Every finding on record at VNA of Franklin

Franklin VNA & Hospice was surveyed on 7/24/24 pursuant to the Emergency Preparedness regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR part 484.102 Appendix Z - Rev. 204, HHA Issued: 4/16/21 with no deficiencies cited.

A Health Recertification Survey was conducted from July 23, 2024, through July 24, 2024, pursuant to 42 CFR Part 484, for Home Health Agencies with deficiencies cited.

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 record review and interview, it was determined that the facility failed to submit Outcome and Assessment Information Set (OASIS) assessments timely for 19 out of 939 records between 7/22/23-7/21/24. Review on 7/23/24 of the Center for Medicare and Medicaid Services (CMS) "HHA [Home Health Agency] Error Summary by Agency" report for 7/22/23 through 7/21/24 revealed the error "-3330 Records Submitted Late: The submission date is more than 30 days after M0090 on this new record" was noted for 19 records of 939 assessments. Interview on 7/23/24 at approximately 3:30 p.m. with Staff A (Chief Executive Officer) confirmed the above findings.

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:

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by:

An Emergency Preparedness survey was conducted on 10/20/21 pursuant to 42 CFR Part 484.102 with deficiencies cited.

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 E.P.P. (Emergency Preparedness Plan) and interview, it was determined that the facility failed to ensure that the E.P.P. was reviewed and updated on a bi-annual basis. Review of the E.P.P. on 10/20/2021 between 8:30 a.m. and 11:30 a.m. with Staff A (Facility Director) revealed the last documented (signed) E.P.P. update was completed on 01/16/2019 with a signed approval and review sheet. A second approval and review sheet was located within the documents and dated for 03/2020 however, their failed to be any approval signatures from the Director, Staff, local emergency management officials, or the Public Health Emergency Coordinator. Interview on 10/20/2021 with Staff A confirmed the above findings and available documentation.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on patient record review and interview, it was determined that the facility failed to ensure that a Home Health Agency patient during a natural or man-made disaster had an individual plan as part of the patient comprehensive patient assessment. Record review on 10/20/2021 between 8:30 a.m. and 11:30 a.m. of Patient #1's assessment history report dated 9/22/21 revealed "Does the agency need to arrange for alternative service for patient?" with a response of "Yes". The Home Health Agency was unable to provide documentation of Patients #1's individualized emergency plan for review. Interview on 10/20/21 between between 2:00 p.m. and 3:00 p.m. with Patient #1 confirmed the above findings. Patient #1 stated that the emergency preparedness plan or evacuation plan had not been discussed or addressed with him/her.

A recertification survey was conducted on 10/20/2021 with no deficiencies cited.