QA Investigation Results

Pennsylvania Department of Health
DYNAMIC HOME HEALTH CARE INC.
Health Inspection Results
DYNAMIC HOME HEALTH CARE INC.
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:

Based on the findings of an unannounced, onsite Medicare recertification survey conducted September 16 through September 18, 2020, Dynamic Home Health Care Inc., was found not to be in compliance with the following requirements of 42 CFR, Part 484 Subparts B and Conditions of Participation: Home Health Agencies.







Plan of Correction:




484.50(c)(8) ELEMENT
Written notice for non-covered care

Name - Component - 00
Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204.

Observations:

Based on review of agency documentation and clinical records, and based on interview with the administrator, the agency failed to ensure notification of the patient's right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care, had been included in the "Patient Orientation Booklet" for two (2) of two (2) patients who were discharged to the community. (Patients #6 and #7)

Findings include:

On September 17, 2020 at approximately 8:15 AM, review of the agency admission folder revealed the following was documented on the "Patient's Bill of Rights" form:
"4.01 Patient's Rights...You may exercise these rights at any time while under our care, or you may have a family member or guardian exercise these rights if you are unable..."

On September 17, 2020 at approximately 8:15 AM, review of the "Patient Orientation Booklet" failed to reveal that notification of the patient's right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care, had been included in the "Patient Orientation Booklet".

Patient #6: On September 18, 2020 at approximately 10:36 AM, review of the clinical record revealed the start of care date was January 14, 2019, the primary diagnosis was pressure ulcer (wound caused by pressure) of unspecified heel-stage 2 (open wound) and that skilled nursing (SN) services were to be provided two (2) to three (3) times a week for nine (9) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020.
Review of "Nursing Visit Note" documentation revealed one (1) SN visit was provided during the treatment week of March 16 through 22, 2020, April 6 through April 12, 2020 and April 13 through April 19, 2020.
There was no documentation in the clinical record which provided evidence that SN services had been provided during the treatment weeks of March 30 through April 5, 2020 nor April 20 through April 26, 2020.
Review of payor source authorization form documentation revealed approval was issued for four (4) skilled nursing visits between March 2 and April 15, 2020 and four (4) skilled nursing visits between April 6 and June 24, 2020.
Review of "Discharge Summary" documentation revealed the following was documented under "Evaluation of Established Goals at Termination, Patient Follow Up...": Current certification period ends 05/07/2020. Discharged patient as of 04/30/2020 as the visit was the last authorized visit by payor source. Further visits denied by payor source. Patient advised of such.
Review of the "Notice of Medicare Non-Coverage" form, which was signed by the patient on April 6, 2020, failed to reveal that the patient was provided with written notification regarding the specific date when home health services would end.
There was no documentation in the clinical record which provided evidence that the patient received written notification of the patient's right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care.

Patient #7: On September 18, 2020 at approximately 11:44 AM, review of the clinical record revealed the start of care date was November 2, 2018, the primary diagnosis was pressure ulcer of unspecified buttock-stage 3 (open wound) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020.
There was no documentation in the clinical record which provided evidence that the patient received written notification of the patient's right to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed the "Patient Orientation Booklet" did not include notification regarding the patient's right receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care.














Plan of Correction:

The HHA will, prior to termination of services, will notify the client the HHA decision to end services via written notification. The HHA will provide this notice to the client no later than two days before the suspected end of services. HHA will be certain to include the date that the coverage will end and the date that the client's financial responsibility begins for continued services.
This will be addressed with the field staff (RN, PT, etc.) via staff meeting and written notice and will be implemented immediately.
The Administrator will monitor the process by reviewing documentation and ascertaining that the written notification is dated and received two days prior to discharge. Time for implementation is immediately. Time for completion is ongoing.

Dynamic's orientation booklet/patient bill of rights will include the following statement:
THE PATIENT HAS THE RIGHT: To be informed in advance about care to be furnished and of any changes in the care to be furnished before the change is made. Proper written notice will be provided prior to services terminating/ending.
THE PATIENT HAS THE RIGHT: to receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care.



484.50(c)(10)(i,ii,iii,iv,v) ELEMENT
Contact info Federal/State-funded entities

Name - Component - 00
Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides:
(i) Agency on Aging
(ii) Center for Independent Living
(iii) Protection and Advocacy Agency,
(iv) Aging and Disability Resource Center; and
(v) Quality Improvement Organization.

Observations:

Based on review of agency documentation and clinical records, and based primary caregiver interview and based on interview with the administrator, the agency failed to ensure five (5) of five (5) active patient received the contact information for the local (offices which serve the area in which the patient resides) Area Agency on Aging, Centers of Independent Living, Protection and Advocacy Agency and Aging and Disability Resource Center. (Patients #1, #2, #3, #4 and #5)

Findings include:

On September 17, 2020 at approximately 8:15 AM, review of the agency admission folder revealed the following was documented on the "Patient's Bill of Rights" form:
"4.01 Patient's Rights...You may exercise these rights at any time while under our care, or you may have a family member or guardian exercise these rights if you are unable..."

On September 17, 2020 at approximately 8:15 AM, review of the "Patient Orientation Booklet" failed to reveal that the contact information for the local Area Agency on Aging, Centers of Independent Living, Protection and Advocacy Agency nor the Aging and Disability Resource Center had been included in the "Patient Orientation Booklet".

