Initial Comments:
Based on the findings on an unannounced Medicare recertification and State relicensure survey conducted on July 15 - July 24, 2019, A Holy Family Home Health was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of this survey two (2) Condition level and thirty (30) standard level deficiencies were cited.
Plan of Correction:
484.65 CONDITION
Quality assessment/performance improvement
Name - Component - 00
Condition of participation: Quality assessment and performance improvement (QAPI).
The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS.
Observations:
This CONDITION is not met as evidenced by:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program, and staff (EMP) interview the agency failed to develop a program 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 (G642); the agency failed to develop a program that utilized quality indicator data, including measures derived from OASIS and other relevant data in the design of its program (G644); the agency failed to develop performance improvement activities that focused on high risk, high volume, or problem prone area (G646, G648); considered incidence, prevalence and severity of problems in those areas (G650); or lead to an immediate correction of an identified problem that potentially threatened the health and safety of patients (G652); the agency failed to develop performance improvement activities that tracked patient adverse events, analyzed their causes and implemented preventative actions (G654); the agency failed to take actions aimed at performance improvement and after implementing those actions measure its success and track performance to ensure that improvements are sustained (G656); the agency failed to conduct performance improvement projects after July 13, 2018, that reflected the scope, complexity, and past performance of the agency's services and operations (G658); the agency's governing body failed to ensure that an ongoing program for QAPI is defined, implemented and maintained, with efforts to address priorities for improved quality of care and patient safety (G660).
The cumulative effect of these systemic practices resulted in the agency's inability to ensure QAPI in accordance with regulatory requirements
Findings included:
Cross Reference tags G642, G644, G646, G648, G650, G652, G654, G656, G658 and G660
Plan of Correction:An approved Plan of Correction is not on file.
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 a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a program 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.
Finding Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(b)(1),(2),(3) STANDARD
Program data
Name - Component - 00
Standard: Program data.
(1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program.
(2) The HHA must use the data collected to-
(i) Monitor the effectiveness and safety of services and quality of care; and
(ii) Identify opportunities for improvement.
(3) The frequency and detail of the data collection must be approved by the HHA's governing body.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a program that utilized quality indicator data, including measures derived from OASIS and other relevant data in the design of its program.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c) STANDARD
Program activities
Name - Component - 00
Standard: Program activities.
The HHA's performance improvement activities must--
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a program with performance improvement activities.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The QAPI program did not contain evidence of any performance improvement activities. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c)(1)(i) ELEMENT
High risk, high volume, or problem-prone area
Name - Component - 00
(i) Focus on high risk, high volume, or problem-prone areas;
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop performance improvement activities that focused on high risk, high volume, or problem prone areas.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c)(1)(ii) ELEMENT
Incidence, prevalence, severity of problems
Name - Component - 00
(ii) Consider incidence, prevalence, and severity of problems in those areas; and
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a QAPI program that considered the incidence, prevalence and severity of problems in those areas for performance improvement activities.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c)(1)(iii) ELEMENT
Activities lead to an immediate correction
Name - Component - 00
(iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a QAPI program with performance improvement projects that lead to an immediate correction of an identified problem that potentially threatened the health and safety of the agency's patients.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c)(2) STANDARD
Track adverse patient events
Name - Component - 00
Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a QAPI program with performance improvement projects that tracked patient adverse events, analyzed their causes and implemented preventative actions.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no evidence of tracking patient adverse events. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(c)(3) ELEMENT
Improvements are sustained
Name - Component - 00
The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to develop a QAPI program with performance improvement projects and failed to take actions aimed at performance improvement and measure its success and track performance to ensure that improvements are sustained.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(d)(1)(2) STANDARD
Performance improvement projects
Name - Component - 00
Standard: Performance improvement projects.
Beginning July 13, 2018 HHAs must conduct performance improvement projects.
(1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations.
(2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program and staff (EMP) interview the agency failed to conduct performance improvement projects after July 13, 2018, that reflected the scope, complexity, and past performance of the agency's services and operations.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. There was no data collected. A record review was completed upon discharge of each patient by the clinical manager. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.65(e)(1)(2)(3)(4) STANDARD
Executive responsibilities for QAPI
Name - Component - 00
Standard: Executive responsibilities.
The HHA's governing body is responsible for ensuring the following:
(1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained;
(2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness;
(3) That clear expectations for patient safety are established, implemented, and maintained; and
(4) That any findings of fraud or waste are appropriately addressed.
