Genus Home Care of San Bernardino

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of seven staff members was knowledgeable about the location of the facility’s designated alternate meeting location in case of emergencies. This failure had the potential for a delay in the overall facility communication and coordination of services for all 38 vulnerable patients at risk who received care from the facility. Findings: During an interview on June 16, 2026, at 10:15 AM, with Licensed Vocational Nurse (LVN 1), at Patient 1’s home, LVN 1 stated that she does not know where the facility’s alternate emergency meeting location was. LVN 1 further stated that she has not been educated or done in-service training (provided to employees while on job) regarding emergency preparedness. During an Interview on February 18, 2026, at 12:30 PM, with the Director of Patient Care services (DPCS), the DPCS stated that, “All staff should have been educated and in-serviced on emergency preparedness, LVN should know the designated and alternate meeting location in case of emergency”. During a follow up concurrent interview and record review on February 18, 2026, at 1:15 PM, with the DPCS, the facility’s document titled, “EMERGENCY PEPAREDNESS / DISASTER RECALL TREE”, undated, was reviewed, and “In-Service Sign-In-Sheet for Emergency Preparedness Training,” (Sign in sheet), dated from May 2025 to June 2026, was reviewed. The “EMERGENCY PEPAREDNESS / DISASTER RECALL TREE” indicated, “…IN THE EVENT THAT THE AGENCY OR ITS SURROUNDING OBATAIN ANY NATURAL DISASTER OR FIRE. THE OFFFICE STAFF WILL MEET WITH FIELD STAFF TO RECONCILE ALL INFORMATION AND PATIENT’S CONDITION IN THE: 1ST Command Post: Parking Lot of County Building at 157 W. 5th Street, San Bernadino, CA 92401, 2nd Command Post: Administrator’s Residence: 1476 W. 9th Street Upland, CA 91786…” The Sign in sheet did not indicate LVN 1 completed the training. The DPCS verified and confirmed that LVN 1 has not completed facility’s in-service emergency preparedness training, and this failure has the potential to place vulnerable patients at risk for delays in communication and coordination of services.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure personal health information was kept confidential for one of three sampled patients (Patient 1) when Licensed Vocational Nurse (LVN 1) received and sent Patient 1’s clinical records using her personal cell phone. This failure resulted in Patient 1’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. Findings: A review of Patient 1’s face sheet (contains demographic and medical information), undated, indicated Patient 1’s start of care date of December 8, 2015, with a certification period of April 14, 2026, to June 12, 2026. Patient 1 had diagnosis that included spastic quadriplegic cerebral palsy (cerebral palsy-CP-a group of disorders affecting a person’s ability to move, maintain balance, and posture, the most severe form of CP, affecting muscle control in all four limbs, the trunk, and the face, caused by brain damage before or around birth). During a home visit observation on June 16, 2026, at 10:00 AM, with LVN1, LVN 1 was sending Patient 1’s confidential personal medical information on her personal cell phone. During a subsequent interview with LVN1, LVN1 verified and confirmed she uses her personal cell phone to send and receive Patient’s confidential information to the agency without using a secure app (a shortened term for “application” or “application program”), LVN 1, further stated that the agency has provided secure app to send or receive patients’ confidential information, but she used her personal cell phone to text patients confidential Information. During an interview on June 18, 2026, at 10:30 AM with the Director of Patient Care Services (DPCS), the DPCS confirmed that the agency has secure app to send or receive patient’s confidential information, but LVN 1 used her personal cell phones to send and receive patient confidential information. During a concurrent interview and record review on June 18, 2026, at 11:30 AM, with the DPCS, the facility’s policy and procedure (P&P) titled, “CONFIDENTIALITY OF INFORMATION POLICY”, dated December 2007, was reviewed. The P&P indicated, “POLICY STATEMENT- it will be the policy of this Agency to insure the confidentiality, security, and integrity of patient and Agency information by all staff members…15. The Agency will assure conformance with current acceptable professional standards and follow state laws that may be more prescriptive…” The DPCS stated LVN 1 did not follow the agency policy for “confidentiality of information policy”.”