Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies-Emergency Preparedness.
Plan of Correction:
484.102(d)(1) STANDARD
EP Training Program
Name - Component - 00
§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), §485.542(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, REHs at §485.542, "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.
Observations:
Based on review of agency personnel files (PF), the agency failed to maintain documentation that demonstrated staff knowledge of emergency procedures initially for three (3) of six (6) PF reviewed (PF#1, 5 and 6).
Findings included:
Review of PF on January 3, 2024, at approximately 9:15am revealed:
Findings include:
PF reviewed 5/7/24 at approximately 9:00am revealed:
PF #1, date of hire (DOH)/ start of services (SOS) 2/20/24: PF contained undated Emergency Preparedness test.
PF#5, DOH/SOS 5/31/23: PF contained undated Emergency Preparedness test.
PF#6, DOH/SOS 1/4/23: PF contained undated Emergency Preparedness test.
Interview with agency Administrator and Director of Nursing completed on May 9, 2024, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Agency will update documentation utilized during the training of Agencies Emergency Preparedness Policy to include signature sign off for employee, agency staff providing training, and date that training was completed. Training on the Agencies Emergency Preparedness Policy will occur at hire, and during the annual skills training completed by the agency.
Prior to an employee being able to provide care to a patient alone, their HR chart must be signed off as complete by 2 agency staff to ensure that all required training and documentation of training has been completed. The chart will first be reviewed by the Director of Employee Relations. Once the Director of Employee Relations feels that the chart is complete, they will then pass the employee chart off to the Chief Compliance Officer, who will provide a second review of the chart. The employee will not be permitted to work on their own with a patient until both agency staff members have signed off their HR chart as complete.
The Director of Employee Relations will conduct employee chart reviews to monitor the employee HR files. 50% of employee HR charts will be reviewed monthly for 2 months. Chart reviews will continue at 20 % employee HR charts reviewed monthly for 6 months, maintaining 80% compliance. Findings will be brought to quarterly meetings.
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.65(a)(1),(2) STANDARD
Program scope
Name - Component - 00
Standard: Program scope.
(1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care.
(2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations.
Observations:
Based on review of policies and procedures, agency Quality Assurance and Performance Improvement (QAPI) documentation, and staff (EMP) interview, the agency QAPI failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations for six (6) of six (6) QAPI meeting minutes reviewed.
Findings include:
Review of QAPI meeting minutes on 5/7/24 at approximately 1:00pm revealed:
QAPI meeting minutes dated 3/31/23 addressed a concern called from a facility related to multiple calls related to leaking foley catheter. No data, adverse events, or quality indicators tracked. No additional information in meeting minutes.
QAPI meeting minutes dated 4/28/23 addressed chart audit findings that OASIS SOC date failed to match physician ordered start of care (SOC) date. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns not updated or addressed. No additional information in meeting minutes.
QAPI meeting minutes dated 7/21/23 addressed chart audit findings that nursing documentation does not reflect top 3 diagnosis. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns or SOC dates not updated or addressed. No additional information in meeting minutes.
QAPI meeting minutes dated 12/4/23 addressed chart audit findings that nursing documentation continues not to reflect top 3 diagnosis and also goals are not being documented as met. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns or SOC dates not updated or addressed. No additional information in meeting minutes.
Interview with agency Administrator and Director of Nursing completed on May 9, 2024, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:The Director of Professional Services/DON will print the agency specific IQIES reports quarterly. These reports will be reviewed by the Director of Professional Services. The findings of the agency specific IQIES reports will be utilized by the Director of Professional Services/DON to conduct patient chart reviews. The patient chart reviews will be completed at 50 % of patients monthly for the first quarter. The findings of these chart reviews will be brought to the quarterly meeting and a QAPI will be developed with the findings of the patient chart reviews. After the 1st quarter, chart reviews will continue at 25 % patient charts monthly, maintaining 80% compliance. The QAPI will include data and adverse effects, and trackable indicators. QAPI will be reviewed annually.