Observations:
Based on a review of agency Quality Assurance Performance Improvement (QAPI) program, agency meeting minutes, and staff (EMP) interview the agency Governing Body failed to ensure that an ongoing program for QAPI is defined, implemented and maintained, with efforts to address priorities for improved quality of care and patient safety.
Findings Included:
Review of agency QAPI program completed on July 24, 2019 at approximately 12:00 p.m. revealed a two (2) page document that was an outline of the Conditions for Participation QAPI requirements. There was attached a set of blank assessment tools that were not completed. The program did not contain any performance improvement projects. A record review was completed upon discharge of each patient by the clinical manager. There was no data collected. The last patient was discharged on 3/28/2019. The agency does not currently have any active patients.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Review of agency Combined annual meeting completed on 7/24/2019 at approximately 9:47 a.m. revealed: "A Holy Family Home Health Minutes of the Combined Annual Meeting...The annual meeting of the Group of Professional Personnel (G.O.P.P.) and the Board of Governors. Date: June 13, 2019...The Quality Assessment and Performance Improvement Form/Checklist was updated, reviewed and approved..."
Plan of Correction:An approved Plan of Correction is not on file.
484.115(k) STANDARD
Registered Nurse
Name - Component - 00
Standard: Registered nurse.
A graduate of an approved school of professional nursing who is licensed in the state where practicing.
Observations:
Based on a review of registered nurse (RN) personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure PF contained health evaluations for two (2) of two (2) RN PF reviewed. (PF2, PF3)
Findings Included:
Review of PF completed on July 24, 2019 at approximately 10:41 a.m. revealed:
PF2, date of hire (DOH) 3/4/2014, PF did not contain evidence of annual TB testing for 2017, 2018, and 2019, CPR card expired 2/2017.
PF3, DOH 4/1/2014, PF did not contain evidence of annual TB testing for 2017, 2018, and 2019,
Interview on July 24, 2019 at approximately 12:34 p.m. with EMP4 confirmed the findings. EMP4 stated. "I do not have a policy on TB or CPR."
Plan of Correction:An approved Plan of Correction is not on file.
484.115(m) STANDARD
Social Worker
Name - Component - 00
Standard: Social worker.
A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting.
Observations:
Based on a review of Medical Social Worker (MSW) personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure PF contained health evaluations for one (1) of one (1) MSW PF reviewed. (PF1)
Findings Included:
Review of PF completed on July 24, 2019 at approximately 10:41 a.m. revealed:
PF1, date of hire 5/23/2014, PF did not contain evidence of annual TB testing for 2017, 2018, 2019
Interview on July 24, 2019 at approximately 12:34 p.m. with EMP4 confirmed the findings. EMP4 stated. "I do not have a policy on TB "
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted July 15 - July 24, 2019, A Holy Family Home Health, 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 CONDITION
Establishment of the Emergency Program (EP)
Name - Component - 00
§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12
The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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:
* (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.)
*[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
*[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:
Observations:
This CONDITION is not met as evidenced by:
Based on review of agency Emergency Preparedness Plan (EPP), staff (EMP) interview, the agency failed to develop and maintain an EPP that was reviewed and updated at least annually (E0004), failed to include a documented agency-based and community-based risk assessment, utilizing an all hazards approach, including strategies for addressing emergency events identified by the risk assessment (E0006), failed to address the patient population, including, but not limited to, the type of services the agency has the ability provide in an emergency, the continuity of operations, including delegations of authority and succession plans (E0007), failed to include a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials in efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the agency's efforts to contact such officials and its participation in collaborative and cooperative planning efforts (E0009), failed to develop and implement EP policies and procedures based on the emergency plan risk assessment and the communication plan reviewed and updated annually (E0013), failed to develop policies and procedures for the agency's patients during a natural or man-made disaster included as part of the comprehensive assessment (E0017), failed to develop policies and procedures to inform State and local EP officials about homebound patients in need of evacuation form their residence at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment (E0019), failed to develop policies and procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and inform the State and local officals of any on duty staff or patients that they are unable to contact (E0021), failed to develop polices and procedures for a system of medical documentation that preserves patient information, protects confidentiality, and secures and maintains availability of records in an emergency or disaster (E0023), failed to develop policies and procedures for the use of volunteers in an emergency or other emergency staffing strategies to address surge needs during an emergency (E0024), failed to develop and maintain an EP communication plan that complies with Federal, State and local laws and was reviewed and updated at least annually (E0029), failed to develop a communication plan that included the names and contact information of staff, contractors, patients, patient physicians and volunteers (E0030), failed to develop a communication plan that included the names and contact information of Federal, State, local, regional EP staff and