Initial Comments:
An onsite follow-up survey conducted on February 21, 2024 found that LifeLine Home Health, Inc. had not corrected one (1) deficiency cited under the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies and failed to follow its plan of correction for Medicare Re-Certification Follow-up Survey completed on December 15, 2023. The deficiencies were cited as a result of a Medicare Re-Certification Follow-up Survey completed on December 15, 2023 and a Medicare Re-Certification survey completed on August 17, 2023.
Plan of Correction:
484.105(b)(1)(iv) ELEMENT
Ensure that HHA employs qualified personnel
Name - Component - 00
(iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies.
Observations:
Based on a review of personnel files (PF), CDC (Centers for Disease Control and Prevention) guideline, the agency's plan of correction for the Medicare Re-certification survey completed on December 15, 2023, and an interview with the administrator, the agency failed to demonstrate the presence of the following:
Screening for mycobacterium tuberculosis (TB) for four (4) of four (4) files reviewed: PF# 9, 11, 12.
Background checks (PATCH (Pennsylvania Access To Criminal History)) for one (1) of one (1) file reviewed: PF# 11.
Findings include:
A review of the home health agency's plan of correction for the Medicare Re-certification Survey completed on December 15, 2023 was conducted on February 21, 2024 at approximately 12:00 PM. The plan of correction reads the following:
1. PF #9, 11 and 12 have been advised to have 2 step TB test or Quantiferon test completed no later than 2/10/24.
2. PF#11 Criminal Background Check was completed on 3/22/2023.
3. LifeLine Home Health will only hire Certified Nursing Assistants to care for Skilled Clients or LPNs who work as Aides. All Home Health Aides will be given a Initial Competency test. Test will be graded and place in personnel files.
4. The plan of correction will be fully implemented by 2/13/2024.
The Centers for Disease Control and Prevention (CDC) and the National TB (Tuberculosis) Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
A review of personnel files (PF) was conducted on February 21, 2024, starting at 12:00 PM. The date of hire (DOH) is indicated below.
PF#9 DOH 8/3/20 did not contain evidence of second step of TST.
PF#11 DOH 3/5/23 did not contain evidence of Background checks including PATCH (Pennsylvania Access To Criminal History). PATCH has date of 6/1/21 which is older than 1 year prior to hire date. PF did not contain second step of TST.
PF#12 DOH 1/20/22 did not contain evidence of second step of TST.
An interview conducted with the administrator on February 21, 2024, at approximately 1:00 PM confirmed agency failed to follow its plan of correction and the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:An onsite follow-up survey conducted on February 21, 2024 found that LifeLine Home Health, Inc. had not corrected one (1) deficiency cited under the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness and failed to follow its plan of correction for Medicare Re-Certification Follow-up Survey completed on December 15, 2023. The deficiency was cited as a result of a Medicare Re-Certification Follow-up Survey completed on December 15, 2023 and a Medicare Re-Certification survey completed on August 17, 2023.
Plan of Correction:
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 a review of the Emergency Preparedness Program documents provided by the agency, the agency's plan of correction for the Medicare Re-certification survey completed on December 15, 2023, and an interview with the administrator, the agency failed to provide evidence that the emergency preparedness plan was tested annually.
Findings include:
A review of the home health agency's plan of correction for the Medicare Re-certification Survey completed on December 15, 2023 was conducted on February 21, 2024. The plan of correction reads the following:
1. LifeLine will conduct either a table top mock disaster drill with responses from field operations or if opportunity arises, record a real disaster with responses from field operations. LifeLine will document any lessons learned from the experience. LifeLine Administrative Staff have examples to follow from previous years to document these events. LifeLine will continue to document these exercises or a real disaster event at least annually, moving forward, per company policy and process.
2. LifeLine Administrative Staff will work with the Administrator and President to insure that this task is completed timely and annually, per Calendar Year.
3. LifeLine will implement a practice to conduct Annual Reviews for compliance, per Calendar Year.
4. In order to confirm that the plan of correction is effective and sustained, the process of Emergency Preparedness Drills and Reviews will be overseen by the Agency Administrator and Agency President.
5. The plan of correction will be fully implemented by 2/13/2024.
A review of the home health agency's emergency preparedness documents conducted on February 21, 2024, approximately 12:00 PM. File did not contain any evidence that exercises to test the emergency preparedness plan were conducted in 2024 or 2023.
An interview conducted with the administrator on February 21, 2024, at approximately 1:00 PM confirmed agency failed to follow its plan of correction and the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
Initial Comments:An onsite follow-up survey conducted on February 21, 2024 found that LifeLine Home Health, Inc. had not corrected one (1) deficiency cited under the requirements of 28 Pa. Code, Part IV, Health Facilities, Subpart G, Chapter 601 and failed to follow its plan of correction for State Re-Licensure Follow-up Survey completed on December 15, 2023. The deficiencies were cited as a result of a State Re-Licensure Follow-up Survey completed on December 15, 2023 and a State Re-Licensure survey completed on August 17, 2023.
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), CDC (Centers for Disease Control and Prevention) guideline, the agency's plan of correction for the Medicare Re-certification survey completed on December 15, 2023, and an interview with the administrator, the agency failed to demonstrate the presence of the following:
Screening for mycobacterium tuberculosis (TB) for four (4) of four (4) files reviewed: PF# 9, 11, 12.
Background checks (PATCH (Pennsylvania Access To Criminal History)) for one (1) of one (1) file reviewed: PF# 11.
Findings include:
A review of the home health agency's plan of correction for the Medicare Re-certification Survey completed on December 15, 2023 was conducted on February 21, 2024 at approximately 12:00 PM. The plan of correction reads the following:
1. PF #9, 11 and 12 have been advised to have 2 step TB test or Quantiferon test completed no later than 2/10/24.
2. PF#11 Criminal Background Check was completed on 3/22/2023.
3. LifeLine Home Health will only hire Certified Nursing Assistants to care for Skilled Clients or LPNs who work as Aides. All Home Health Aides will be given a Initial Competency test. Test will be graded and place in personnel files
4. Lifeline will implement a practice to conduct quarterly personnel files to ensure ongoing compliance.
5. Discrepancies will be corrected upon discovery.
6. Lifeline Staff Coordinator and Administrator will be responsible to follow Lifeline's Agency policy and procedure regarding hiring practices.
7. The plan of correction will be fully implemented by 2/13/2024.
The Centers for Disease Control and Prevention (CDC) and the National TB (Tuberculosis) Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19).
A review of personnel files (PF) was conducted on February 21, 2024, starting at 12:00 PM. The date of hire (DOH) is indicated below.
PF#9 DOH 8/3/20 did not contain evidence of second step of TST.
PF#11 DOH 3/5/23 did not contain evidence of Background checks including PATCH (Pennsylvania Access To Criminal History). PATCH has date of 6/1/21 which is older than 1 year prior to hire date. PF did not contain second step of TST.
PF#12 DOH 1/20/22 did not contain evidence of second step of TST.
An interview conducted with the administrator on February 21, 2024, at approximately 1:00 PM confirmed agency failed to follow its plan of correction and the above findings.
Plan of Correction:An approved Plan of Correction is not on file.
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