisdiction...The Administrator...is responsible to provide information by telephone or in person about the Agency's needs and ability to provide assistance...." Facility policy titled, "...Emergency Operations Plan (EOP) Training Program...." approved December 2, 2023 revealed: "...The Agency has developed and maintains an emergency preparedness training program that is based on the EOP, risk assessment, policies and procedures and the communication plan...The training program is reviewed and updated at least annually...The Agency will do the following...Provide initial training in emergency preparedness...to all new and existing staff, individuals providing service under arrangement and volunteers...Provide emergency preparedness training at least annually...Maintain documentation of the training...." Facility policy titled, "...Testing Program for Emergency Operations Plan (EOP)...." approved December 2, 2023 revealed: "...The Agency will conduct exercises to test the EOP at least annually....Analyze the Agency's response to and maintain documentation of all drills, tabletop exercises and emergency events...." Attached to the Facility policy was a document titled, "...Emergency Operations Plan Evaluation/Analysis...." A review of the Select Home Care Emergency Preparedness Operations Plan, Emergency Preparedness Binder, Emergency Preparedness Training and Testing records revealed the following: Documents contained within the Emergency Preparedness binder such as the Emergency On-Call Designee tree, Select Home Care Emergency Evacuation Plan, Designated Safe Refugee Area Map and Select Home Care Building Emergency Evacuation Procedures contained building information from the prior address of Select Home Care on Hayden Road in Scottsdale and for the previous management team. The Designated Safe Refugee Area Map contained a most recent date of May 2015. A facility-based HVA (hazard vulnerability analysis) was completed on June 7, 2023 and a community-based HVA was completed on January 4, 2024. The facility-based HVA was evaluated on January 5, 2024. However, neither HVAs identified any emergencies as having a risk of high impact. Only multiple staff illnesses were identified as having moderate human impact on the facility. The facility was rated as having a low ability to provide service in all emergency scenarios in both HVAs. In an interview conducted with Employee #1 on August 15, 2024, Employee #1 stated that the HVAs were not understood and had been completed incorrectly. A review of 17 (seventeen) patient records revealed that the Individual Patient Emergency Preparedness Plan included as an attachment with the "...Emergency Operations Plan and Policies...." was not completed for 17 (seventeen) patients reviewed. No contact phone numbers or documentation of efforts at collaboration or attempts to contact local, tribal, regional, state and Federal emergency preparedness officials could be found in the EP plan nor was requested documentation provided. The Other Sources of Assistance Contact Information document attached to the Communications Plan was blank and had not been completed. The Staff Contact Information and Contracted Services Information lists attached to the Communications Plan were blank and had not been completed. A patient contact list was found in the EP binder from 2019. In an interview conducted with Employee #1 on August 15, 2024, Employee #1 stated that patient contact lists are printed weekly on Tuesdays. Employee #1 was asked for a current patient contact list but Employee #1 was not able to provide one. The EOP did not contain a means of providing information about the facility's needs and ability to provide assistance to the AHJ (authority having jurisdiction). Facility policy, "...Communication Plan and Policy for Emergency Operations Plan (EOP)...." approved December 2, 2023 revealed: "...The communication plan includes the following...A means of providing information about the Agency needs, and its ability to provide assistance, to the authority having jurisdiction...The Administrator...is responsible to provide information by telephone or in person...." No further detail is provided in the Plan. Documentation of Emergency Preparedness training at hire could not be found for 10 (ten) out of 13 (thirteen) employees reviewed, Employees #1, 4, 5, 6, 7, 9, 10, 11, 12 & 13. Documentation of Emergency Preparedness training annually could not be found for 12 (twelve) out of 13 (thirteen) employees reviewed, employees #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12 &13. Copies of documentation of Emergency Preparedness drills for 2023 and 2024 were requested but could not be provided. in an interview conducted with Employee #1 on August 14 2024, Employee #1 confirmed that documentation of Emergency Preparedness drills for 2023 and 2024 could not be provided.

