Every finding on record at Sunrise County Home Care Services, LLC

Recertification Survey Survey Dates: 04/16/2024, 04/17/2024, and 04/23/2024 Sunrise County HomeCare Services, a Home Health Agency, is not in compliance with 42 Code of Federal Regulations 482.22, Condition of Participation: Emergency Preparedness. Conditional Level Deficiencies Identified: §484.102 CoP: Emergency Preparedness The following requirements have not been met:

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 document reviews and interviews, it was determined that the Condition of Participation for Emergency Preparedness was not met as the agency failed to ensure that the Emergency Preparedness Plan was reviewed and updated every year and that all policies and procedures were updated and reviewed every two (2) years. Findings: 1. Standard: §484.102(a) also known as E-0004 - Based on document reviews and interviews, agency staff failed to ensure that the Emergency Preparedness Plan was reviewed and updated every year. See findings under E-0004 for details. 2. Standard: §484.102(b) also known as E-0013 - Based on document reviews and interviews, the facility failed to ensure that all policies and procedures were updated and reviewed every two (2) years. See findings under E-0013 for details. The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.

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), §485.542(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 document reviews and interviews, it was determined that the agency failed to ensure the Emergency Preparedness Plan was updated and reviewed annually. Findings include: A review of the Healthways/Regional Medical Center at Lubec/Sunrise County Homecare Services policy dated 10/26/2017 states in part, ..."SCHS'S Emergency Preparedness Plan (EPP) is fully integrated with HealthWays/Regional Medical Center at Lubec's (HW/RML) Emergency Preparedness Plan (EPP), however this policy outlines procedures unique to SCHS". The review of the HealthWays/Regional Medical Center at Lubec Emergency Preparedness Plan revealed that it was last updated and reviewed in 2019. On 4/16/2024 at 12:11 PM, an interview was conducted with the Senior Human Resources Director and the Administrator, who confirmed that the Emergency Preparedness Plan had not been updated and reviewed since 2019. .

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on document reviews and interviews, it was determined the agency failed to ensure that Emergency Preparedness policies and procedures were updated at least every two (2) years. Findings include: A review of the Healthways/Regional Medical Center at Lubec/Sunrise County Homecare Services policy dated 10/26/2017, stated in part ..."SCHS'S Emergency Preparedness Plan (EPP) is fully integrated with HealthWays/Regional Medical Center at Lubec's (HW/RML) Emergency Preparedness Plan (EPP), however this policy outlines procedures unique to SCHS". A review of the Healthways/Regional Medical Center at Lubec policy Emergency Preparedness Management last reviewed 3/31/2021, stated in part..."The purpose of this policy is to ensure that Healthways/Regional Medical Center at Lubec (HW/RMCL) and its employees has access to information that prepares them to react to emergencies and disasters that occur within HW/RMCL facilities and communities it serves...The Emergency Preparedness Committee (EPC) is responsible for evaluating and maintaining the Emergency Preparedness Plan". On 4/16/2024 at 12:20 PM, an interview was conducted with the Senior Human Resources Director and the Clinical Manager, and it was confirmed that the Emergency Preparedness policies and procedures had not been reviewed and updated since 2017 and 2021.

Federal Recertification Survey Survey Dates: 04/16/2024, 04/17/2024, and 04/23/2024 Sunrise County Homecare Services, a Home Health Agency, is in substantial compliance with 42 Code of Federal Regulations Part 484.22 Conditions of Participation.

Federal Recertification Survey Survey Dates: 8/2/2021- 8/4/2021 Sunrise County Home Care Services, a Home Health Agency, is in substantial compliance with 42 Code of Federal Regulations Part 484.22 Condition of Participation: Emergency Preparedness.

Federal Recertification Survey Surey Dates: 8/2/2021 - 8/4/2021 Sunrise County Home Care Services, a Home Health Agency, is in substantial compliance with 42 Code of Federal Regulations Part 484.22 Conditions of Participation. However, the following standard level requirement was not met:

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to implement the United States Centers for Disease Control ("US CDC's") recommendations for Coronavirus Disease 2019 ("COVID-19") in relation to a screening process and visual alerts. These failures have the potential to affect agency staff and homebound patients. Findings: 1. The US CDC's "Interim Infection Prevention and Control Recommendation for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 11/4/2020, 2/10/2021 and 2/23/2021, states, "Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the healthcare facility is assessed for symptoms of COVID-19...". The US CDC's "Symptoms of Coronavirus" states "people with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness...People with the following symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea". The agency's "COVID-19 SCREENING QUESTIONNAIRE", dated 5/28/2021, stated the following: "1. Have you experienced any of the following symptoms in the past 48 hours? Fever or chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, and nausea, vomiting or diarrhea". On 8/3/2021 and 8/4/2021, surveyors entered the facility and the only screening consisted of temperature taking and surveyors were given a mask to wear. Based on the review of the questionnaire and the surveyors not being asked the questions, the agency failed to ensure a process was in place to screen for all symptoms of COVID-19. 2. The US CDC's "Interim Infection Prevention and Control Recommendation for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 11/4/2020, 2/10/2021 and 2/23/2021, states, "Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the healthcare facility is assessed for..., or exposure to others suspected or confirmed SARS-CoV 2 infection...". On 8/2/2021 and 8/3/2021 at 9 AM, the surveyors entered the agency thru two (2) doors and then proceeded to the COVID-19 screening station. Outside the second door there was hand sanitizer. The screener provided a mask and took the temperature of both surveyors. No screening questions were asked, and the surveyors were not asked to sanitize their hands. On 8/3/2021 at 1:15 PM, the Administrator was interviewed. It was explained to her that when both surveyors entered the facility on 8/3/2021 and 8/4/2021, no questions were asked related to COVID-19. The Administrator stated, "That surprises me. Staff and all visitors are supposed to be asked questions at the door". Based on the review of the questionnaire being utilized by the facility and the screening process the surveyors encountered on 8/3/2021 and 8/4/2021, the agency failed to ensure a consistent process was in place to ensure that individuals entering their facility were assessed for exposure to others suspected or confirmed SARS-CoV 2 infection. 3. The US CDC's "Interim Infection Prevention and Control Recommendation for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic", updated 11/4/2020, 2/10/2021 and 2/23/2021, states, "Post visual alerts (e.g. signs, posters) at entrances and strategic places (waiting areas, elevators, and cafeterias) to provide instructions (in appropriate languages) about ... how and when to perform hand hygiene". On 8/2/2021, 8/3/2021, and 8/4/2021, the surveyors observed no visual alerts related to how and when to perform hand hygiene posted at the front entrance or in the vestibule where individuals were before entering the waiting area. On 8/4/2021 at 2:30 PM the Administrator was informed about the lack of visual alerts about how and when to perform hand hygiene. She stated that those alerts used to be there.