Review of clinical records revealed the following:
Patient #1: On September 16, 2020 at approximately 1:40 PM, review of the clinical record revealed the start of care date was August 20, 2020, the primary diagnosis was hypertensive heart disease with heart failure and that skilled nursing (SN) and home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 20 through October 18, 2020.
Patient #2: On September 16, 2020 at approximately 2:07 PM and September 18, 2020 at approximately 10:18 AM, review of the clinical record revealed the start of care date was August 14, 2020, the primary diagnosis was type 2 diabetes mellitus (diabetes) with diabetic neuropathy (nerve pain) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 14 through October 12, 2020.
Patient #3: On September 16, 2020 at approximately 3:03 PM, review of the clinical record revealed the start of care date was September 10, 2020, the diagnoses included glaucoma and that SN, HHA and physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020.
Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that SN service were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020.
Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020. During a home visit conducted on September 17, 2020 at approximately 9:30 AM, the patient's primary caregiver reported that the patient could use financial assistance to purchase needed equipment/supplies as the patient has been responsible for payment for the hospital bed, Hoyer lift (transfer device) and other supplies required for the patient's care.
There was no documentation in the clinical records which provided evidence that the above referenced patients received the contact information for the local Area Agency on Aging, Centers of Independent Living, Protection and Advocacy Agency and the Aging and Disability Resource Center.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed the "Patient Orientation Booklet" did not contain the contact information for the local Area Agency on Aging, Centers of Independent Living, Protection and Advocacy Agency nor the Aging and Disability Resource Center.






















Plan of Correction:

The HHA will make all the necessary changes to the Patients Orientation Booklet to include and advise the clients and/or family of all the names, addresses, and telephone numbers of the following Federally and State funded entities that service the area where the client resides. This information will include the Center for Independent Living, Area of Aging/Agency on Aging, Aging and Disability Resource Center, Protection and Advocacy Agency and the Quality Improvement Organization.
Once the Patient's Orientation Booklet is updated, the Administrator will ensure that all the Skilled SOC Admission Folders have the updated version of Patient Orientation Booklet to include all the information stated above. All skilled field staff will receive verbal notice and review of the updated info and will be advised to highlight the info with the client during the admission process. Time for implementation is immediately. Target completion date is 10/17/2020.


484.50(c)(12) ELEMENT
Access to auxiliary aids and language service

Name - Component - 00
Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services.

Observations:

Based on review of agency documentation and clinical records, and based on interview with the administrator, the agency failed to ensure written information/instructions regarding the patient's right to access auxiliary aids (accessible web sites, assistive aids identified in the American's with Disabilities Act) and language services, and the means/processes to access those services was provided to five (5) of five (5) active patients. (Patients #1, #2, #3, #4 and #5)

Findings include:

On September 17, 2020 at approximately 8:15 AM, review of the agency admission folder revealed the following was documented on the "Patient's Bill of Rights" form:
"4.01 Patient's Rights...You may exercise these rights at any time while under our care, or you may have a family member or guardian exercise these rights if you are unable..."

On September 17, 2020 at approximately 8:15 AM, review of the "Patient Orientation Booklet" failed to reveal that written information/instructions regarding the patient's right to access auxiliary aids and language services, nor the means/processes to access those services, had been included in the "Patient Orientation Booklet".

Review of clinical records revealed the following:
Patient #1: On September 16, 2020 at approximately 1:40 PM, review of the clinical record revealed the start of care date was August 20, 2020, the primary diagnosis was hypertensive heart disease with heart failure and that skilled nursing (SN) and home health aide (HHA) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 20 through October 18, 2020.
Patient #2: On September 16, 2020 at approximately 2:07 PM and September 18, 2020 at approximately 10:18 AM, review of the clinical record revealed the start of care date was August 14, 2020, the primary diagnosis was type 2 diabetes mellitus (diabetes) with diabetic neuropathy (nerve pain) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 14 through October 12, 2020.
Patient #3: On September 16, 2020 at approximately 3:03 PM, review of the clinical record revealed the start of care date was September 10, 2020, the diagnoses included glaucoma and that SN, HHA and physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020.
Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020.
Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
There was no documentation in the clinical records which provided evidence that the above referenced patients received written information/instructions regarding the patient's right to auxiliary aids/language services and the means/processes to access those services.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed the "Patient Orientation Booklet" did not include written information/instructions regarding the patient's right to auxiliary aids/language services nor the means/processes to access those services.















Plan of Correction:

The HHA will make all the necessary changes to the Patients' Bill of Rights to include and advise the clients and/or family of information and instructions regarding the client's right to access auxiliary aids and language services and provide the means and processes on how to access those services. Included will be accessible websites and assistive aids identified through the ADA-Americans' with Disabilities Act.
Once the Patients' Bill of Rights is updated, the Administrator will ensure that all Skilled SOC Admission Folders have the updated version of Patients' Bill of Rights booklet to include the information stated above. All skilled staff will receive verbal notice of the updated info and will be advised to highlight the info with the client and family during the admission process. Will review process with the office staff responsible for making the SOC folders to ensure it is being completed correctly and with the correct information. We will have updated Patient Bill of Rights and the old ones will be discarded immediately. Time for implementation is immediately. Target completion date is 10/17/2020.