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G. Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on review of policies and procedures, therapy contract, personnel files (PF), and an interview with the agency administrator the agency failed to ensure files contained required information including completed orientation documentation for three (3) of six (6) PF (PF#1, 5, &; 6), Federal background checks for two (2) of six (6) PF (PF#5 &; 6), and failed to ensure negative Tuberculosis screening prior to patient contact for three (3) of six (6) PF (PF#4, 5, &; 6).
Findings include:
Agency Employee Handbook reviewed 5/9/24 at approximately 9:00am revealed: "HEALTH REQUIREMENTS 1. Tuberculosis....A PPD test is requires prior to patient contact..."
Therapy Services Agreement reviewed 5/9/24 at approximately 9:15am revealed: "Therapy Services Agreement: Home Health...3. Responsibilities of Contractor. The responsibilities of the Contractor are as follows: 3.1 Providers. ...The contractor will follow an orientation, evaluation, and reference check acceptable to the agency and in conformance with Medicare Conditions of Participation...4. Responsibilities of the Agency...4.2 Orientation. Agency will provide Contractor with Initial Orientation...Al health care providers will be oriented prior to initiating care. The initial orientation shall include, but not be limited to: a. A review of the Agency's overall policies and systems; b. A review of clinical and infection control policies and procedures for providers providing direct patient care; c. Documentation and meeting expectations of Agency..."
PF reviewed 5/7/24 at approximately 9:00am revealed:
PF #1, date of hire (DOH)/ start of services (SOS) 2/20/24: PF contained an orientation checklist indicating review needed in the areas of Tube Feeding, Specimen Collection, Seizure Precautions, Skin Breakdown/Wounds, Catheterization, Dressings, Enema, Gastro, IV medications, Nephrostomy, Venipuncture, Orthopedic, Admission, Recertification, Transfer/Discharge, Case Management, and Follow-up Home visits. No evidence in PF that nurse was competent or trained on these areas of care prior to providing patient care.
PF#4, DOH/SOS 11/7/23: PF contained negative first step Tuberculosis screening dated 11/26/23, 19 days after patient contact.
PF#5, DOH/SOS 5/31/23: PF failed to contain documentation of agency orientation and FBI background check. PF contained negative first step Tuberculosis screening with date crossed out, surveyor unable to determine if read prior to patient contact.
PF#6, DOH/SOS 1/4/23: PF failed to contain documentation of agency orientation and FBI background check. PF contained negative first step Tuberculosis screening dated 1/15/23, 11 days after patient contact.
Interview with agency Administrator and Director of Nursing completed on May 9, 2024, at approximately 2:00 pm confirmed the above findings.
Plan of Correction:Prior to any staff providing direct patient care, including contracted staff, employee must first complete an orientation conducted by Community Care including, but not limited to agency policies and procedures, review of clinical and infection control policies and procedures and documentation required of the agency. Documentation will be completed by agency staff, and employees with signatures and dates that orientation was completed successfully.
TB policy will be updated clarifying that staff must have one step completed with negative results prior to providing direct patient care.
FBI clearance will be completed by all agency staff, including contracted staff. Staff will not be permitted to provide direct patient care (unsupervised) prior to having completed FBI clearance.
Prior to an employee being able to provide care to a patient alone, their HR chart must be signed off as complete by 2 agency staff to ensure that all required training and documentation of training has been completed. The chart will first be reviewed by the Director of Employee Relations. Once the Director of Employee Relations feels that the chart is complete, they will then pass the employee chart off to the Chief Compliance Officer, who will provide a second review of the chart. The employee will not be permitted to work on their own with a patient until both agency staff members have signed off their HR chart as complete.
The Director of Employee Relations will conduct employee chart reviews to monitor the employee HR files. 50% of employee HR charts will be reviewed monthly for 2 months. Chart reviews will continue at 20 % employee HR charts reviewed monthly for 6 months, maintaining 80% compliance. Findings will be brought to quarterly meetings.
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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