Every finding on record at Spectrum Home Health and Hospice Care, Inc

An Emergency Preparedness survey was conducted at Spectrum Home Health Center from 10/26/21 through 10/27/21 for compliance with § 484.22 Emergency Preparedness for Home Health Agencies (HHA's) and the following deficiency was cited:

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), §485.625(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, "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 policy review and interview the agency failed to provide initial training in emergency preparedness policies and procedures for new staff consistent with their expected role. Review of the agency's Emergency Operations Plan Training Program, no date, indicated; - The agency will do the following; provide initial training in emergency preparedness policies and procedure to all new staff consistent with their expected roles. During an interview on 10/27/21 at 2:00 P.M., the Executive Director said that the agency had not provided emergency preparedness training for new employees.

A recertification survey was conducted at Spectrum Home Health Center from 10/26/21 through 10/27/21 for compliance with the Federal Conditions of Participation Governing Home Health Agencies and the following deficiency was cited:

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to maintain required items in the clinical records. Specifically, the agency failed to included complete clinical notes related to the measurements of wounds for two Patients (#4 and #1) out of a total sample of seven patients. Findings include: 2. For Patient #1, the facility failed to document weekly wound measurements. Patient #1 was admitted to the agency in August 2021. Review of the readmission nurse's note, dated 10/10/21, indicated the patient had three left lower leg wounds. Further review of the note indicated there was no documented measurements for the three wounds on the left lower extremity. Review of nurse's notes, dated 10/11/21 and 10/15/21, indicated wound measurements were undocumented. During an interview on 10/27/21 at 3:00 P.M., the ED said, after reviewing the note dated 10/11/21 and 10/15/21, the documentation was incomplete and should have included wound measurements. Review of the agency's Basic Wound Care policy, dated 2/10/16, indicated: Observed wound and document weekly; size; length, width and depth. 1. For Patient #4, the agency failed to document wound measurements on a weekly basis. Patient #4 was admitted to the agency September 2021. Review of the admission assessment, dated 9/21/21, indicated the resident had three wounds; - Right shin wound that measured 0.3 centimeters (cm) x 6.5 cm x 0.1 cm., - Left knee wound that measured 0.2 cm x 4.4 cm x 0.1 cm. and - Right calf wound that measured 2.3 cm x 2.0 cm.. Review of the nurse's note, dated 9/30/21, indicated the right calf wound had healed. In addition, there were measurements for the right shin and left knee wounds. Review of the nurse's notes, dated 10/3/21, 10/6/21, 10/9/21, 10/11/21, 10/14/21 and 10/19/21 indicated there were no documented measurements for the wounds to the patient's right shin or left knee. During an interview on 10/26/21 at 2:05 P.M., the Executive Director (ED) said that she had reviewed the nurse's notes and could not find any further measurements for the wounds. The ED said, all wounds needed to be measured weekly and the measurements needed to be documented in the clinical record. During an interview on 10/27/21 at 10:15 A.M. with Nurse #1, she said she was the nurse that cared for Patient #4. She said she should have measured and documented wound measurements on a weekly basis, but did not.