other sources of assistance (E0031), failed to develop a communication plan that included a primary and alternate means of communication with staff, Federal, State, regional, and Local emergency management agencies (E0032), failed to develop a method for sharing information and medical documention for patients under the agency's care, with other health providers to maintain continuity of care during an emergency situation (E0033), failed to develop policies and procedures of providing information about the agency's needs and its ability provide assistance to the authority having jurisdiction (E0034), failed to develop and maintain and EP training and testing program based on the EPP and was reviewed and updated annually (E0036), failed to ensure all new and existing staff were initially trained in EP policies and procedures consistent with their expected role, failed to provide annual EP training, failed to maintain documention of training, staff failed to demonstrate knowledge of EP procedures (E0037) failed to conduct exercises to test the EP annually, failed to participate in a full scale community based exercise, failed to conduct a second full scale or tabletop exercise, failed to analyze the agency response to and maintain documentation of all exercises, drills and emergency events and revise the agency plan as needed (E0039)
The cumulative effect of these systemic practices resulted in the agency's inability to ensure emergency preparedness in accordance with regulatory requirements.
Findings Included:
Cross Reference tags E0004, E0006, E0007, E0009, E0013, E0017, E0019, E0021, E0023, E0024, E0029, E0030, E0031, E0032, E0033, E0034, E0036, E0037, and E0039.
Plan of Correction:An approved Plan of Correction is not on file.
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), §485.542(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 a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop and maintain an EPP that was reviewed and updated annually.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ..." Document failed to contain a date when it was originally put into place and when it was updated annually.
Review of agency Combined annual meeting completed on 7/24/2019 at approximately 9:47 a.m. revealed: "A Holy Family Home Health Minutes of the Combined Annual Meeting...The annual meeting of the Group of Professional Personnel (G.O.P.P.) and the Board of Governors. Date: June 13, 2019...The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community based preparedness officials is pending" Document failed to contain signatures of those in attendance.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
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), §485.542(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 Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to develop a risk assessment specific to the agency and include strategies to address emergency events identified by the risk assessments.
Findings included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ...1) Documented facility based risk assessment utilizing an all hazard approach. 2) The plan includes strategies for addressing emergency events identified by risk events..." The EPP failed to contain documentation of a completed risk assessment utilizing an all hazard approach and failed to contain documentation for strategies for addressing emergency events identified by the risk assessment.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(a)(4) STANDARD
Local, State, Tribal Collaboration Process
Name - Component - 00
§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:]
(4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. *
* [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP included documentation of the agency efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ...4) The plan includes a process for cooperation and collaboration of: a) local, b) regional, c) State, d) Federal preparedness officials to maintain an integrated response during a disaster emergency situation. This cooperation and collaboration would include documentation of this HHA's efforts to contact such officials and, when applicable of its participation..." Agency EPP failed to contain documentation of collaboration with local, regional, State and Federal EP officals with the exception of the template received below.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b) STANDARD
Development of EP Policies and Procedures
Name - Component - 00
§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).
(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.
*Additional Requirements for PACE and ESRD Facilities:
*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.
*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop and maintain EPP policies and procedures.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ..." The EPP failed to contain policies and procedures developed and based on the agency risk assessment and the community based risk assessment utilitizing the all hazards approach.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b)(1) STANDARD
HHA Comprehensive Assessment in Disaster
Name - Component - 00
§484.102(b)(1) Condition for Participation:
[(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.
At a minimum, the policies and procedures must address the following:]
(1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55.
Observations:
Based on review of consumer records (CR), agency policy, and staff (EMP) interviews, the agency failed to provide the patient a written individualized emergency plan for four (4) of four (4) CRs that were reviewed. CR1-CR4
Findings included:
Review of agency emergency preparedness policies and procedures on July 24, 2019, at approximately 11:00 a.m. revealed "The 'EP' plan addresses...(b) individual plans for each patient as part of the comprehensive patient assessment..."
CR1 reviewed on 7/24/19 at approximately 9:33 a.m. with a start of care (SOC) 8/21/2018 and a certification period reviewed of 8/21/2018-8/30/2018 did not contain documented evidence of information for emergency preparedness or individualized emergency preparedness plan.
