Dependable Home Health, Inc.

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: The facility must demonstrate it maintains an effective infection control program that protects patients, families, visitors, and personnel by preventing and controlling infections and communicable diseases including monitoring staff for compliance with policies and procedures related to infection control. This requirement was NOT MET as evidenced by: Based on observation and staff interviews, the establishment failed to follow facility policy “Tuberculosis Exposure Control Plan”. This deficient practice has the potential to unnecessarily increase the risk of potential infections leading to possible outbreaks, staff shortages, and adversely affecting patient outcomes. Findings include: Review of facility policy, “Tuberculosis Exposure Plan Policy No. 6-028.1” revealed, “...An annual organization TB risk assessment will be completed to determine the need, type and frequency of testing/assessment for direct care personnel. Dependable Home Health Inc., will reassess the risk of transmission of TB to evaluate effectiveness of the TB exposure plan. The risk assessment will include consideration of local and state regulations regarding Tuberculin Skin Tests (TSTs) for employees....” Review of facility’s infection control binder revealed organization TB risk assessment had not be completed for 2022, 2023 or 2024. During interview with employee #2, they acknowledged a facility TB risk assessment for 2022, 2023, or 2024 had not been completed. Employee #2 completed and presented a facility TB risk assessment for 2024 during survey. Review of facility policy, “Tuberculosis Exposure Plan Policy No. 6-028.1” revealed, “...E. In addition to the TB screening test, all patient care personnel will be given an individual TB risk assessment to establish a baseline....” Review of facility’s personnel records revealed employees #1,#2,#3,#4, #5, #6, #7, #8, #9 , #10, #11, #12 TB risk assessment for personnel not present in employee record. In Interview with employee #2 it was acknowledged the initial individual Tb risk assessments could not be provided for employees #1,#2,#3,#4, #5, #6, #7, #8, #9 , #10, #11, #12.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: The facility must ensure contact information for the facility’s administrator, including the administrator’s name, business address, and business phone number is included in admission packet in order to receive complaints in a timely manner. This requirement was NOT MET as evidenced by: Based on observation and staff interviews, the facility failed to ensure that the administrator’s name, business address, and business phone number is included in admission packet. Failure to include the correct contact information can result in a delay in receiving and resolving patient complaints which has the potential to adversely affect patient satisfaction, quality of care, and outcomes. Findings include: Review of facility admission packet revealed name and contact information was for another employee and not the administrator. During interview, the administrator acknowledged the name and contact information was incorrect.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: The facility must demonstrate the administrator has been appointed by and accountable to the governing body This requirement was NOT MET as evidenced by: Based on observation and staff interviews, the facility failed to provide governing board minutes supporting the appointment of the current administrator. Findings include: Review of the governing body minutes did not reveal appointment of an administrator. During interview with employee #1, it was acknowledge that governing body minutes could not be produced verifying appointment of current administrator but verified they held the position. During interview with employee #2 it was confirmed that employee #1 held the title as Administrator. Personnel file requested but not provided.”