Genesis Home Health Care LLC

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to implement and maintain an Emergency Preparedness program specific to facility, conduct a community risk assessment, and all hazards approach for all patients. This deficient practice is likely to result in patients not being safe before, during and after an emergency or natural disaster. The findings are: A. Record review of the facility’s Emergency Preparedness binder did not reveal an all-hazards approach, facility-based and community-based risk assessment. B. During an interview with S(Staff)1 Who is staff 1, Administrator on 05/16/24 at 3:00 PM, S1 explained the facility had been short staffed and had not had a chance to implement Emergency Preparedness to include filling out the EP plan that was provided and developed by (name of consultant agency). C. During an interview with S5, Operations Manager on 05/21/24 at 11:16 AM, S5 explained the facility does not have enough staff, and the facility hasn’t gotten around to implementing Emergency Preparedness.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to have a process of tracking quality indicators to be reviewed by Quality Assessment and Performance Improvement (QAPI) program for all patients. This deficient practice is likely to result in patients not receiving quality care and services delivered by the home health Agency. The findings are: A. Record review of a binder titled “Quality Assessment and Performance Improvement” did not reveal Meeting Minutes, Satisfaction surveys, Quality Measure reports or Performance Improvement Projects. B. During an interview with S(Staff) 5 Operations Manager, on 05/21/24 at 11:13 AM, S5 confirmed the facility has not implemented a QAPI program.”

“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 and interview, the facility failed to ensure proper hand hygiene was conducted while providing care for 2 (P(Patient)3 and P7) of 3 (P3, P7, andP8) patients. This deficient practice is likely to result in the spread of health care-associated infections. The findings are: A. During an observation of P3’s residence on 05/15/24 at 10:00 AM, Staff (S)3, Licensed Practice Nurse did not perform hand hygiene after the removal of gloves on four occurrences while providing care. B. During an observation of P7’s residence on 05/15/24 at 11:30 AM, S3 did not perform hand hygiene after the removal of gloves on three occurrences while providing care. C. During an interview with S3 on 05/16/24 at 2:50 PM, S3 explained hand hygiene is to be done before and after contact with patient’s and after removing gloves.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the facility failed to provide supervisory assessment of Home Health Aids for 3 (P(Patient)1, P2 and P7) of 7 (P1-P7) patients. This deficient practice is likely to result in unsupervised patient care. The findings are: A. Record review of P1’s medical record labeled Supervisory Visits, revealed that P1 was admitted on 03/29/24 and received skilled nursing. P1 did not have any supervisory assessment. B. Record review of P2’s medical record revealed that P2 was admitted on 04/26/24 and received skilled nursing. P2 did not have any supervisory assessment. C. Record review of P7’s medical record revealed that P7 was admitted on 04/18/24 and received skilled nursing. P7 did not have any supervisory assessment. D. During an interview with S(staff)3, Licensed Practical Nurse on 05/21/24 at 2:11 PM, S3 confirmed no supervisory assessments were conducted for P1, P2, and P3.”