CR2 reviewed on 7/24/2019 at approximately 9:57 a.m. with a SOC 5/27/2017 with a certification period reviewed of 5/27/2017-6/13/2017 did not contain documented evidence of information for emergency preparedness or individualized emergency preparedness plan.
CR3 reviewed on 7/24/2019 at approximately 10:32 a.m. with a SOC 3/14/2019 with a certification period reviewed of 3/14/2019-3/30/2019 did not contain documented evidence of information for emergency preparedness or individualized emergency preparedness plan.
CR4 reviewed on 7/24/2019 at approximately 10:57 a.m. with a SOC 5/31/2018 with a certification period reviewed of 5/31/2018-6/11/2018 did not contain documented evidence of information for emergency preparedness or individualized emergency preparedness plan.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b)(2) STANDARD
Homebound HHA/Hospice Inform EP Officials
Name - Component - 00
§418.113(b)(2), §460.84(b)(4), §484.102(b)(2)
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
*[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview it was determined the agency failed to ensure the agency polices and procedures informed State Emergency Preparedness officials about homebound patients in need of evacuation from their residence.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ...6)...c) the procedure to inform the State and local 'EP' officials about the patient/s need of evacuation from their residences at any time due to an emergency situation based on the patients 'medical' and psychiatric condition and home environment..." The EPP failed to contain policies and procedures developed to inform State and local EP officials about homebound patients in need of evacuation.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b)(3) STANDARD
HHA- Procedures for Follow up Staff/Pts.
Name - Component - 00
§484.102(b)(3) Condition of Participation:
[(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
(3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop an EPP procedure to follow up with on duty staff and patients to determine services that are needed to inform State officials for any that they are unable to contact.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ...7) This HHA's EP plan addresses the procedure to follow up the on duty staff for patients to determine: a) services that are needed in the event that there is an interruption of services during or due to an emergency, b) The HHA will inform the State and Local emergency official of any agency staff or patient that the agency is unable to contact..." The EPP failed to contain the procedure to address the need for State and Local EP officials to assist with contacting staff or patients the agency is unable to contact.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b)(4) STANDARD
Policies/Procedures for Medical Documentation
Name - Component - 00
§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.
*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop and maintain a policy and procedure for medical documention that maintained availability of records in an emergency.
Findings Included:
Review of agency EPP completed on 7/24/2019 at approximately 11:00 a.m. revealed a three (3) page documented titled "A HOLY FAMILY HOME HEALTH EMERGENCY PREPAREDNESS POLICY AND PROCEDURES...A Holy Family Home health 'Policy and Procedure' plan for 'Emergency Preparedness' includes and based on the following: ...8) This HHA's EP does include a medical documentation that preserves: a) patient information, b) protects patient confidential information, c) secures and maintain the availability of patients records..." EPP failed to contain a back up plan for documentation. CR documentation was all paper format. CR are not maintained and secured as agency office, they are secured and maintained at 309 Huron St, Industry PA per EMP4 "my other office"
Review of agency policy on 7/24/2019 at approximately 12:34 p.m. revealed: "Policies for Protection of Clinical Records...At the time of admission, a permanent office file will be established, The patients chart generated at the patients home will upon each discharge be retrieved and returned to the patients permanent office file. All clinical documents/records will be made available/accessible to pertinent people, with knowledge and permission of the administrator. Due to the privacy act, such clinical documents/records will be duly protected, kept under lock and key."
Observation conducted on 7/24/2019 at approximately 9:30 a.m. Surveyor entered A Holy Family Home health office to find the office space door was a bifold non secured office door. The space did not contain a lockable file cabinet. On a sofa was two (2) cardboard boxes with binders and files in them. Surveyor asked for a list of patients. EMP4 pulled four (4) binders from one (1) of the cardboard boxes and removed a piece of paper from the copy machine and then wrote the names of the patients on a piece of paper. Surveyor then asked to see where the files were secured. EMP4 then stated "they are not kept here they are kept at my other office"
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(b)(5) STANDARD
Policies/Procedures-Volunteers and Staffing
Name - Component - 00
§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]
(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency.
*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
Observations:
Based on review of agency EPP and interview with staff (EMP), the agency failed to incorporate emergency staffing strategies for use of volunteers or a process and role for integration of State and Federally designated health care professionals to address surge needs to sustain operations during an emergency.