484.60(a)(1) STANDARD
Plan of care

Name - Component - 00
Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

Observations:

Based on review of agency policies/procedures and clinical records, and based on interview with the administrator, the agency failed to ensure the plan of care included wound treatment/status goals for two (2) of three (3) active patients for whom the "Home Health Certification and Plan of Care" included wound care orders. (Patients #4 and #5)

Finding include:

On September 18, 2020 at approximately 12:52 PM, review of agency policy C-580, titled "Plan of Care", revealed the following:
"Purpose...To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals. To assure that the plan meets state/federal guidelines, and all applicable laws and regulations...
Special Instructions...2. The Plan of Care shall be completed in full to include...p. Treatment goals..."

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that skilled nursing (SN) was to provide the following wound treatment to the right buttock pressure ulcer as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020: Cleanse with normal saline solution (NSS), apply silver sulfate (wound treatment) and Mepilex dry dressing. Change daily and as needed.
Review of "Recertification/Follow-Up Assessment" documentation dated July 23, 2020 revealed the right buttock wound measured 2.1 cm x 1.7 cm x 0.1 cm and the right upper extremity wound measured 3.2 cm x 2.4 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the RN (employee #4) provided the following wound care to the buttock and/or the upper extremity wounds on July 27 and 30, 2020, August 3, 6, 11, 13, 18, 20, 25 and 27, 2020 and September 1 and 3, 2020: Wound cleansed with NSS, Medihoney (wound treatment) applied followed by Covaderm dressing (wound dressing).
There was no documentation that wound treatment/status goals were included on the "Home Health Certification and Plan" for the recertification period of July 27 through September 24, 2020.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
Review of the "Recertification/Follow-Up Assessment" revealed the right lower extremity wound measured 1.4 cm x 0.7 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the patient had open wounds of the left lower extremity and that the RN (employee #4) provided the following wound care to the left lower extremity wounds:
-August 7, 11, 13, 25, 28 and 31, 2020 and September 3, 2020: Irrigate with NSS, apply ABD (thick dressing), secure with Kerlix (gauze wrap) and tape, followed by the application of a compression stocking;
-August 19 and 21, 2020 and September 8 and 10, 2020: Cleansed with soap/water, irrigated with NSS, silver alginate (wound treatment) applied followed by gauze/dry sterile dressing, Kerlix, ace wrap/compression stocking; and
-September 15 and 17, 2020: Compression stocking/ace bandage to bilateral (both) lower extremities (legs).
There was no documentation that wound treatment/status goals were included on the "Home Health Certification and Plan" for the recertification period of August 4 through October 2, 2020.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation that wound treatment/status goals were included on the "Home Health Certification and Plan" for the above identified patients.
















Plan of Correction:

HHA will address and review with all skilled staff the importance of following the POC/485 as written and signed off by the treating physician. They will be re-educated that each client must receive the home health services that are written in the plan of care specific to that client and that client-specific measurable outcomes and goals are identified and established and must be periodically reviewed. To be specifically addressed, will be the concern that wound care, and all ordered must be followed as directed/ordered by the physician. Should there be a change in wound care orders or any other orders, there must be a documented physician order indication such change. The physician or allowed practitioner is to be consulted to approve additions or modifications to the original plan. Any deviation of care from the signed POC/485 is considered providing treatment or care without a physician's approval/order. The Administrator will assume the responsibility of reviewing the Plan of Care policy and procedure as written for the HHA with all skilled staff providing care to the skilled clients. A copy will be provided to each individual. In addition, there will be a process put into place where the skilled nurse, PT, etc. will have a copy of the most current POC/485 for the client they are providing services for. The above-mentioned process will be monitored via chart reviews for accuracy and compliance of all physician orders. Time for implementation is immediately. Time for completion is ongoing.


484.60(b)(1) ELEMENT
Only as ordered by a physician

Name - Component - 00
Drugs, services, and treatments are administered only as ordered by a physician.

Observations:

Based on review of agency policies/procedures and clinical records, and based on interview with the administrator, the agency failed to ensure wound care was provided as per physician order for three (3) of three (3) active patients for whom the "Home Health Certification and Plan of Care" included wound care orders. (Patients #2, #4 and #5)

Finding include:

On September 18, 2020 at approximately 12:30 PM, review of agency policy C-635, titled "Physician Orders", revealed the following:
"Policy...All medications, treatments and services provided to clients must be ordered by a physician..."

Patient #2: On September 16, 2020 at approximately 2:07 PM and September 18, 2020 at approximately 10:18 AM, review of the clinical record revealed the start of care date was August 14, 2020, the primary diagnosis was type 2 diabetes mellitus (diabetes) with diabetic neuropathy (nerve pain) and that skilled nursing (SN) was to provide the following wound treatment to the sacral wound (base of spine) as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 14 through October 12, 2020: Cleanse with normal saline solution (NSS), apply zinc oxide (mineral wound treatment), perform 3 to 5 times a week.
Review of the start of care "Comprehensive Adult Nursing Assessment" dated August 14, 2020 revealed the sacral wound measured 0.5 cm (centimeters) in length, 1.0 cm in width and 0.5 cm in depth (0.5 cm x 1.0 cm x 0.5 cm) and that the registered nurse (RN-employee #2) applied triamcinolone cream (corticosteroid wound treatment) to the sacral wound instead of zinc oxide.
There was no documentation in the clinical record which provided evidence that a physician order had been obtained to apply triamcinolone cream to the sacral wound on August 14, 2020.

