Helping Hands Home Healthcare and Staffing , LLC

“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 document review and interview, it was determined the Governing Body failed to develop and maintain an emergency preparedness training program that was implemented upon hire and completed annually thereafter. Findings include: 1. The Emergency Preparedness Policy (updated 1-12-2024) was reviewed on 1/9/2024 at approximately 11:00 AM. The manual states, “Training and Exercise Program: 1. Emergency Preparedness information is provided to staff during the orientation period. 2. On-going, Emergency Preparedness training is conducted no less than annually. Training techniques include discussion-based exercises such as tabletop exercises and drills or full-scale exercises.” 2. The Employee Roster was reviewed on 1/8/2024 at approximately 2:00 PM. It was noted that 9 of 20 staff did not have Emergency Preparedness training documented as completed nor demonstrated staff knowledge of the emergency procedures. The following personnel records lacked evidence of Emergency Preparedness Training: Director of Nursing (E#1), DATE OF HIRE (DOH) 1/30/2017 Certified Nurses Aide (E#4), DOH 3/16/2023 Home Health Aide (E#5), DOH 8/21/2024 Registered Nurse (E#6), DOH 1/29/2019 Occupational Therapist Assistant (E#7), DOH 4/10/2023 Licensed Practical Nurse (E#8), DOH 7/21/2021 Occupational Therapist Assistant (E#9), DOH 9/13/2023 Physical Therapy Assistant (E# 14), DOH 2/14/2019 Registered Nurse (E#15), DOH 5/31/2016 3. An interview was conducted with E#1 on 1/9/2024 at approximately 10:30 AM. E#1 verbally confirmed that the Emergency Preparedness training is to be conducted annually and is not compliant.”

“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 document review and interviews it was determined for 7 of 18 employees, the Agency failed to ensure staff received infection control/prevention education upon hire, and for 17 of 18 employees, the Agency failed to ensure staff received continued annual infection control/prevention education. Findings include: 1. The policy titled “Infection Control Plan” (Revised 2/7/2024) was reviewed on 1/9/2025 at approximately 10:30 AM. The document noted “...Establishes a training program upon employment which: -Educates employees in the infection control program, -Advises employees of any revisions or when changes occur…”. 2. The following employee files were reviewed on 1/8/2025 at approximately 10:00 AM through 1/9/2025 at approximately 3:00 PM, and were noted to lack documentation of initial infection control/prevention training: a) Employee (E#1) Director of Nursing Date of Hire (DOH) 1/30/17 b) E#4 Certified Nurse Aide DOH - 3/16/23 c) E#5 Home Health Aide DOH – 8/21/24 d) E#6 Registered Nurse, CEO/Owner DOH - 1/29/19 e) E#7 Occupational Therapy Assistant DOH - 4/10/23 f) E#8 Licensed Practical Nurse DOH- 7/21/21 g) E#12 Physical Therapy Assistant DOH-10/20/21 3. The following employee files were reviewed on 1/8/2025 at approximately 10:00 AM through 1/9/2025 at approximately 3:00 PM, and were noted to lack documentation of yearly infection control/prevention training: a) Employee (E#1) Director of Nursing Date of Hire (DOH) 1/30/17 b) E#3 Registered Nurse DOH - 5/28/19 c) E#4 Certified Nurse Aide DOH - 3/16/23 d) E#7 Occupational Therapy Assistant DOH - 4/10/23 e) E#8 Licensed Practical Nurse DOH- 7/21/21 f) E#9 Occupational Therapy Assistant DOH- 9/13/23 g) E#10 Physical Therapist DOH- 12/9/21 h) E#11 Occupational Therapist DOH - 3/3/19 i) E#12 Physical Therapy Assistant DOH-10/20/21 j) E#13 Physical Therapist DOH- 5/12/22 k) E#14 Physical Therapy Assistant DOH - 2/4/19 l) E#15 Registered Nurse DOH - 5/31/16 m) E#16 Physical Therapy Assistant DOH - 10/12/17 n) E#17 Registered Nurse DOH- 6/26/19 o) E#18 Physical Therapist DOH - 5/4/18 p) E#19 Occupational Therapy Assistant DOH- 10/07/2020 4. During an interview with E#6, CEO/Owner, on 1/10/2025 at approximately 10:30 AM, E#6 noted the Director of Nursing (E#1), is responsible for ensuring the initial and yearly infection control/prevention trainings are completed. 