Community Home Health of Maryland

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: The Home Health Agency (HHA) failed to develop, implement, and maintain a comprehensive emergency preparedness program to ensure the safety and well-being of patients and staff during emergencies. Specifically, the HHA has not maintained an emergency preparedness plan for all its branches over the past four years and has failed to conduct required testing exercises, compromising its ability to respond effectively to emergencies. A review of administrative records on 7/1/24 revealed that the agency has not maintained an emergency preparedness plan for the past four consecutive years (2020, 2021, 2022, 2023). The records indicate an absence of a documented emergency preparedness plan and no testing exercises or actual events documented for 2020, 2021, 2022. The emergency preparedness plan submitted to this surveyor, dated December 20, 2023, pertains solely to the Towson location. There is no evidence of an emergency preparedness plan for the Lanham Branch or the Frederick Branch. An interview with the administrator on 7/3/24 confirmed that the agency does not have additional documents to support emergency preparedness plans or testing exercises for the Lanham or Frederick branches. An administrative records review on 10/4/24 revealed that that agency has begun implementing an emergency preparedness plan for each branch.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: The home health agency (HHA) failed to maintain an ongoing quality assessment and performance improvement (QAPI) program that demonstrated measurable improvement in indicators for which there was evidence that improvement led to improved health outcomes. On 07/01/2024, a review of the agency’s administrative records revealed that the HHA provided QAPI meeting reports for the periods from October to December 2023 and January to March 2024 for the Towson location. However, as requested, the facility has not had QAPI meeting reports for the past two years. On 7/1/24, a review of the agency’s policy QAPI HH5002 on page 4 of 6, under the bullet titled “Patient Record Review,” revealed that “quarterly record reviews will occur at each agency. A sample of the active and discharged charts are reviewed quarterly up to a maximum of five active and discharged charts per quarter.” Upon review of the QAPI plan meeting for October to December 2023, no patient record review was completed.”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: The facility failed to implement a comprehensive infection control program to prevent and control infections and communicable diseases, resulting in inadequate infection prevention practices. A review of administrative records on 07/01/2024 revealed that the HHA did not have documented procedures for the surveillance and identification of infectious and communicable disease problems. Additionally, there was no evidence of preventative measures or control protocols being implemented. The absence of these critical components indicates non-compliance with the requirements for a comprehensive infection control program as part of the HHA’s QAPI program.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: The facility failed to develop and maintain a comprehensive emergency preparedness plan for 2020, 2021, 2022, and 2023. The provided plan was inadequate as it lacked staff members’ specific roles, responsibilities, and authority. It did not address the needs of patients with limited mobility, procedures for safe evacuation, or strategies for managing staff roles and surge capacity during emergencies. Not having a plan places the agency’s patients and the agency’s staff at risk for adverse outcomes in the event of an emergency. A review of administrative records on 07/01/2024 revealed no emergency preparedness plan for 2020, 2021, 2022, and 2023. The provided call tree only included names and phone numbers without specifying staff members’ roles, responsibilities, or authority. Furthermore, the plan did not address the needs of patients with limited mobility, procedures for safe evacuation, or strategies for managing staff roles and surge capacity during emergencies.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: The agency failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Specifically, there was no documented evidence of such processes for the previous years at the Towson location. The agency’s administrative staff provided no emergency management plan for the Lanham and Frederick locations. The agency provided an emergency management plan dated 12/20/2023 for the Towson location. There was no evidence of a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials in previous years. The agency did not provide an emergency management plan for the Lanham and Frederick locations. This demonstrates a failure to establish and maintain an integrated response plan that includes cooperation and collaboration with the appropriate emergency preparedness officials.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: The agency failed to develop and maintain an emergency preparedness communication plan. Specifically, there was no documented evidence of a communication plan that included the required contact information and coordination details for effective communication during emergencies. A review of administrative records on 07/01/2024 revealed the following: The agency did not provide any documentation of an emergency preparedness communication plan for the Towson, Lanham, and Frederick locations for the year of 2020, 2021, 2022. The facility provided an emergency management plan dated 12/20/2023 for the Towson location only. This lack of documentation indicates a failure to ensure contact information availability for staff, service providers, patients’ physicians, and other necessary parties during an emergency, as required by Federal and State law.”