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that skilled nursing (SN) was to provide the following wound treatment to the right buttock pressure ulcer as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020: Cleanse with normal saline solution (NSS), apply silver sulfate (wound treatment) and Mepilex dry dressing. Change daily and as needed.
Review of "Recertification/Follow-Up Assessment" documentation dated July 23, 2020 revealed the right buttock wound measured 2.1 cm x 1.7 cm x 0.1 cm and the right upper extremity wound measured 3.2 cm x 2.4 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the RN (employee #4) provided the following wound care to the buttock and/or the upper extremity wounds on July 27 and 30, 2020, August 3, 6, 11, 13, 18, 20, 25 and 27, 2020 and September 1 and 3, 2020: Wound cleansed with NSS, Medihoney (wound treatment) applied followed by Covaderm dressing (wound dressing).
There was no documentation in the clinical record which provided evidence that a physician order had been obtained for SN to provide the above referenced wound care to the buttock and upper extremity wounds between July 27 and September 3, 2020.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
Review of the "Recertification/Follow-Up Assessment" revealed the right lower extremity wound measured 1.4 cm x 0.7 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the patient had open wounds of the left lower extremity and that the RN (employee #4) provided the following wound care to the left lower extremity wounds:
-August 7, 11, 13, 25, 28 and 31, 2020 and September 3, 2020: Irrigate with NSS, apply ABD (thick dressing), secure with Kerlix (gauze wrap) and tape, followed by the application of a compression stocking;
-August 19 and 21, 2020 and September 8 and 10, 2020: Cleansed with soap/water, irrigated with NSS, silver alginate (wound treatment) applied followed by gauze/dry sterile dressing, Kerlix, ace wrap/compression stocking; and
-September 15 and 17, 2020: Compression stocking/ace bandage to bilateral (both) lower extremities (legs).
There was no documentation in the clinical record which provided evidence that a physician order had been obtained for SN to provide the above referenced wound care to the left lower extremity wounds between August 7 and September 17, 2020.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that a physician order had been obtained for SN to provide the above referenced wound care to the above identified patients on the aforementioned dates.















Plan of Correction:

The HHA and its staff must operate and furnish care as per physician orders. The HHA accordingly with the Administrator will ensure that physician orders are followed as written by the ordering provider. HHA will review the process with the treating providers (RN, Pt, OT, ST, etc.) SN and therapy notes will be checked upon submission to assure proper care was rendered. Administrator to hold a meeting with the field staff immediately to review the importance of following the proper patient treatment as per physicians orders.
Administrator to ensure all field staff has a copy of all updated orders in their possession.
Time for completion: Ongoing




484.60(e)(1) ELEMENT
Visit schedule

Name - Component - 00
Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.

Observations:

Based on review of agency policies/procedures, documentation and clinical records, home visit observation, and based on agency staff/patient interview and interview with the administrator, the agency failed to ensure written instructions regarding visit frequencies had been provided to three (3) of three (3) patients for whom a home visit was conducted. (Patients #3, #4 and #5)

Finding include:

On September 18, 2020 at approximately 12:52 PM, review of agency policy C-580, titled "Plan of Care", revealed the following:
"Purpose...To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals. To assure that the plan meets state/federal guidelines, and all applicable laws and regulations..."

Patient #3: On September 16, 2020 at approximately 3:03 PM, review of the clinical record revealed the start of care date was September 10, 2020, the primary diagnosis was paroxysmal atrial fibrillation (irregular heart rate) and that the following visit frequencies were included on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020:
-Skilled Nursing (SN): One (1) to three (3) times a week for nine (9) weeks (1-3 x a wk x 9 wks);
-Home Health Aide (HHA): 2 x wk x 9 wks; and
-Physical Therapy (PT): Evaluation visit then 1-2 x q wk.
During a home visit conducted on September 17, 2020 at approximately 10:25 AM, the registered nurse (RN-employee #2) reported that SN services will be provided 2 x a wk and that after the admission visit, a SN visit was completed on 09/17/2020. The patient reported that PT services are to be provided 2 x a wk but reported that HHA services had not yet been initiated. Review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that written instructions regarding the above referenced SN, HHA nor PT visit frequencies had been provided to the patient.

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of the right buttock-stage 2 (open wound) and that the following visit frequency was included on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020:
-SN: 1-3 x a wk x 9 wks.
During a home visit conducted on September 17, 2020 at approximately 11:35 AM, review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that written instructions regarding the above referenced SN visit frequency had been provided to the patient.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that the following visit frequencies were included on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020:
-SN: 1-2 x a wk x 9 wks; and
-PT: Evaluation visit then 1-2 x wk.
During a home visit conducted on September 17, 2020 at approximately 9:30 AM, review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that written instructions regarding the above referenced SN and PT visit frequencies had been provided to the patient.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation which provided evidence that written instructions regarding the above referenced frequencies had been provided to above identified patients in writing.














