QA Investigation Results

Pennsylvania Department of Health
CARE PLUS HOME HEALTH SERVICES, INC.
Health Inspection Results
CARE PLUS HOME HEALTH SERVICES, INC.
Health Inspection Results For:


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Initial Comments:


Based on the findings of an unannounced onsite Medicare Recertification survey completed on May 14, 2021, Care Plus Home Health Services, Inc was found to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.






Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure and Medicare re-certification survey completed May 14, 2021, Care Plus Home Health Services, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies-Emergency Preparedness.










Plan of Correction:




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

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

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at 482.15 and CAHs at 485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:


Based on a review of the agency Emergency Operations Plan and Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to develop and maintain an EPP that was reviewed and updated every two years.

Findings Included:

Review of the agency Emergency Preparedness Plan/Policies occurred on 5/12/2021 at approximately 1:15 PM. Documentation revealed that the plan was last revised on 8/16/2018.

Discussion with EMP1 (Administrator) and EMP2 (Office Manager) occurred on 5/12/2021 at 1:30PM regarding Emergency Preparedness. EMP1 and EMP2 were unable to provide evidence of documentation that the emergency preparedness program was reviewed or updated for the period of 2020 or later.

Findings were confirmed with EMP1 and EMP2 during an exit interview that was conducted on 5/14/2021 at approximately 1:40 PM.





Plan of Correction:

Bases on our recent state inspection that found Care Plus out of compliance with the emergency preparedness plan (EPP). Care Plus administrative team will revise and update our Epp. We plan to consult with healthcare coalition of southwestern Pennsylvania (HCSWPA) for guidance in creating an updated EPP. The office manager and administrator will work with HCSWPA in developing an EPP for all our patients that we serve. The Epp will be in compliance with all applicable federal, state and local emergency preparedness requirement of section 484.102(a). Our first step will be data analyzes of hazard vulnerability for our service area. We will use a hazard vulnerability assessment toll that accurately indicates and evaluates risk levels for emergencies that our agency may face in the futures. Some tools that we have looked at measure the event, probability level, vulnerability level, preparedness level, and our scores. Care Plus will choose the best assessment tool for our agency in determining our EPP.
Following completion of the hazard vulnerability assessment tool, Care Plus will determine what events/emergencies are a concern for Care Plus and will devisde an EPP. Care Plus plans to work closely with HCSWPA to create the best and most appropriate EPP for the events that were found in the hazard vulnerability assessment.
After completion of the EPP Care Plus will hold a meeting that will be mandatory for all staff to attend. staff signature and dates will be obtained and filed to ensure completion and attendance was completed for the training on the updated EPP. The office manager and administrator will be in charge of the meeting/training. Following the meeting/training all staff will sign off on the EPP training and will acknowledge understanding of the EPP. From that point forward Care Plus will require annual training and education regarding the EPP as well as upon hiring of all new staff. Epp will also be reviewed and discussed annually during the annual review meeting of the governing body.
Care Plus will have the EPP updated, revised, completed with all staff training on the updated EPP by 6/25/2021


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

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

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

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

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

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

*[For LTC facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
(2) Include strategies for addressing emergency events identified by the risk assessment.

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

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

Observations:


Based on a review of the agency Emergency Operations Plan and Preparedness Plan (EPP) and staff (EMP) interview, it was determined the agency failed to ensure documentation of a facility-based and community-based risk assessment for 2020.

Findings include:

Review of the agency Emergency Preparedness Plan/Policies occurred on 5/12/2021 at approximately 1:15 PM, including the agency hazard vulnerability assessment tool. Documentation revealed that the hazard vulnerability assessment tool was last revised on 10/25/2017.

Discussion with EMP1 (Administrator) and EMP2 (Office Manager) occurred on 5/12/2021 at 1:30PM regarding Emergency Preparedness and the hazard vulnerability assessment tool. EMP1 and EMP2 were unable to provide evidence that the hazard vulnerability assessment tool was reviewed or updated for the period of 2020 or later.

Findings were confirmed with EMP1 and EMP2 during an exit interview that was conducted on 5/14/2021 at approximately 1:40 PM.





Plan of Correction:

Bases on our recent state inspection that found Care Plus out of compliance with the emergency preparedness plan (EPP). Care Plus administrative team will revise and update our Epp. We plan to consult with healthcare coalition of southwestern Pennsylvania (HCSWPA) for guidance in creating an updated EPP. The office manager and administrator will work with HCSWPA in developing an EPP for all our patients that we serve. The Epp will be in compliance with all applicable federal, state and local emergency preparedness requirement of section 484.102(a). Our first step will be data analyzes of hazard vulnerability for our service area. We will use a hazard vulnerability assessment toll that accurately indicates and evaluates risk levels for emergencies that our agency may face in the futures. Some tools that we have looked at measure the event, probability level, vulnerability level, preparedness level, and our scores. Care Plus will choose the best assessment tool for our agency in determining our EPP.
Following completion of the hazard vulnerability assessment tool, Care Plus will determine what events/emergencies are a concern for Care Plus and will devisde an EPP. Care Plus plans to work closely with HCSWPA to create the best and most appropriate EPP for the events that were found in the hazard vulnerability assessment.
After completion of the EPP Care Plus will hold a meeting that will be mandatory for all staff to attend. staff signature and dates will be obtained and filed to ensure completion and attendance was completed for the training on the updated EPP. The office manager and administrator will be in charge of the meeting/training. Following the meeting/training all staff will sign off on the EPP training and will acknowledge understanding of the EPP. From that point forward Care Plus will require annual training and education regarding the EPP as well as upon hiring of all new staff. Epp will also be reviewed and discussed annually during the annual review meeting of the governing body.
Care Plus will have the EPP updated, revised, completed with all staff training on the updated EPP by 6/25/2021


Initial Comments:


Based on the findings of an onsite unannounced state relicensure and Medicare re-certification survey completed May 14, 2021, Care Plus Home Health Services, Inc. was found 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:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure and Medicare re-certification survey completed May 14, 2021, Care Plus Home Health Services, Inc. was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.










Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced state relicensure and Medicare re-certification survey completed May 14, 2021, Care Plus Home Health Services, Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).









Plan of Correction: