Every finding on record at The Evangelical Lutheran Good Samaritan Society

An unannounced Federal recertification survey was completed at this agency on 5/5/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held with the Administrator and Clinical Nursing Supervisor on 4/26/2022 at 10:50 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments. Definitions and abbreviations: CFR - Code of Federal Regulations

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and review of documentation, it was determined that the facility failed to provide a communication plan that included an updated list with staff contact information. Findings: On 5/4/2022, review of document titled "Home and Community Based Services Emergency Management Plan," last updated: 4/05/2021, revealed a section titled "B. Direction and Control." This section lists "who is in charge during an emergency" and "the chain of command to ensure continuous authority." Two individuals, not listed on the current list of employees were identified in this document. Review of document titled "Home and Community Based Services Emergency Management Plan," last updated: 4/05/2021, revealed the statement, "List must be updated every time there is a change in staff/leadership ... phone tree which is updated every 3 months or as needed as staff leaves [sic] or is hired." On 5/4/2022 at 12:12, the Administrator verified that the two individuals listed in the section "B. Direction and Control" were previous employees who no longer worked at the agency.

An unannounced Federal recertification survey was completed at this agency on 5/5/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held on 4/26/2022 at 10:50 AM with the Administrator and the Clinical Nursing Supervisor. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers, and comments. Definitions and abbreviations: CFR - Code of Federal Regulations CM - Case Manager MR - Medical Record PCP - Primary Care Physician SOC - Start of Care

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and medical record review, it was determined the agency failed to perform communication with physician involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care for 1 of 12 active patient medical records reviewed (Patient # 2). Findings: Review of the medical record for Patient #2 with a SOC date of 4/4/4022, revealed a document titled "Home Health Certification and Plan of Care," dated 04/04/22. Under the "Assessment" section of this document it is noted, "Client possibly suffering from delusions of grandeur and paranoia. CM will update PCP on current mental status." The "Communication" section of this document lacked documentation that CM notified physician. During interview with Employee # 2 on 5/4/2022 at 09:34 AM, he/she stated "I did contact the Physician, but I don't know if I charted anything about it. They were aware of the patient's mental status." During interview with the Administrator on 5/4/2022 at 10:55 AM, he/she stated, "I looked through the patient record and did not find any additional information about the physician being notified."