Plan of Correction:

HHA will again review with and re-educate the skilled field staff in writing and via staff meeting the importance of following the Plan of Care policy and procedure C580 to ensure that written instructions regarding visit frequencies are furnished to each client. This is to include all disciplines, PT, OT, HHA, RN services, etc. The frequency of visits can and will be documented in the Admission Consent Form midway down alongside the service provided section. The admission consent can be found in each Skilled SOC Folder. Should there be any alterations to the visit frequency, the client shall also be notified of such changes. The administrator will have oversight of this and will review the carbon copy of the Admissions Consent Form submitted with each SOC to assure that the proper protocol of notifying the client of visit frequency has been adhered to. Should there be a deviation from the proper process, the administrator will ensure that the info is provided in writing to the client. Time for implementation will be immediately. Time for completion will be ongoing.


484.60(e)(3) ELEMENT
Treatments and therapy services

Name - Component - 00
Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services.

Observations:

Based on review of agency policies/procedures, documentation and clinical records, home visit observation and based on interview with the administrator, the agency failed to ensure written instructions regarding the type of treatments to be provided by skilled nursing (SN) were provided to one (1) of one (1) patients for whom the "Home Health Certification and Plan of Care" included wound care orders. (Patient #4)

Finding include:

On September 18, 2020 at approximately 12:52 PM, review of agency policy C-580, titled "Plan of Care", revealed the following:
"Purpose...To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals. To assure that the plan meets state/federal guidelines, and all applicable laws and regulations..."

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that skilled nursing (SN) was to provide the following wound treatment to the right buttock pressure ulcer as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020: Cleanse with normal saline solution (NSS), apply silver sulfate (wound treatment) and Mepilex dry dressing. Change daily and as needed.
During a home visit conducted on September 17, 2020 at approximately 11:35 AM, review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that written instructions regarding the above referenced wound care had been provided to the patient.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation which provided evidence that a copy of the aforementioned wound care had been provided to patient #1 in writing.


















Plan of Correction:

Understanding that the expectation of the HHA is to meet the client's nursing, rehabilitative and social needs in the place they reside, the HHA will make available to the client an individualized plan of care in written format. The HHA will make available to each client a copy of their POC/485. HHA will ensure that the written document will include an individualized care plan advising the client of the services and care they require to meet the client's individual need including measurable outcomes. Once the SOC/Recert/ROC, etc. is complete, the 485 will be provided to the treating discipline to give to the client or if for some reason this is not possible, the documentation will be mailed to the client with an explanation included. This process, including the Policy and Procedure policy C-580, and the client's right to know its care will be reviewed with the field staff and the Skill's Department Staffing Skills Coordinator. The administrator will have oversight of this. We will create a log for tracking when each 485 is provided to the skilled staff and the client which will be adhered immediately moving forward. Once a 485 is created we will forward the documents within two day. Time for implementation will be immediately. Time for completion will be ongoing.


484.60(e)(5) ELEMENT
Name/contact information of clinical manager

Name - Component - 00
Name and contact information of the HHA clinical manager.

Observations:

Based on review of agency policies/procedures, documentation and clinical records, and based on patient interview and interview with the administrator, the agency failed to ensure the name and contact information of the clinical manager (CM-employee #1) had been provided to three (3) of three (3) patients for whom a home visit was conducted. (Patients #3, #4 and #5)

Finding include:

On September 18, 2020 at approximately 12:52 PM, review of agency policy C-580, titled "Plan of Care", revealed the following:
"Purpose...To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals. To assure that the plan meets state/federal guidelines, and all applicable laws and regulations..."

Patient #3: On September 16, 2020 at approximately 3:03 PM, review of the clinical record revealed the start of care date was September 10, 2020, the primary diagnosis was paroxysmal atrial fibrillation (irregular heart rate) and that skilled nursing (SN), home health aide (HHA) and physical therapy services (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of September 10 through November 8, 2020.
During a home visit conducted on September 17, 2020 at approximately 10:25 AM, the patient reported that HHA services had not yet been initiated. Review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that the name and contact information for the CM had been provided to the patient in writing.

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of the right buttock-stage 2 (open wound) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020.
During a home visit conducted on September 17, 2020 at approximately 11:35 AM, review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that the name and contact information for the CM had been provided to the patient in writing.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
During a home visit conducted on September 17, 2020 at approximately 9:30 AM, review of the agency's admission folder revealed there was no documentation on the agency documents included in the folder which provided evidence that the name and contact information for the CM had been provided to the patient in writing.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation which provided evidence that the name and contact information for the CM had been provided to above identified patients in writing.












Plan of Correction:

HHA will update all necessary documents, as per policy C580, to include the name of current the Clinical Manager. Should the name of the Clinical Manager change for whatever reason, HR will be responsible for updating that change on all forms accordingly. Time for implementation will be immediately. Time for completion will be 10/17/2020.The administrator will review as needed that all folders given to patients contain the proper document with the name of the correct administrator/DON. This information will also be reviewed and updated as needed during each quarterly management meeting.


484.70(c) STANDARD
Infection control education

Name - Component - 00
Standard: Education.
The HHA must provide infection control education to staff, patients, and caregiver(s).

Observations:

Based on review of agency policies/procedures, clinical records and personnel files, and based on interview with the administrator, the agency failed to ensure to two (2) of two (2) contracted therapists attended/completed an infection control education session. (Employees #6 and #8).

Findings include:

On September 17, 2020 at approximately 8:15 AM, review of agency policy B-401, titled "Infection Control Plan" revealed the following as documented under "Orientation and Continuing Education of Personnel":
"All new employees of the agency will complete an education session that covers Blood Borne Pathogens Exposure Control Plan, Tuberculosis Plan, Hand Hygiene Guidelines and basic infection control..."

