D’first Home Care, Inc.

“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 record review and interview, the provider failed to ensure that all staff participate in the emergency preparedness training at least every 2 years and maintain documentation of the training for 2 out 10 sample personnel records reviewed. Staff D and Staff E Findings included: On 11/15/2023, the Administrator provided in-service(s) training dated 02/2023 related to the agency’s emergency plan. Review of personnel records conducted on 11/14/23 to 11/15/23 for Staff D (Physical Therapist) and Staff E (Physical Therapist Assistant) revealed no documentation that demonstrated the staff participated on the most recent emergency training for the Home Health Agency. Interview was conducted with the Administrator on 11/15/2023 between 3:38 PM and 3:55 PM, acknowledged that the Staff D and Staff E providing physical therapy service have not participated in the education in-service from the provider.”

“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 observation, record review and interview, the home health agency staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases for 1 out of 3 Sampled Patients (SP) with home visits made. SP#1 Findings include: During a home visit made to SP#1 on 11/14/23 at 10:08 AM surveyor observed Staff C (Licensed Practical Nurse) remove old dressing from left lower extremity. Staff C at 10:10 am then removed gloves, sanitized hands and donned clean gloves. At 10:12 AM, Staff C provided wound care to the left lower extremity stump by cleansing with normal saline and 4x4 gauze. At 10:12 AM, the Staff C with dirty gloves (after cleansing wound) picked from clean 4x4 gauze pack to continue providing wound care. At 10:13 AM, Staff C with dirty gloves (gloves used after cleansing wound) applied medicated ointment and clean 4x4 gauze, wrapped left extremity with kerlix and secured it in place with tape. Interview conducted with the Administrator on 11/15/23 between 3:38 PM and 3:55 PM that confirmed Staff C failed to maintain infection control when providing wound care to SP#1.”

“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: Based on record review and interview, the provider failed to demonstrate that 2 out of 10 active staff received annual in-service on infection control. (Staff D and Staff E) Findings include: Record review revealed the provider provided infection control education in-service on 04/2023 to its employees. Further record review revealed no documentation to show that active Staff D and Staff E participated in the infection control education in-service. Interview was conducted with the Administrator on 11/15/2023 between 3:38 PM and 3:55 PM acknowledged that the Staff D and Staff E are providing physical therapy service to patients of the home health agency and have not received infection control education in-service from the provider.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate it had obtained the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities for 2 out of 7 Sampled Patients (SP). SP#4 and SP#6 Findings include: Clinical records review was conducted from 11/13/23 to 11/15/23 of SP#4 and SP#6. Active clinical record review of SP#4 revealed a start of care date 11/03/2023 with the Client Service Agreement signed and dated 11/03/2023. Further review of SP#4 clinical record contained a consent form that under “Relationship of Authorized Representative” was left blank. A telephone interview was conducted with the Registered Nurse providing care to SP#4 on 11/14/2023 at 3:10 PM in the presence of the Administrator. The Registered Nurse confirmed that the ALF Administrator signed the consent for service for SP#4. Closed record review of SP#6 revealed a start of care date 08/22/2023 with the Client Service Agreement missing page 2 (the signature page). Interview conducted with the Administrator on 11/15/2023 at 3:34 pm confirmed that the clinical record for SP#6 is missing the signature page. The Administrator stated that the Human Resource is unable to find the missing page.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to assure communication with the patient’s physician involved in the plan of care for 1 out of 7 Sampled Patients (SP). SP#6 Findings include: Clinical record review conducted on 11/13/23 to 11/15/23 of SP#6 contained a physician order dated 08/21/2023 ordering “HHA/HHC (home health agency/home health care) 1. Aide to assist in ADL’s (activities of daily living) 2. RN (registered nurse) for medication education and evaluation 3. PT/OT (physical therapy / occupation therapy) eval and treatment for deconditioning.” The Plan of Care (POC) for certification period 08/22/2023 to 10/20/2023 revealed Skilled Nurse, Physical Therapy and Home Health Aide services was provided. The clinical record omitted documentation reason why the provider failed to provide the Occupational therapy, and that the physician was notified and approved of the service ordered and not provided. Interview conducted with the Administrator on 11/15/23 at 3:34 PM stated that SP#6 must have refused the Occupational Therapy. The Administrator acknowledged that the clinical record omitted any notation reason for not providing the occupational therapy service and no documentation the physician was notified.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, record review and interview, the home health agency staff failed to provide physical therapy service within the scope of practice as ordered by the physician and indicated in the plan of care for 1 out of 3 Sampled Patients (SP) with home visits done. SP#3 Findings include: Clinical record review conducted 11/13/23 to 11/14/23 of SP#3 contained a Plan of Care with certification period of 10/03/23 to 12/11/23 that reads “PT (physical therapy) to assess and evaluate vital signs T – P – R and BP (Temperature – Pulse – Respiration and Blood Pressure) on every visit”. During a home visit made to SP#3 on 11/14/23 at 11:00 AM, the surveyor observed Staff E (Physical Therapy Assistant) obtain blood pressure and pulse reading only. The home visit was completed at 11:15 AM. The Staff E stated that he was done with assessing the SP#3. Interview was conducted with the Administrator on 11/14/23 at 11:50 AM acknowledged that the Staff E failed to obtain Temperature and Respiration during assessment as part of the vital signs.”

“Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This Element is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate a completed annual on-site visit for 1 out of 5 employee records reviewed. (Staff H) Findings include: Review of personnel records conducted on 11/14/23 for Staff H contained a titled document “Home Health Aide Competency Evaluation” dated 08/09/2022. Further review of the documentation revealed it was blank; the provider is unable to demonstrate that an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care was conducted for Staff H by the Registered Nurse. Interview conducted with the Administrator on 11/15/2023 between 3:38 PM and 3:55 PM confirmed that the form is blank.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the provider is unable to demonstrate a completed discharge summary for 2 out of 7 Sampled Patients (SP). SP#6 and SP#7 Findings include: Closed record reviews of SP#6 and SP#7 were conducted on 11/13/23 to 11/15/23. The clinical record for SP#6 contained a discharge summary from the agency with a discharge date 10/06/23; and SP#7 contained a discharge summary from the agency with a discharge date 10/11/23. The discharge summaries for SP#6 and SP#7 omitted information such as the type of services provided and frequency of services; and omits any Lab data (as applicable). Interview was conducted with the Administrator on 11/15/2023 between 3:38 PM and 3:55 PM, acknowledged that the summaries for SP#6 and SP#7 were incomplete, missing the required notations as previously mentioned.”