“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 agency did not establish a communication plan to include the necessary methods for sharing patient information and medical documentation with other healthcare providers during an emergency. 1. A review of administrative records on 07/01/2024 revealed that the agency did not provide a documented communication plan for the years of 2020, 2021, 2022 for the Towson, Lanham, and Frederick locations. 2. A review of administrative records on 7/1/2024 revealed that the agency did not provide a communication plan for the year of 2023 for the Lanham and Frederick locations. There was also no documented process for coordinating the transfer of patient information with external healthcare providers nor a method for confirming receipt and understanding of the information shared. The absence of these critical elements indicates that the agency has not established the necessary protocols for effective communication during emergencies.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: The facility did not implement and maintain an emergency preparedness training and testing program as required. This deficiency impacts the facility’s compliance with emergency preparedness regulations and ability to respond to emergencies effectively. 1. A review of administrative records on 07/01/2024 revealed no testing exercises or employee training conducted for 2020, 2021, 2022. 2. A review of administrative records on 10/4/2024 for the year of 2023 revealed only one table table-top exercise was conducted on 6/12/23 and one fire drill on 9/22/24 for the Towson location. No exercises were conducted for the Frederick and Lanham location.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: The HHA failed to conduct performance improvement projects that meet the regulatory requirements for scope, implementation, and evaluation, thereby not ensuring continuous quality improvement in patient care. A review of the agency’s administrative records on 07/01/2024 revealed that the HHA did not conduct performance improvement projects in the past 12 months. The records showed no documented evidence of performance improvement projects to track adverse patient events, analyze their causes, or implement preventive actions, as required by the regulatory standards.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: The HHA must maintain an ongoing QAPI program, only providing reports from October to December 2023 and January to March 2024, failing to meet the regulatory requirements for continuous quality improvement documentation. A review of the agency’s administrative records on 07/01/2024 revealed that the HHA provided QAPI meeting reports from October to December 2023 and January to March 2024 for the Towson location only. However, the agency did not have QAPI meeting reports from the previous two years or for the other branch locations.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: The facility failed to implement and maintain a comprehensive infection control program, which includes coordinated surveillance, identification, prevention, and control measures for infectious and communicable diseases as part of the HHA’s QAPI program. This deficiency results in inadequate infection control practices and an increased risk of infectious disease spread within the facility. A review of administrative records on 07/01/2024 revealed that the HHA did not have a method for identifying infectious and communicable disease problems. There were no documented procedures for surveillance, identification, prevention, control, or investigation of infectious diseases. The absence of these critical components indicates non-compliance with the requirements for a comprehensive infection control program as part of the HHA’s QAPI program.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: During a home visit with Patient #2, escorted by the Clinical Manager, it was observed that the Licensed Practical Nurse (LPN) improperly placed a blood pressure cuff and stethoscope. Improper vitals assessment, such as blood pressure, can lead to inaccurate readings, which may result in incorrect treatment decisions, potentially putting the patient’s health at risk. During observation with patient #2 on July 3, 2024, the LPN placed the blood pressure cuff on the patient’s upper right arm and then placed the stethoscope above the cuff before inflating it to take a blood pressure reading. Proper placement requires the stethoscope to be positioned below the cuff to hear the blood flow sounds accurately. These sounds indicate the blood pressure levels. Incorrect placement can result in an inaccurate blood pressure reading, affecting patient care and treatment decisions.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Review of clinical records revealed non-compliance with physician orders for wound care and dressing changes. The review indicated that prescribed frequencies were not followed and that wound care was provided without a signed physician order, impacting the patients’ care and recovery processes. Patients: #7, #10, #12 A review of patient #7 clinical records revealed that the physician ordered wound care to be performed once a week for one week, twice a week for two weeks, and then once a week for six weeks. Documentation showed that the start of care was on 5/4/24, with only one skilled nursing visit conducted on 5/4/24. No subsequent skilled nursing visits for wound care were conducted, failing to meet the specified frequency outlined in the physician’s orders. A review of patient #10’s clinical records revealed that 6/26/24 a Registered Nurse performed wound care without a signed physician order. The wound care occurred despite a verified and signed order, demonstrating a failure to adhere to the standard of administering treatments only as ordered by a physician​​. A review of patient #12 clinical records revealed that the physician ordered dressing changes to be performed twice weekly. Documentation showed that from the start of care on 6/13/24 to the date of this survey on 7/1/24, skilled nursing visits for dressing changes were conducted only once a week.”

“Patient, caregiver, and family counseling CFR(s): 484.75(b)(4) Patient, caregiver, and family counseling; This Element is not met as evidenced by: During a home visit with Patient #2, escorted by the Clinical Manager, the surveyor observed that the Licensed Practical Nurse (LPN) failed to educate the caregiver and patient regarding managing a bleeding sacral ulcer. The LPN was also unable to identify the medication applied to the wound and did not address the caregiver and patient inquiries about the bleeding. 1. During a home visit along with the agency’s Clinical Manager on July 3, 2024, observation of care for patient #2 by the Licensed Practical Nurse (LPN) revealed that the LPN failed to educate the caregiver and patient about the cause of bleeding in one of the two sacral ulcers. 2. Upon leaving the patient’s home, a debrief with the LPN and Clinical Manager revealed that the LPN did not know the purpose of the medication applied to the wound, thereby being unable to educate the patient and caregiver.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on the clinical records reviewed, the agency’s clinical staff failed to promptly document a skilled professional visit. Clinical records are the source healthcare providers use to monitor, evaluate, and develop plans of care for patients. Records not updated timely place patients at risk of not receiving appropriate care and compromise the continuity of care. On 7/3/2024, a review of the clinical record for patient #12 revealed the skilled professional visit occurred on 6/28/24. During the record review five days later, no visit note is documented in the patient’s clinical record. A review of the agency’s policies and procedures, titled Medical Recording, Correction, and Documentation, page 3, revealed that notes are to be completed within 24 hours of the visit.”

“Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This Element is not met as evidenced by: The Home Health Agency (HHA) failed to ensure that its branches were provided with direct support and administrative control as required. This lack of oversight resulted in the absence of a QAPI program and an emergency preparedness plan for its Lanham and Frederick locations, undermining the agency’s ability to ensure consistent quality improvement, patient safety, and emergency readiness across all its service areas. A review of the agency’s administrative records on 7/1/24 revealed that the HHA did not have a QAPI program in place for its Lanham and Frederick locations. Further records review on 7/1/24 revealed that the Lanham and Frederick branches did not have an emergency preparedness plan or perform the required testing exercises, including tabletop exercises and full-scale drills, for the past four years (2020, 2021, 2022, 2023).”