Patient #2: On September 16, 2020 at approximately 2:07 PM and September 18, 2020 at approximately 10:18 AM, review of the clinical record revealed the start of care date was August 14, 2020, the primary diagnosis was type 2 diabetes mellitus (diabetes) with diabetic neuropathy (nerve pain) and that physical therapy (PT) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of August 14 through October 12, 2020.
Review of physical therapy visit note documentation revealed the PT (employee #6) provided PT services in August and September 2020.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
Review of physical therapy visit note documentation revealed the PT (employee #8) provided PT services in August 2020.

Review of personnel/training files on September 17, 2020 at approximately 12:35 PM and September 18, 2020 at approximately 9:33 AM revealed the following:
Employee #6: The date of hire of the contract PT was November 27, 2019.
Employee #8: The date of hire of the contract PT was October 20, 2015.
There was no documentation in the personnel files which provided evidence that employee #6 nor employee #7 had attended/completed an infection control education session on or after the date of hire.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation in the above referenced personnel/training files which provided evidence that neither employee #6 nor employee #7 had attended/completed an infection control education session.










Plan of Correction:

Based on findings during the survey and as per HHA policy and procedure B401, the HHA with the assistance of the HR department will ensure that all employees (new and current) including the ones in question will properly complete an education session regarding Infection Control. This will include Blood Borne Pathogens, TB Plan, Hand/Hygiene guidelines and basic infection control. The administrator along with the HR department will have oversight of this process. They will make certain that the Infection Control Educational Session will take place immediately upon employment to the agency and whenever else necessary.HR to keep track of this in her system and will check employee files periodically for accuracy and updated paperwork requirements. Time for implementation will be immediately and time for completion will be ongoing.


484.75(b)(1) ELEMENT
Interdisciplinary assessment of the patient

Name - Component - 00
Ongoing interdisciplinary assessment of the patient;

Observations:

Based on review of agency policies/procedures and clinical records, and based on interview with the administrator, the agency failed to ensure wound measurements were obtained as per agency policy/procedure for two (2) of three (3) active patients for whom the "Home Health Certification and Plan of Care" included wound care orders. (Patients #4 and #5)

Finding include:

On September 18, 2020 at approximately 12:31 PM, review of agency policy G-100, titled "Application of Dry Dressing", revealed the following:
"Procedure...11. Assess wound size, characteristics and drainage...
Documentation Guidelines...1. Document in the clinical record: a. Appearance, odor, and size of the wound..."

On September 18, 2020 at approximately 12:35 PM, review of agency policy G-150, titled "Assessment/Staging of Pressure Ulcers", revealed the following:
"Pressure Ulcer Assessment Guide....In assessing pressure ulcer, the following parameters should be addressed consistently. Site, stage of ulcer, and the size of the ulcer (include length, width and depth)..."

On September 18, 2020 at approximately 12:39 PM, review of agency policy C-155, titled "Client Reassessment/Update of the Comprehensive Assessment", revealed the following:
"Purpose...To identify decline or improvement in health status, modify the plan of care and document changes that may affect care..."

Patient #4: On September 17, 2020 at approximately 2:20 PM, review of the clinical record revealed the start of care date was May 29, 2020, the primary diagnosis was pressure ulcer (wound caused by pressure) of right buttock/stage 2 (open wound) and that skilled nursing (SN) was to provide the following wound treatment to the right buttock pressure ulcer as documented on the "Home Health Certification and Plan of Care" for the recertification period of July 27 through September 24, 2020: Cleanse with normal saline solution (NSS), apply silver sulfate (wound treatment) and Mepilex dry dressing. Change daily and as needed.
Review of "Recertification/Follow-Up Assessment" documentation dated July 23, 2020 revealed the right buttock wound measured 2.1 cm x 1.7 cm x 0.1 cm and the right upper extremity wound measured 3.2 cm x 2.4 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the registered nurse (RN-employee #4) provided the following wound care to the buttock and/or the upper extremity wounds on July 27 and 30, 2020, August 3, 6, 11, 13, 18, 20, 25 and 27, 2020 and September 1 and 3, 2020: Wound cleansed with NSS, Medihoney (wound treatment) applied followed by Covaderm dressing (wound dressing).
There was no documentation in the clinical record which provided evidence that wound measurements of the buttock and upper extremity wounds were obtained by the RN during the above referenced SN visits performed between July 27 and September 3, 2020.

Patient #5: On September 17, 2020 at approximately 2:58 PM, review of the clinical record revealed the start of care date was June 5, 2020, the primary diagnosis was lymphedema (swelling caused by damage to the lymph nodes) and that SN and PT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of August 4 through October 2, 2020.
Review of the "Recertification/Follow-Up Assessment" revealed the right lower extremity wound measured 1.4 cm x 0.7 cm x 0.1 cm.
Review of "Nursing Visit Note" documentation revealed the patient had open wounds of the left lower extremity and that the RN (employee #4) provided the following wound care to the left lower extremity wounds:
-August 7, 11, 13, 25, 28 and 31, 2020 and September 3, 2020: Irrigate with NSS, apply ABD (thick dressing), secure with Kerlix (gauze wrap) and tape, followed by the application of a compression stocking; and
-August 19 and 21, 2020 and September 8 and 10, 2020: Cleansed with soap/water, irrigated with NSS, silver alginate (wound treatment) applied followed by gauze/dry sterile dressing, Kerlix, ace wrap/compression stocking.
There was no documentation in the clinical record which provided evidence that wound measurements of the lower extremity wounds were obtained by the RN during the above referenced SN visits performed between August 7 and September 3, 2020.

