Arizona Home Care

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §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. This Standard is not met as evidenced by: The facility must develop polices and procedures to address a surge in staffing needs to ensure adequate qualified personnel (including volunteers) are available in the event of a natural disaster, pandemic, or other community event to enable patients/clients to continue to receive needed services as required as identified in each patients/clients plan of care. This requirement was NOT MET as evidenced by: Based on observation, record review and staff interviews, the facility failed to develop polices and procedures to address a surge in staff needs. Failure to formalized polices and procedures to address surge staffing needs has the potential to negatively impact patient safety, increase patient mortality and morbidity, risk the health and welfare of existing staff, and disrupt healthcare system function. Findings include: Review of facility’s Emergency Preparedness Policy and Emergency Preparedness Binder contents revealed no information could be found to address surge staffing needs. During interview with Employee #1 it was revealed, “No formalized/written policy or procedure has been developed around surge staffing needs.”

“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: The facility must develop and maintain an emergency preparedness communication plan that includes names and contact information for the staff, entities providing services under arrangement, patients’ physicians, and volunteers. This requirement was NOT MET as evidenced by: Based on observation, documentation review, and staff interviews, the facility failed to create a plan that includes documenting contact information for entities providing services under arrangement and volunteers. This deficient practice has the potential to negatively impact patient services and safety. Findings include: Review of the facility’s Emergency Preparedness Policies and Procedures documents presented revealed no documentation containing contact information for entities providing services under arrangement and volunteers. During interview with Employee #1 it was revealed, “No Emergency Preparedness documentation containing contact information for entities providing services under arrangement and volunteers currently existed. We are working to create now.””

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §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. This Standard is not met as evidenced by: The facility must develop and maintain an emergency preparedness communication plan that includes contact information for Federal, State, tribal, regional, and local emergency preparedness staff. This requirement was NOT MET as evidenced by: Based on observation, record review and staff interviews, the facility failed to present polices and procedures that includes contact information for Federal, State, tribal, regional, and local emergency preparedness staff. Failure to develop and maintain an emergency preparedness communication plan that includes contact information for Federal, State, tribal, regional, and local emergency preparedness staff has the potential to negatively impact patient safety can contribute to increased patient mortality and morbidity. Findings include: Review of the facility’s Emergency Preparedness Policies and Procedures documents presented revealed no documentation that includes contact information for Federal, State, tribal, regional, and local emergency preparedness staff. During interview with Employee #1 it was revealed, “Contact information for Federal, State, tribal, regional, and local emergency preparedness staff information was available to staff but did not exist in the emergency preparedness communication plan.””

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: The facility must provide infection control education to staff at orientation, annually, and as needed to meet the staff’s learning needs to provide adequate care. Education must include identify infection signs and symptoms; identify routes of infection transmission; appropriately disinfect/sanitize/transport equipment and devices used for patient care; and use proper medical waste disposal techniques. Such education must include instructions on how to implement current infection prevention/treatment practices in the home setting. This requirement was NOT MET as evidenced by: Based on policy review, record review, and staff interview, the facility failed to provide documentation to support infection control education to staff annually and as needed to meet the staff’s learning needs to provide adequate care. A lack of continuous training and education on infection control practices can lead to complacency and errors resulting in an increased risk of healthcare-associated infections among patients leading to complications, patient morbidity, and mortality. Review of the facility’s personnel records for employees # 1,2,3,4,5,6,7.8,9,10 and in-service documentation provided, failed to reveal annual infection control education being provided to staff. Review of facility policy, “Inservice Education”, revealed, “...2. Certain in-service programs are determined by the Agency to be mandatory initially and annually for all staff. Theses include, but are not limited to: OSHA bloodborne pathogens, TB risk program, Hazardous materials in the workplace (Right To Know Program), Emergency Operations Plan...10.Ongoing education, including in-services are provided:...To emphasize safety and infection prevention and control as applicable to each employee’s job responsibilities...12. All in-service and education programs will be documented....” Review of facility policy, “Personnel Records”, revealed, “...Procedure: 1. The personnel record or personnel information for an employee will include, but not be limited to, the following:.. Inservice education record...” During interview with Employee #1 it was acknowledged employee #1 was unaware of the infection control education requirements and would ensure the facility is in compliance in the future.”

“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 provide patients with contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This requirement was NOT MET as evidenced by: Based on observation, record review and staff interviews, the facility failed to provide patients the name of the HHA administrator in order to receive complaints. This deficient practice can lead to a delay in receiving and addressing patients concerns and complaints can potentially result in a delay in patient care, increased patient dissatisfaction, a loss of trust in the healthcare provider, potential escalation of the issue, as well as damage to the facility’s reputation. Review of the facility’s Patient Handbook, page 18, presented revealed “Jason Smidt” as the administrator to contact regarding complaints. Review of facility policy, “Complaint Resolution”, revealed, “...2. Each patient receives in writing during the initial evaluation visit contact information for the Agency Administrator, including name, business address and business telephone number for receiving complaints...” During interview, Employee #1 acknowledged Patient Handbook should be updated to reflect the current administrator.”