Every finding on record at Sterling Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/20/25. Standard level deficiencies 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 a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 06/17/25 at 2:00 PM. The Plan lacked documentation that the Plan was based on a facility-based and or community-based risk assessment, utilizing an all-hazards approach. 2. Findings of the Agency's Emergency Preparedness Plan lacking documentation that the Plan was based on a facility and or community risk assessment, was confirmed during an interview with the Administrator and Agency Supervisor on 06/18/25 at 11:30 AM.

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 the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to provide training of Emergency Preparedness Plan to Agency's staff at least every two years. Findings include: 1. The Emergency Preparedness Plan was reviewed on 06/17/25. The Plan lacked documentation indicating that Agency's staff received training on the Emergency Preparedness Plan since 2022 (at least every two years). 2. During an interview with the Administrator and Agency Supervisor on 06/18/25 at 11:30 AM, finding of the Agency failing to provide staff training was confirmed.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 06/20/25. Standard level deficiencies cited. Abbreviations: OASIS = Outcome and Assessment Information Ste.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 710 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days, resulting in a warning. Findings include: 1. The Error Summary report for 06/17/24 to 06/17/25, was reviewed on 06/17/25. The report included an error for 369 of 710 submissions of OASIS assessments (51.97%) were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator and Agency Supervisor on 06/18/25 at 11:30 AM the Administrator confirmed the late submissions.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: AM = Morning PM = Afternoon SOC = Start of Care Pt./Pts. = Patient/Patients

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: A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 4 of 7 (Pts. #1, 5, 6 and 4) clinical record reviewed. 4. Pt. #4 SOC: 1/3/22 Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record of Pt. #4 was reviewed on 3/15/22 at 2:45 PM. The record included documentation of a form titled “Notice of Medicare Non-Coverage” form that had been signed by Pt. #4, but not completed by Agency staff. The form contained several fill-ins the blank areas that had been left blank. 6. The findings of the incomplete clinical records were confirmed with the Administrator and Agency Supervisor on 3/16/22 from 1:00 PM to 2:00 PM. Findings include: 1. Pt. #1. SOC 12/29/21. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 3/15/22 at 12:30 PM. The record contained a "Notice of Medicare Non-Coverage" document. The sections "The Effective Date Coverage of... Current Services Will End" and the description of services that Medicare probably will not pay for, were left blank. This document was signed by the Pt., and dated 12/29/21, which was the SOC date. 2. Pt. #5. SOC 2/8/22. Primary Diagnosis: Other Spondylosis, Thoracolumbar Region. The clinical record was reviewed on 3/15/22 at 1:30 PM. The record contained a "Notice of Medicare Non-Coverage" document. The sections "The Effective Date Coverage of... Current Services Will End" and the description of services that Medicare probably will not pay for, were left blank. This document was signed by the Pt., but not dated. 3. Pt. #7. SOC 7/19/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. The clinical record was reviewed on 3/16/22 at 11:40 AM. The record contained a "Notice of Medicare Non-Coverage" document. The sections "The Effective Date Coverage of... Current Services Will End" and the description of services that Medicare will not pay for, were left blank. This document was signed by the Pt. and dated 7/19/22, which was the SOC date. During an interview with the Administrator and Director of Nursing on 3/16/22 at 1:15 PM, the Director of Nursing stated that the document should be provided to the Pt. at least one week prior to discharge from Agency and should be signed and dated at that time.