During interview on September 18, 2020 at approximately 1:25 PM, the administrator confirmed that there was no documentation in the clinical record which provided evidence that wound measurements were obtained by the RN for the above referenced wounds for the above identified patients.









Plan of Correction:

Based on findings and as per agency policy G-100, HHA will assure that all skilled professionals who provide care to clients directly must participate in the coordination of care of every client. This includes but not limited to attention to wound care and wound measurements. It is required that all wounds be measured at the very least on a weekly basis. The skilled professional will document the size, the appearance/characteristics, and odor if any. He/she will also document the staging of the client's wound if indicated. Policy guidelines indicate that it must be documented in the clinical records. The skilled staff responsible for patient care and assessment with be re-educated on the guidelines of wound care management. This will occur via staff meeting and review of the agency's policy and procedure mentioned above. The administrator will also be responsible for arranging a wound care in-service by a local wound care company. The administrator will have oversite of this process and will do chart reviews weekly or more if needed. Any discrepancies will be addressed immediately with the skilled staff responsible. Time for implementation will be immediately. Time for completion will be ongoing.


Initial Comments:

Based on the findings of an unannounced, onsite Medicare recertification survey conducted September 16 through September 18, 2020, Dynamic Home Health Care Inc., was found not to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.








Plan of Correction:




484.102(a) STANDARD
Develop EP Plan, Review and Update Annually

Name - Component - 00
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.

.

Observations:

Based on review of agency policies/procedures and documentation, and based on interview with the administrator, the agency failed to ensure the "Emergency Preparedness Plan" was reviewed/updated in either 2018 or 2019.

Findings included:

On September 18, 2020 at approximately 12:45 PM, review of agency policy B-400, titled "Emergency Management Policy", revealed the following as documented under "Policy": "The agency conducts an analysis to identify potential emergencies and the direct and indirect effects of those emergencies may have on the agency operations and the demand for services. The agency will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management..."

On September 18, 2020 at approximately 10:04 AM, review of the "Emergency Preparedness Plan" failed to reveal that the emergency plan had been reviewed/updated in 2018 nor 2019.

During interview on April 25, 2018 at 3:05 PM, the administrator confirmed there was no documentation which provided evidence that the "Emergency Preparedness Plan" had been reviewed/updated in 2018 nor 2019.

























Plan of Correction:

HHA, to maintain compliance with Federal, State, and local requirements and our agency policy B400 will create and maintain a comprehensive Emergency Preparedness Program that meets all requirements. The agency will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management. This plan will be created as required by upper management including the administrator who will also have oversight of the process throughout. Meetings will take place frequently with involved parties to monitor how the project is progressing. Moving forward, the HHA will create a document which provides evidence that the "Emergency Preparedness Plan" has been reviewed and updated every two years.
Time for implementation will be immediately and time for completion will be 10/17/2020.


484.102(a)(1)-(2) STANDARD
Plan Based on All Hazards Risk Assessment

Name - Component - 00
403.748(a)(1)-(2), 416.54(a)(1)-(2), 418.113(a)(1)-(2), 441.184(a)(1)-(2), 460.84(a)(1)-(2), 482.15(a)(1)-(2), 483.73(a)(1)-(2), 483.475(a)(1)-(2), 484.102(a)(1)-(2), 485.68(a)(1)-(2), 485.625(a)(1)-(2), 485.727(a)(1)-(2), 485.920(a)(1)-(2), 486.360(a)(1)-(2), 491.12(a)(1)-(2), 494.62(a)(1)-(2)

[(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 the following:]

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.*

(2) Include strategies for addressing emergency events identified by the risk assessment.

* [For Hospices at 418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
(2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

*[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. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

*[For ICF/IIDs at 483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:

(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients.
(2) Include strategies for addressing emergency events identified by the risk assessment.

Observations:

Based on review of agency policies/procedures and documentation, and based on interview with the administrator, the agency failed to ensure the "Emergency Preparedness Plan" included a completed risk assessment/hazard vulnerability analysis (HVA).

Findings included:

On September 18, 2020 at approximately 12:45 PM, review of agency policy B-400, titled "Emergency Management Policy", revealed the following as documented under "Policy": "The agency conducts an analysis to identify potential emergencies and the direct and indirect effects of those emergencies may have on the agency operations and the demand for services. The agency will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management..."

On September 18, 2020 at approximately 10:04 AM, review of the "Emergency Preparedness Plan" failed to reveal that the emergency plan included a completed risk assessment/hazard vulnerability analysis (HVA).

During interview on April 25, 2018 at 3:05 PM, the administrator confirmed there was no documentation which provided evidence that the "Emergency Preparedness Plan" included a completed risk assessment/hazard vulnerability analysis (HVA).














