1st Care Home Health Services of Pennsylvania

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan and an interview with an agency Board Member, agency failed to ensure policies and procedures address the use of volunteers or other emergency staffing strategies in an emergency for one (1) of one (1) emergency preparedness plans (EP) reviewed (EP# 1). Agency policy requested on January 16, 2025 at approximately 12:00 p.m.. No specific policy provided related to the use of volunteers. A review of the agency Emergency Preparedness Plan conducted on January 16, 2025 at approximately 10:00 a.m. revealed the following: EP #1: No documentation provided of the agency Emergency Preparedness Plan addressing the use of volunteers or other emergency staffing strategies in an emergency. An interview conducted with an agency Board Member on January 16, 2025 at approximately 12:15 p.m. confirmed the above findings.”

“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 review of agency policy, a review of clinical records, and an interview with an agency Board Member, agency failed to send a discharge summary 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 home health agency (HHA) (if any) within five (5) business days of the date of the order for discharge from the responsible physician, per policy, for two (2) of five (5) discharged clinical records (CR) reviewed (CR#11, CR#13). Agency policy reviewed on January 16, 2025 at approximately 12:00 p.m. Policy ‘5.22 Transfer & Discharge Policy’ ‘Discharge Procedure’ (5) “Prior to discharging the patient the attending physician shall be notified. A written discharge summary must be completed, and a copy sent to the physician within five (5) business days of discharge will be maintained in the clinical record.” A review of CRs was completed on January 16, 2025 at approximately 11:45 a.m. The patients start of care (SOC) is listed below. CR#11 SOC 12/04/24: Patient discharged from agency on December 30, 2024. Documentation provided of the Discharge Summary being sent to the physician on January 7, 2025. (6 business days). CR#13 SOC 11/11/24: Patient discharged from agency on December 6, 2024. Documentation provided of the Discharge Summary being sent to the physician on December 16, 2025. (6 business days). An interview conducted with an agency Board Member on January 16, 2025 at approximately 12:15 p.m. confirmed the above findings.”