Findings included:
Review of EPP on July 24, 2019 at approximately 11:00 a.m. revealed the EPP was not dated and did not contain details to develop communication systems to prevent major disruptions in the care and treatment of clients, to identify and respond to priority clients at highest risk, to establish individualized emergency preparedness plan for each consumer, and to provide for the safety of staff. The EPP did not identify a process or role for volunteers/state or federally designated health care professionals if needs arose to require staffing surge. The EPP stated "This HHA 'EP' plan addresses the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State or Federally health care professional to address surge needs during an emergency."
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
During interview on July 24, 2019 at approximately 1:00 p.m., EMP4 continued to insist that surveyors look at template documentation labeled "Dialysis."
Plan of Correction:An approved Plan of Correction is not on file.
484.102(c) STANDARD
Development of Communication Plan
Name - Component - 00
§403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c).
(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].
Observations:
Based on review of agency Emergency Preparedness Plan (EPP) and interview with EMP4, the agency failed to establish and maintain an emergency preparedness communication plan.
Findings included:
Review on July 24, 2019 at approximately 11:00 a.m., of agency Emergency Preparedness Plan revealed the EPP contains no dated or detailed information. The EPP stated "The emergency preparedness (EP) plan includes an intra-agency and extra-agency 'Communication Plan'."
Review of "The annual meeting of the Group of Professional Personnel (G.O.P.P.) and the Board of Governors" dated June 13, 2019, revealed "members discussed and updated the following policies and procedures...The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness officials is pending." No further details or documented evidence was provided.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(c)(1) STANDARD
Names and Contact Information
Name - Component - 00
§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1).
[(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:]
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [facilities].
(v) Volunteers.
*[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians
(iv) Other [hospitals and CAHs].
(v) Volunteers.
*[For RNHCIs at §403.748(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Next of kin, guardian, or custodian.
(iv) Other RNHCIs.
(v) Volunteers.
*[For ASCs at §416.45(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For Hospices at §418.113(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Hospice employees.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Other hospices.
*[For HHAs at §484.102(c):] The communication plan must include all of the following:
(1) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Patients' physicians.
(iv) Volunteers.
*[For OPOs at §486.360(c):] The communication plan must include all of the following:
(2) Names and contact information for the following:
(i) Staff.
(ii) Entities providing services under arrangement.
(iii) Volunteers.
(iv) Other OPOs.
(v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).
Observations:
Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP communication plan included names and contact information for staff, patient physicians, and volunteers readily available and accessible during an emergency.
Findings Included:
Review of facility EPP on July 24, 2019 at approximately 11:00 a.m. revealed: "...The emergency preparedness (EP) plan includes an intra-agency and extra-agency 'Communication Plan'." No futher documentation existed.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
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), §485.542(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 emergency preparedness plan (EPP) and staff (EMP) interview, the agency failed to ensure the EPP communication plan included contact information for local, tribal, regional, state, federal emergency preparedness staff.
Findings included:
Review of EPP on July 24, 2019 at approximately 11:00 a.m., revealed the EPP without date of approval. The EPP failed to list contacts for federal, state, regional, and local emergency management offices/personnel.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(c)(3) STANDARD
Primary/Alternate Means for Communication
Name - Component - 00
§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3).
[(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:
(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.
*[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.
Observations:
Based on review of agency policy and procedure manual, review of meeting minutes, and interview with administrator, the agency failed to establish and maintain an emergency preparedness communication plan that included primary and alternate means to communicate with agency staff and local/regional/state/federal emergency preparedness agencies and that the plan was reviewed and updated annually.
Findings included:
The EPP reviewed on July 24, 2019 at approximately 11:00 a.m., of revealed "The emergency preparedness (EP) plan includes an intra-agency and extra-agency 'Communication Plan'." The EPP was not dated.. The EPP did not contain evidence of a communication plan that included primary and alternate means to communicate with agency staff and local/regional/state/federal emergency preparedness agencies in event of an emergency.
During interview on July 24, 2019 at approximately 1:00 p.m., the agency administrator, EMP4, directed surveyors to "Minutes of the Combined Annual Meeting..." date June 13, 2019. The document contained "At this meeting the members discussed and updated the following policies and procedures...The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness official is pending..." No futher documentation was provided.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(c)(4)-(5) STANDARD
Methods for Sharing Information
Name - Component - 00
§403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).
[(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:
(4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care.
(5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)]
(6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4).
*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative.
*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).