Plan of Correction:

In conjunction with the above POC this HHA, in order to maintain compliance with Federal, State, and local requirements and to ensure the "Emergency Preparedness Plan" includes a completed risk assessment/hazard vulnerability analysis will create an Emergency Plan which again will include a preparedness plan that will be reviewed and updated at least every two years. It will also be based on and include a documented risk assessment, using an all-hazards approach and will Include tactics for addressing emergency incidents identified by the risk assessment. This plan will be created as required by upper management including the administrator who will also have oversight of the process throughout. Meetings will take place frequently with involved parties to monitor how the project is progressing.
Time for implementation will be immediately and time for completion will be 10/17/2020


484.102(c)(2) STANDARD
Emergency Officials Contact Information

Name - Component - 00
403.748(c)(2), 416.54(c)(2), 418.113(c)(2), 441.184(c)(2), 460.84(c)(2), 482.15(c)(2), 483.73(c)(2), 483.475(c)(2), 484.102(c)(2), 485.68(c)(2), 485.625(c)(2), 485.727(c)(2), 485.920(c)(2), 486.360(c)(2), 491.12(c)(2), 494.62(c)(2).

[(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:

(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

*[For LTC Facilities at 483.73(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) The State Licensing and Certification Agency.
(iii) The Office of the State Long-Term Care Ombudsman.
(iv) Other sources of assistance.

*[For ICF/IIDs at 483.475(c):] (2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.
(iii) The State Licensing and Certification Agency.
(iv) The State Protection and Advocacy Agency.

Observations:

Based on review of agency policies/procedures and documentation, and based on interview with the administrator, the agency failed to ensure the "Emergency Preparedness Plan" included the contact information for state, regional and local emergency preparedness staff.

Findings included:

On September 18, 2020 at approximately 12:45 PM, review of agency policy B-400, titled "Emergency Management Policy", revealed the following as documented under "Special Instructions": "15. The emergency plan will identify the links to local community organizations that may be needed to assist the agency in responding to client needs or who may need to utilize agency staff and resources to respond to community events..."

On September 18, 2020 at approximately 10:04 AM, review of the "Emergency Preparedness Plan" failed to reveal that the emergency plan included the contact information for state, regional and local emergency preparedness staff.

During interview on April 25, 2018 at 3:05 PM, the administrator confirmed there was no documentation which provided evidence that the "Emergency Preparedness Plan" included the contact information for state, regional and local emergency preparedness staff.













Plan of Correction:

Again in conjunction with the above POC this HHA, in order to maintain compliance with Federal, State, and local requirements the "Emergency Preparedness Plan" Emergency Plan which again will include a preparedness plan that will be reviewed and updated at least every two years will also include the contact information of the Federal, State, Regional and/or local emergency preparedness staff. The creation of these documents will also ensure that the HHA is in compliance with the agency policy B-400, titled Emergency Management Policy. This plan will be created as required by upper management including the administrator who will also have oversight of the process throughout. Meetings will take place frequently with involved parties to monitor how the project is progressing. Time for implementation will be immediately and time for completion will be 10/17/2020.


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), 485.625(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, "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 policies/procedures, documentation and personnel files, and based on interview with the administrator, the agency failed to ensure nine (9) of nine (9) agency staff had received/completed emergency preparedness training. (Employees #1, #2, #3, #4, #5, #6, #7, #8 and #9)

Findings included:

On September 18, 2020 at approximately 12:45 PM, review of agency policy B-400, titled "Emergency Management Policy", revealed the following as documented under "Special Instructions": "2. Agency staff members will be oriented to the emergency management plan and their associated responsibilities..."

Review of personnel/training files on September 17, 2020 at approximately 12:35 PM and September 18, 2020 at approximately 9:33 AM revealed the following:
Employee #1: The date of hire of the administrator/director of nursing was January 28, 2020.
Employee #2: The date of hire of the registered nurse (RN) was April 4, 2019.
Employee #3: The date of hire of the RN was June 23, 2013.
Employee #4: The date of hire of the RN was September 7, 2018.
Employee #5: The date of hire of the home health aide (HHA) was April 18, 2019.
Employee #6: The date of hire of the contract physical therapist (PT) was November 27, 2019.
Employee #7: The date of hire of the HHA was November 2, 2015.
Employee #8: The date of hire of the contract PT was October 20, 2015.
Employee #9: The date of hire of the occupational therapist was August 21, 2020.
There was no documentation in the personnel files which provided evidence that the above identified employees had received/completed emergency preparedness training.

During interview on April 25, 2018 at 3:05 PM, the administrator confirmed there was no documentation in the personnel/training files which provided evidence that the above identified employees had received/completed emergency preparedness training.














Plan of Correction:

The HHA The HHA will create and uphold an emergency preparedness training and testing program as per the agencies policy B-400, titled "Emergency Management Policy" which states that all agency staff members will be oriented to the emergency management plan. In accordance with the requirements the training and testing program will be reviewed and revised at least every 2 years.
HHA will ascertain that all Initial training in emergency preparedness as per policies and procedures will be provided to new and existing staff and that HHA provide EP training at least every 2 years will be maintaining documentation of the training. HHA will demonstrate staff knowledge of emergency procedures and if the EP policies and procedures are updated, the HHA will conduct training on the updates made to the policy and procedures. This information will be available in each staff member's personnel file.
Again, this plan/process will be created by upper management to include HR and the administrator will have full oversight of the project. Meetings to take place frequently with involved parties to monitor how the project is progressing. Time for implementation will be immediately and time for completion will be 10/17/2020.