5. During an interview with E#1, Director of Nursing, on 1/9/2025, at approximately 2:35 PM, E#1 verified documentation of the initial and yearly infection control/prevention training was not present in the identified employee files to evidence the trainings as being completed. E#1 additionally noted the Agency does not have previous versions of the policy titled “Infection Control Plan” (Revised 2/7/24).”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, document review, and interview, it was determined for 2 of 3 patients (Pt #2 and Pt #3) home visits observed, the Agency failed to ensure medication reconciliation was complete and accurate. 5. Pt. #3 SOC 12/6/24 Diagnosis: Non Traumatic Hematoma of Tissue. A home visit was conducted on 1/7/2025 at approximately 3:30 PM with the Physical Therapist (PT) E #17. E#17 failed to perform medication reconciliation during the visit. 6. During an interview with the Director of Nursing (E#1) on 1/9/25 at approximately 10:30 AM, E#1 stated the PT should be conducting medication reconciliation at each visit. Findings include: 1. A home visit was conducted on 1/8/2024 at approximately 9:30 AM with the Registered Nurse (RN, E #3) for Pt #2. E#3 did not perform medication reconciliation during the visit. 2. The Home Health Certification and Plan of Care for Pt# 2, dated 12/18/2024 ,was reviewed on /1/8/2024 at approximately 11:00 am and noted the following order: “SN to perform medication review each skilled nursing visit and reconcile medications as indicated…” 3. A review was done on 1/9/2024 of the Medication Reconciliation Policy. The policy states, “Medication ordered while the patient is receiving care will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 4. During an interview on 1/9/2024 at approximately 10:00 AM, the Director of Nursing (E#1) agreed the medication reconciliation should take place during each visit.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on document review and interview, it was determined in 2 of 7 (Pt #3 and Pt #5) patients’ records reviewed, the Agency failed to ensure the Plan of Care (POC) included accurate patient care orders. Findings include: 1. Pt #3 SOC: 12/6/24 Diagnosis: Nontraumatic Hematoma of Tissue. The clinical record was reviewed on 1/8/25. The Plan of Care dated 12/16/24 noted noted orders for discipline and treatment Notify Physician of ....: Fasting Blood Sugar: greater than 400 mg/dl less than 60 mg/dl. Random Blood sugar: greater than 400 mg/dl less than 60 mg/dl. The record lacked documentation of blood sugars results by the Physical Therapist (PT) on the 1/7/25 visit. 2. Pt. #5 SOC : 11/7/24 Diagnosis: Pressure Ulcer. The clinical record was reviewed on 1/8/25. The Plan of Care (POC) dated 11/7/24 noted orders for discipline and treatment Notify Physician of ... Fasting Blood Sugar: greater than 400 mg/dl less than 60 mg/dl. Random Blood sugar: greater than 400 mg/dl less than 60 mg/dl. The Skilled Nurse (SN) visited the patient 1- 2 times a week from 11/7/24 to 1/6/25. The record lacked documentation of any blood sugars results by the SN. 3. During an interview with the Director of Nursing (DON), Employee (E #1) on 1/9/25 at approximately 10:00 AM. E#1 noted that patients #3 and #5 didn’t need to have blood sugars checked and that it wasn’t to be on their POC but with the software company that Agency uses for records it automatically comes on all the Plan of Cares.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on document review and interview it was determined 1 of 7 charts lacked the Supervision of Licensed Practical Nurse (LPN). Findings include: 1. On 1/8/2024 at approximately 1:00 PM, a review of Pt #2’s chart was conducted for the following dates: 11-10-24 to 1-8-2025. It was noted an LPN Supervisory visit was completed on 11-18-24. No other LPN Supervisory visits were conducted. 2. The policy for Supervision of LPN’s was reviewed on 1/8/2024 at approximately 1:30PM. The policy states, “…Procedure 1. Services furnished by a LPN will be furnished under the supervision of a qualified Registered Nurse (RN). Supervisory visits will occur every 30 days.” 3. During an interview on 1/9/2024 at approximately 10:00 AM, Director of Nursing (E#1) verbally agreed that no LPN Supervisory Visit was conducted for the month of December and should have taken place.”