Every finding on record at Suky Hlth Care Svcs Inc

During the recertification survey conducted on 10/11/22 to 10/12/22 at Suky Health Care Services, Inc. a Home Health Agency, Emergency Preparedness was reviewed. Suky Health Care Services, Inc. is not compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies (HHAs). The following is a description of the non-compliance:

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 record review and interview, the provider failed to demonstrate that all existing staff have received training on the emergency preparedness training at least every 2 years and maintain documentation of all emergency preparedness training for 3 out of 6 active staff. (Staff A, Staff C and Staff E) Findings include: Review of the emergency preparedness plan conducted on 10/12/22 showed documentation present for in-service dated 11/15/21 with outline titled “Emergency Preparedness and Response”. Further record review revealed no documentation to show that 3 out of 6 active staff (Staff A, Staff C and Staff E) participated in the in-service. During an interview conducted on10/12/22 at 12:54 pm, the Assistant Administrator acknowledged that the (3) active staffs providing home health aide services did not received the in-service from the provider on date 11/15/21.

A recertification survey was conducted on 10/11/22 to 10/12/22 at Suky Health Care Services, Inc. The home health agency was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies. The following is a description of the non-compliance:

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that 5 out of 6 active staff (Staff A, Staff B, Staff C, Staff D and Staff E) received annual in-service on infection control. Findings include: Personnel record review conducted on 10/12/22 revealed the Home Health Agency provided infection control education in-service(s) on 12/15/21 and 02/16/22 to its employees. Further review revealed no documentation to show that Staff A, Staff B, Staff C, Staff D and Staff E participated in the infection control education in-service(s). During an interview conducted on10/12/22 at 12:55 pm the Assistant Administrator acknowledged that the (5) active staffs providing home health aide services have not received infection control education in-service from the provider. The Assistant Administrator stated that if the name of the employee is not present on the sign in sheet, then they must have not come in to receive the in-service and will need to schedule them to receive the in-service.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must 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. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to ensure that the Registered Nurse (RN) conducted a supervisory visit of the Home Health Aide (HHA) while the HHA is providing patient care, no less frequently than every 60 days, who is not receiving skilled care service in 4 out of 10 Sample Patients (SP). SP#5, SP#6, SP# 8 and SP#9 Findings include: Clinical records review was conducted on 10/11/22 to 10/12/22 of SP#5, SP#6, SP# 8 and SP#9. Further review revealed that SP#5, SP#6, SP# 8 and SP#9 are patients actively receiving home health aide services for assistance with personal care. Review of SP#5 documentations revealed the registered nurse last supervisory visits were conducted on 08/03/22 and then on 10/03/22, which is an interval of 61 days. Review of SP#6 documentations revealed the registered nurse last supervisory visits were conducted on 08/03/22 and then on 10/04/22, which is an interval of 62 days. Review of SP#8 documentation revealed the registered nurse last supervisory visit was on 08/08/22 and as of 10/11/22 no further supervisory visit noted, which is an interval of 64 days. Interview conducted with the Registered Nurse Supervisor on 10/11/22 at 3:30 pm confirmed that the supervision for SP#8 has not been done and needs to be done this week. Review of SP#9 documentations revealed the registered nurse last supervisory visits were conducted on 08/03/22 and then on 10/04/22, which is an interval of 62 days. The Assistant Administrator, Director of Nursing and Registered Nurse Supervisor on 10/12/22 at 1:45 pm acknowledged findings made by the surveyor, the provider failed to perform an on-site 60-day supervision.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: This CONDITION is not met as evidence by: Based on interview, facility record review and clinical record review, it was determined that the Home Health Agency (HHA) failed to have skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis; and failed to show that services were provided by direct employees (G982). The effect of the systemic practice resulted in the agency's inability to ensure that the patient's skilled care needs would be met.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to have skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis. Findings include: Review of the licensure application dated 12/28/21 revealed the agency chose (2) Nursing and (1) Home Health Aide and (1) Certified Nursing Assistant as the direct service. On 10/11/22 at 10:25 am the Assistant Administrator stated that they are not providing skilled nursing service, stating “it’s been a while since last case.” On 10/11/22 at 10:48 am the Assistant Administrator provided the active patient list and confirmed only providing non-skilled services.

A Complaint Survey for complaint #2021010042 was conducted on August 11, 2021 at Suky Health Care Services Inc. The Home Health Agency was not in compliance with 42 CFR 484 Subpart A-C requirements for Home Health Agencies.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to coordinate care delivery to meet the patient's needs for 1 out of 3 Sampled Patients (SP). SP#3 Clinical record review of SP#3 conducted on 08/11/21 revealed the patient was admitted on 04/26/21 and was receiving homemaking services Monday thru Friday. Review of the clinical record revealed documentation of missed visits for scheduled dates 06/28/21, 06/29/21, 06/30/21, 07/05/21 and 07/16/21. Telephone interview conducted with the Home Health Aide (staff assigned to provide care to SP#3) on 08/11/21 at 1:17 pm stated that she provided service on 06/28/21, 06/29/21 and 06/30/21 but since she submitted the documentation late, the office staff did not accept the notes and therefore were documented as missed visits. The Home Health Aide added that she did not provide care to SP#3 on 07/05/21 because she was sick and on 07/06/21 she was still sick, but the agency sent another staff to cover. The Home Health Aide stated that on 07/16/21 she was scheduled to make the visit to SP#3 at 4:30 pm but that she called the SP#3's caregiver at 4 pm to inform that she was not going to make the visit. The Home Health Aide acknowledged that she only called the SP#3's caregiver and did not inform the agency of the missed visit. Interview conducted with SP#3's caregiver on 08/11/21 at 1:30 pm confirmed that Home Health Aide missed visit on 07/05/21 and 07/16/21. Interview conducted with the Assistant Administrator on 08/11/21 at 1:52 pm stated that the Home Health Aide reported of no visits made as per SP#3's family request on 06/28/21, 06/29/21 and 06/30/21. The Assistant Administrator provided documentation that no visit was made on 06/28/21, 06/29/21 and 06/30/21 as reflected on the insurance software system. The Assistant Administrator then stated that on 07/16/21 the SP#3's caregiver called to inform the agency that Home Health Aide called him and informed him that she could not make the visit. The Assistant Administrator clarified that the Home Health Aide on 07/05/21 did not notify the agency of being sick and therefore did not make the visit, once on 07/06/21 that the aide again could not make the visit, the SP#3's called the office on 07/06/21 to request someone else to cover for the Home Health Aide. The Assistant Administrator stated that again on 07/16/21 the Home Health Aide had not called the agency to notify that she could not make the visit, the SP#3's caregiver called the office to inform of the missed visit.