Observations:
Based on review of agency emergency preparedness plan (EPP) and staff (EMP) interview, the agency failed to develop a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health care providers to maintain continuity of care for patients.
Findings Included:
Review on July 24, 2019 at approximately 11:00 a.m., of facility policy and procedure manual revealed the EPP contains no dated or detailed information.
Review of "The annual meeting of the Group of Professional Personnel (G.O.P.P.) and the Board of Governors" dated June 13, 2019, revealed "members discussed and updated the following policies and procedures...The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness officials is pending." No further details or documented evidence was provided.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(c)(6) STANDARD
Information on Occupancy/Needs
Name - Component - 00
§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7).
[(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:
(7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.
Observations:
Based on review of agency policy and procedure manual and interview with administrator, the agency failed to establish and maintain an emergency preparedness communication plan that included a method for sharing of information about the agency's needs and ability to provide assistance to the authority having jurisdiction during an emergency event.
Findings included:
The EPP reviewed on July 24, 2019 at approximately 11:00 a.m., of revealed "The emergency preparedness (EP) plan includes an intra-agency and extra-agency 'Communication Plan'." The EPP was not dated.. The EPP did not contain evidence of a communication plan that included sharing information about the agency's need and ability to provide assistance during an emergency event.
During interview on July 24, 2019 at approximately 1:00 p.m., the agency administrator, EMP4, directed surveyors to "Minutes of the Combined Annual Meeting..." date June 13, 2019. The document contained "At this meeting the members discussed and updated the following policies and procedures...The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness official is pending..." No futher documentation was provided.
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to develop and maintain an emergency preparedness training and testing program based on the agency's emergency plan and to review and update the training/testing program annually.
Findings Included:
Review on July 24, 2019 at approximately 11:00 a.m. revealed an EPP that was not dated and did not contain detailed information regarding completion of exercises. The EPP did contain "The 'EP' plan includes a 'Training' and 'Testing program which is reviewed and update at least annually and takes into account a) 'risk assessment' b) 'EP' policies and porcedure, c) communication plan...The training in 'EP' will be done...Note: The HHA to 'demonstrate' and document the 'EP' training. 'EP' plan testing....5) Maintain documentation of drills."
Interview on July 24, 2019 at approximately 1:00 p.m. with EMP4 confirmed the findings and directed surveyors to meeting minutes that revealed "The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness officials is pending."
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no" Surveyor asked was a testing and training program completed. EMP4 stated "yes" Surveyor asked where is the documentation. EMP4 stated "I don't have any"
Plan of Correction:An approved Plan of Correction is not on file.
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 the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to develop and maintain an emergency preparedness training and program based on the agency's emergency plan and to review and update the training/testing program annually.
Findings Included:
Review on July 24, 2019 at approximately 11:00 a.m. revealed an EPP that was not dated and did not contain detailed information regarding completion of exercises. The EPP did contain "The 'EP' plan includes a 'Training' and 'Testing program which is reviewed and update at least annually and takes into account a) 'risk assessment' b) 'EP' policies and porcedure, c) communication plan...The training in 'EP' will be done...Note: The HHA to 'demonstrate' and document the 'EP' training. 'EP' plan testing....5) Maintain documentation of drills."
Interview on July 24, 2019 at approximately 1:00 p.m. with EMP4 confirmed the findings and directed surveyors to meeting minutes that revealed "The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness officials is pending."
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no" Surveyor asked was a testing and training program completed. EMP4 stated "yes" Surveyor asked where is the documentation. EMP4 stated "I don't have any"
Plan of Correction:An approved Plan of Correction is not on file.
484.102(d)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to develop and maintain an emergency preparedness testing program based on the agency's emergency plan and to review and update the training/testing program annually.
Findings Included:
Review on July 24, 2019 at approximately 11:00 a.m. revealed an EPP that was not dated and did not contain detailed information regarding completion of exercises. The EPP did contain "The 'EP' plan includes a 'Training' and 'Testing program which is reviewed and update at least annually and takes into account a) 'risk assessment' b) 'EP' policies and porcedure, c) communication plan...The training in 'EP' will be done...Note: The HHA to 'demonstrate' and document the 'EP' training. 'EP' plan testing....5) Maintain documentation of drills."
Interview on July 24, 2019 at approximately 1:00 p.m. with EMP4 confirmed the findings and directed surveyors to meeting minutes that revealed "The Emergency Preparedness Policy was updated, reviewed and approved, however contact with the community-based preparedness officials is pending."
