Every finding on record at Tachiinii Nursing Services, Inc

42 CFR 484.102 Home Health The facility must meet all applicable Federal, State and local 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. The following deficiencies were noted at the time of the survey conducted on October 19, 2022-October 20, 2022.

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), §485.625(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 review of the agency's emergency preparedness plan and interview conducted on October 20, 2022, it was determined that the agency failed to maintain annual updates of the emergency preparedness plan. The failure to conduct an annual update to the plan could increase hazards to the patients and staff through a lack of knowledge of available resources. Findings Include: The emergency preparedness plan was requested for review. The plan from 2019-2020 was presented. The Alternate Administrator was interviewed on October 20, 2020 and stated that the plan was last reviewed in 2020 during the pandemic and had not been updated since that time. Failure to review and update emergency preparedness increases the potential risks to patients and personnel in the event of an actual emergency.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's emergency plan and Administrator interview conducted on October 19, 2022, it was determined that the agency's plan failed to incorporate the use of volunteers. The failure to incorporate the use of volunteers could lead to poor outcomes for patients in the event that additional resources are needed for assistance. Findings Include: The review of the agency emergency plan revealed that volunteers were not incorporated into the plan. The interview with the Administrator confirmed that the agency's plan did not include the use of volunteers.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on the review of the agency's emergency drills and Administrator interview conducted on October 19, 2022 it was determined that the agency failed to conduct any drills since COVID 19 began in March of 2020. The failure to conduct drills and ensure that agency staff have been educated on emergency procedures increases the likelihood of risks during an actual event. Findings Include: The emergency preparedness plan and drills were requested and provided for review. The last drill was noted to have been conducted in March of 2020. The Administrator interview conducted on October 19, 2022, revealed that the last drill was the actual full scale emergency event that took place on the reservation during the COVID 19. The Administrator stated that the agency had not documented the event very well, due to the lock down and devastation that was experienced on the reservation. The failure to have a tested emergency plan increases the probability of poor outcomes related to patient care and available resources.

The following deficiencies were cited at the time of the unannounced onsite Medicare Recertification survey conducted October 19, 2022 through October 20, 2022. One home visit was conducted. Appendix Z Emergency Preparedness was surveyed, and deficiencies were cited.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on agency policy and procedure, Administrator interview and the lack of data presented for review, it was determined that the agency had failed to evaluate quality data for the past 12 months. The failure to identify patterns or trends in the delivery of care increases the risk for substandard quality of care to patients. Findings Include: The agency policy and procedure entitled "Quality Management" revealed "...The agency will establish and maintain an ongoing Quality Assessment and Performance Improvement (QAPI) Program comprised of a system of measures that captures significant outcomes that are essential to optimal care and are used in the care planning and coordination of services and events. The QAPI committee is appointed by the Administrator and approved by the governing body. The Director of Nursing is responsible for the day-to-day QI (Quality Improvement) activities...." The Administrator confirmed during interview on October 19, 2022, that he/she had not collected or reviewed quality data for the past 12 months. He/ she further stated that the agency had only served 2 patients during the past 12 months and that the Navajo Nation was still under strict COVID 19 restrictions. The past twelve months of QAPI data was requested at the time of the recertification survey and none was provided.