MD Home Health

“Names and Contact Information CFR(s): 484.102(c)(1) §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). This Standard is not met as evidenced by: Based on review of facility policy, facility documentation and staff interview, it was determined the facility failed to include names and contact information for staff, patient physicians and entities providing services under arrangement in the facility communications plan. Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event for staff and patients. Findings include: Review of facility Policy titled “Emergency Preparedness Response Plan EC.40” revealed, “...Purpose...I. To ensure the Agency complies with all applicable federal, state, and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains....communication plan...IV. Continuity of Operations Business Plan...1, Communication a. The Agency will maintain a current list of staff, and volunteers, and all applicable contact numbers...b. The Agency will also develop, maintain... a current list of names and contact information for patients’/clients’ physicians....” Review of facility emergency preparedness documentation presented on July 16, 2025, revealed staff contact list, not dated, did not include employees #3, #4 and included employee #12 who terminated on 5/14/2025, employee #13 who terminated 2/14/2025 and employee #14 who terminated on 11/11/2024. On July 17, 2025 at 11:15 am, an updated staff list was presented to surveyors inclusive of employees #3 and #4 and excluding employees #12, #13, and #14. Review of facility emergency preparedness documentation presented on July 16, 2025, revealed Active Census Report patient dated 5/12/2025 with a sticky note attached: “UPDATE weekly Every Monday”. This list was not inclusive of patients #2,#14, #15, #16. No documentation presented evidencing any patient physician’s name and contact information including patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16. Employee #1 confirmed in an interview on July 18, 2025, the emergency preparedness staff contact list and active patients and their physicians’ names and contact information should be kept up to date in the agency’s emergency preparedness documentation.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on review of facility policies and procedures, documentation and staff interview it has been determined that the facility failed to ensure all personnel have documentation of a negative Mantoux skin test or other tuberculosis screening test dated within 12 months before the date the individual begins providing services on behalf of the healthcare institution. This deficient practice has the potential to place patients, colleagues, and members of the community at risk of unnecessary exposure to infectious tuberculosis. Findings include: Review of facility policy titled, “Exposure Control Plan - Addendum...IC.5-AZ” revealed: “...Procedure...II...A. HCP must provide one of the following on or before the date the individual begins providing services at or on behalf of the Agency as evidence of freedom from infectious disease....” Review of personnel records revealed: Employee #2 No evidence of initial TB testing in personnel record Employee #4 TB testing is invalid as read time is not documented Employee #5 No evidence of initial TB testing in personnel record Employee #6 TB testing is invalid as administration and read times are not documented Employee #8 No evidence of initial TB testing in personnel record Employee #9 TB testing is invalid as administration and read times are not documented Employee #10 TB testing is invalid as administration and read times are not documented Employee #11 No evidence of initial TB testing in personnel record In an interview conducted on July 15, 2025 with employee #1, it was acknowledged that some steps in the hiring process had been missed for several employees during tenure of previous HR employee.”