Interview completed on 7/24/2019 at approximately 1:00 p.m. with EMP4 confirmed the findings.
EMP4 handed Surveyor a blank Emergency template on 7/24/2019 at approximately 1:00 p.m. with an email received from Beaver County Emergency Management on June 19, 2019. The template was blank and not completed and marked Dialysis. Surveyor asked EMP4 if he had worked on making this his EPP. EMP4 stated "no" Surveyor asked was a testing and training program completed. EMP4 stated "yes" Surveyor asked where is the documentation. EMP4 stated "I don't have any"
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:
Based on the findings of an unannounced on-site State re-licensure and Medicare re-certification survey conducted July 15-July 24, 2019, A Holy Family Home Health was found not to be in compliance with the requirements of 28 PA Code, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
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 a review of personnel files (PF) and staff (EMP) interview, it was determined the agency failed to ensure PF contained health evaluations for three (3) of three (3) PF reviewed. (PF1-PF3)
Findings Included:
Review of PF completed on July 24, 2019 at approximately 10:41 a.m. revealed:
PF1, date of hire (DOH) 5/23/2014, PF did not contain evidence of annual TB testing for 2017, 2018, 2019
PF2, DOH 3/4/2014, PF did not contain evidence of annual TB testing for 2017, 2018, and 2019, CPR card expired 2/2017.
PF3, DOH 4/1/2014, PF did not contain evidence of annual TB testing for 2017, 2018, and 2019,
Interview on July 24, 2019 at approximately 12:34 p.m. with EMP4 confirmed the findings. EMP4 stated. "I do not have a policy on TB or CPR."
Plan of Correction:An approved Plan of Correction is not on file.
601.22(c) REQUIREMENT
ANNUAL PROGRAM EVALUATION
Name - Component - 00
601.22(c) Annual Program Evaluation.
The home health agency has written
policies requiring an overall
evaluation of the agency's total
program at least once a year by: (i)
the group of professional personnel
(or a committee of this group), agency
staff and consumers, or by (ii)
professional people outside the agency
working in conjunction with consumers.
The evaluation consists of an overall
policy and administrative review and a
clinical record review. The
evaluation assesses the extent to
which the agency's program is
appropriate, adequate, effective and
efficient. Results of the evaluation
are reported to and acted upon by
those responsible for the operation of
the agency and are maintained
separately as administrative records.
As a part of the evaluation process
the policies and administrative
practices of the agency are reviewed
to determine the extent to which they
promote patient care that is
appropriate, adequate, effective, and
efficient. Mechanisms are established
in writing for the collection of
pertinent data to assist in
evaluation. The data to be considered
may include but are not limited to:
number of patients receiving each
service offered, number of patient
visits, reasons for discharge,
breakdown by diagnosis, sources of
referral, number of patients not
accepted, with reasons, and total
staff days for each service offered.
Observations:
Based on review of agency policies, agency meeting minutes, and staff (EMP) interview, the agency failed to develop a policy with defined mechanisms for what data would be collected to assist with program evaluation and conduct an evaluation and report results to those responsible for operation of the agency, and evaluate whether agency policies and practices promoted patient care that was appropriate, adequate, effective and efficient.
Findings included:
Review of agency policy and procedures completed on July 24, 2019 at approximately 10:30 a.m. revealed all agency policy and procedures were dated 2014. Documentation failed to contain a policy for annual program evaluation.
Review of agency Combined annual meeting completed on 7/24/2019 at approximately 9:47 a.m. revealed: "A Holy Family Home Health Minutes of the Combined Annual Meeting...The annual meeting of the Group of Professional Personnel (G.O.P.P.) and the Board of Governors. Date: June 13, 2019..." Documentation failed to contain documentation that the annual program evaluation was completed.
Interview completed on July 24, 2019 at approximately 1:00 p.m. with EMP4 confirmed the findings. Surveyor asked EMP4 was an annual program evaluation completed. EMP4 stated "yes it is in the minutes" Surveyor asked "where is the additional documentation" EMP4 stated "all I have is what is in the minutes"
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:
Based on the findings of an unannounced Medicare recertification and state relicensure survey conducted July 15-July 24, 2019, A Holy Family Home Health was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart F, Chapter 601 and Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification and State re-licensure survey conducted July 15 - July 24, 2019, A Holy Family Home Health, was found to be in compliance with the requirements of 35 P.S.448.809 b.
Plan of Correction:
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