Deficiencies were cited during the unannounced onsite Medicare Recertification survey conducted on August 13, 2024, through August 16, 2024. State Agency recommends continued certification of this home health program. Seven (7) home visits were conducted during the survey. Appendix Z, Emergency Preparedness was surveyed at the time of the Medicare Recertification, deficiencies were cited.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and staff interviews it was determined the Home Health Agency (HHA)failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. This deficient practice has the potential that infections are not being recognized, causes evaluated, addressed, and changes implemented to decrease risks of infections posing the risk of negative and poor patient outcomes. Findings include: A review of Select policy titled, " Infection Control Committee", revealed, "... The infection control committee will oversee the Agency's infection control program...PROCEDURE 1. The Agency infection control committee is composed of: Director of Clinical Services Clinical Manager Appropriate staff representation...2. The responsibilities of the committee include: Analyzing data from infection control surveillance system... Developing, reviewing[sic] and revising infection control policies and procedures... 3. The committee will meet annually. Reports from the meetings will be forwarded to the QAPI Committee., Administrator, and Governing Body. A request was made for the infection control committee report(s) on 08/13/2024. No documentation was provided. A document titled, "Annual Infection Control Program Evaluation", was provided on 08/15/2024. An illegible signature was on the evaluation form and the "...Date..." was blank. A request was made for the names appointed to the infection control committee. No documentation was provided. A request was made for the infection control report submitted to the QAPI Committee, Administrator, and Governing Body. No documentation was provided. A request was made for the HHA's infection control program data,. Employee #1 provided a one (1) page document that contained one (1) patient name that did not give any information on follow-up of the reason(s) for the infection(s). The document was a report from the Electronic Medical Record (EMR) system. A request was made for the Quality Assessment and Improvement Program (QAPI). The QAPI program did not include infection control measures. A review of a document titled, "Meeting-Governing Body-Select", dated, 12/2/23, revealed, " Issues: - Upcoming move to Mesa -CHOI(855) for move -Staff turnover issues reducing -Rezoning needing (East Valley/West Valley) - Reduce case acceptance in Scottsdale/Ftn Hills...." No documentation of the infection control reports being reviewed or submitted was documented. In an interview conducted on 08/15/2024 with Employee #1, he/she confirmed the information provided was all of the available infection control program and QAPI program information.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interview, review of facility policies and procedures and facility documentation, the Department has determined the Administrator failed to ensure that staff who provided skilled professional services participated in agency-sponsored in-service education for 8 out of 8 skilled professional service staff reviewed, Employees #3, 5, 6, 7, 9, 10, 11 & 12. Failure to ensure that skilled professional service staff participate in agency-sponsored in-service education and documentation retained in the personnel records can result in staff not being adequately trained to provide coherent and up-to-date care to patients. Findings include: Facility policy titled, "...Inservice Education...." approved December 2, 2023 revealed: "...Certain inservice programs are determined by the Agency to be mandatory initially and annually for all staff. These include, but are not limited to...OSHA bloodborne pathogens...TB risk program...Hazardous materials in the workplace (Right-to-Know Program)...Emergency Operations Plan...Ongoing education, including inservices are provided...All inservice and education programs will be documented....." Facility policy titled, "...Contractual Staff...." approved December 2, 2023 revealed: "...Contractual staff includes employees of organizations or independent individuals who contract directly with the Agency on an hourly or other basis per visit to provide services to Agency patients according to a written agreement/contract...Personnel files will be maintained or accessible by the Agency which includes, at a minimum...Inservice education records...." A review of the personnel records for Employees #3, 5, 6, 7, 9, 10, 11 & 12 revealed no documentation of in-service trainings provided by the agency both at hire and annually according to facility policies and procedures. In a subsequent interview conducted by Employee #1 on August 14, 2024, Employee #1 confirmed that further documentation of in-service trainings could not be provided but that trainings should be documented according to facility policies and procedures.