Good Shepherd Home Care

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) could not provide evidence that the required in-service training of at least 12 hours during each 12-month period for 1 of 2 sampled home health aides had occurred. (Employee identifier: 3.) Findings include: Surveyors reviewed the medical records of patients 1, 2, 3, 4, 5, 6, and 7 on September 18, 2025. IEPs could not be found in any of the 7 patients’ medical records. On September 16, 2025, at 4:06 PM, the licensor conducted a telephone interview with the assistant director of nursing (ADON). The ADON was asked to provide copies of IEPs for all patients reviewed. The ADON responded, “It is a verbal plan, it is done while going over the OASIS with patients at the admission visit, then the patient is referred to the admission packet for more information.””

“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 interview and record review, it was determined that the home health agency (HHA) did not ensure infection control education was provided for 6 of 7 sampled employee files. (Employee identifiers: 1, 2, 3, 5, 6, and 7.) Findings Include: Surveyors reviewed seven employee files for infection control training and prevention. There was no documented evidence that employees 1, 2, 3, 5, 6, and 7 had received infection control education in the past 3 years. On September 18, 2025, at 1:49 PM, the surveyor interviewed the administrator. The administrator stated, “I know infection control training is taught by the registered nurse (RN), but we cannot find documentation.””

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) could not provide evidence that the required in-service training of at least 12 hours during each 12-month period for 1 of 2 sampled home health aides had occurred. (Employee identifier: 3.) Findings Include: Surveyors reviewed the agency’s home health aide personnel records on September 17, 2024. There was no documented evidence that employee 3 had received any in-service training hours for the last 12 months. On September 18, 2025, at 1:49 PM, the surveyor interviewed the administrator. The administrator stated, “in-services for the agency’s aides were completed annually.” The Administrator further stated he could not provide sign-in sheets because the registered nurse provides the teaching individually. No documented evidence could be provided to indicate that employee 3 had received any of the required in-service training.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure participation in HHA-sponsored in-service training for 5 of 5 skilled professionals whose personnel records were reviewed. (Employee identifiers: 1, 2, 5, 6, and 7.) Findings include: Surveyors reviewed the agency’s skilled professional personnel records for employees 1, 2, 5, 6, and 7 on September 17, 2025. No documentation regarding HHA-sponsored in-service trainings could be located in any of the skilled professional personnel records. On September 18, 2025, at 1:49 PM, the surveyor interviewed the agency Administrator. The Administrator stated that in-service training for the agency’s aides was completed annually; however, in-service training had not been provided to skilled professionals.”