Medtec Home Health Agency, 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 a review of the Agency’s Emergency Preparedness program, review of In-service binder and staff interview, it was determined the Agency failed to conduct staff training, relative to the Agency’s Emergency Preparedness plan. Findings include: 1. The Emergency Preparedness program and In-service binder was reviewed on 5/30/24. As of 5/30/24, the Agency lacked documentation that staff received Emergency preparedness training in 2021, 2022 and 2023. 2. During an interview with the Administrator, Director of Nursing and Nursing Supervisor on 5/30/24 at 11:30 AM, the Administrator confirmed the Agency was unable to provide documentation that staff received training relative to the Agency’s Emergency Preparedness plan.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report and Staff interview, it was determined that in 19 of 415 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 05/01/23 to 04/30/24 (12 months), was reviewed on 05/31/24. The report included a warning for 19 (3.89 %) assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview with the Administrator on 05/31/24 at 9:30 AM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, clinical records, observation during home visits and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed in writing of the frequency of visits provided by each discipline. Findings include: 1. The patient’s admission folder was reviewed on 5/28/24 and included the form titled, “Service Agreement, Consent And Authorization”. The Agency requires the SN to complete the Agreement form during the SOC visit. The form lacked a section that includes the frequency of their visits. 2. The clinical records were reviewed from 5/28/24 to 5/30/24, and included documentation that the following services were provided: Pt. #1. SOC 10/10/23. SN and HHA. Pt. #2. SOC 4/19/24. SN and PT. Pt. #3. SOC 11/7/23. SN. Pt. #4. SOC. 2/28/24. PT, OT, and ST. Pt. #5. SOC 10/6/23. SN and PT. Pt. #6. SOC 2/1/23. SN. Pt. #7. SOC 7/26/23. SN. The records included the form titled, “Service Agreement, Consent And Authorization” completed by the RN, signed by the Pt./patient’s representative, and dated with the SOC date. The records lacked documentation that the Pt. or Pt.’s representative was notified of each discipline’s frequency of visits, prior to providing Pt. care and services. 3. During interviews with the Director of Nursing and Nursing Supervisor on 5/30/24 from 10:30 AM to 12:00 PM, the administrative team confirmed the above findings.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on a review of clinical records, Agency policy review and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the Agency assessed the need for Influenza and Pneumococcal vaccination during admission (Start of Care) per Agency policy. 1. The following clinical records were reviewed from 5/28/24 to 5/30/24: Pt. #1 SOC 11/7/23 Pt. #2 SOC 4/19/24 Pt. #3 SOC 11/7/23 Pt. #4 SOC 2/28/24 Pt. #5 SOC 10/6/23 Pt. #6 SOC 2/1/23 Pt. #7 SOC 7/26/23 The clinical records contained SOC comprehensive assessments, completed by the RN or PT on admission and lacked complete information for influenza and pneumococcal vaccination status of Pts. #1 through 7. 2. The Agency’s policies on Influenza and Pneumonia Vaccines, were reviewed on 5/31/24. The policies required admitting staff to get information from the patient as to whether patient received Influenza and Pneumonia vaccines in the past and documented in the clinical record. 3. . During interviews with the Administrator, Director of Nursing and Nursing Supervisor on 5/30/24 from 10:30 AM to 12:00 PM and on 5/31/24 at 10:00 AM, the Director of Nursing confirmed the above findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 5/29/24. The folder lacked information identifying the Clinical Manager’s name and contact information. 2. The clinical records of the following Pts. were reviewed from 5/29/24 to 5/30/24: Pt. #1. SOC 10/10/23 Pt. #2. SOC 4/19/24 Pt. #3. SOC 11/7/23 Pt. #4. SOC 2/28/24 Pt. #5. SOC 10/6/23 Pt. #6. SOC 2/1/23 Pt. #7. SOC 7/26/23 The clinical records reviewed lacked information identifying the Clinical Manager’s name and contact information. 3. The following home visits were conducted on 5/28/24 from 1:45 PM to 5/29/24 at 9:15 AM. Pt. #1. SOC 10/10/23 Pt. #2. SOC 4/19/24 Pt. #3. SOC 11/7/23 4. During the home visits, on 5/28/24 from 1:45 PM to 5/29/24 at 9:15 AM, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Clinical Manager. 5. During interviews with the Director of Nursing and Nursing Supervisor on 5/30/24 from 10:30 AM to 12:00 PM, it was indicated the same folder is given to all Patients. The administrative team also confirmed the above findings.”