Calumet County Hhc Agency

“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: Based on record review and interview, the agency failed to develop a comprehensive agency specific Emergency Preparedness Program in 1 of 1 Emergency plans reviewed. Findings include: Per record review of policy and procedure titled “Emergency Preparedness Plan for Home Health Care and Hospice” dated 04/10/2023 revealed this plan does not outline agency specific details related to Emergency Preparedness and failed to outline details for Emergency Preparedness Core Elements as follows: This plan failed to ensure that Emergency Preparedness Plan included processes for cooperation and collaboration with local, tribal, regional, state, and federal officials. See E-0009. This plan failed to ensure that Emergency Preparedness policies and procedures are developed based on an all-hazards risk assessment. See E-0013. This plan failed to ensure that Emergency Preparedness policies and procedures included a system of medical documentation for patient records. See E-0023. This plan failed to ensure that Emergency Preparedness policies and procedures included alternate means of communication provided. See E-0032. This plan failed to ensure that an agency training program is developed. See E-0037. The cumulative effect of these systemic problems resulted in the agency’s inability to effectively develop a program that contained agency specific emergency preparedness policy and procedures utilizing an all-hazards risk assessment, emergency preparedness communication plan, and emergency preparedness training program .”

“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: Based on record review and interview, the agency failed to integrate EPP (Emergency Preparedness Plan) processes for collaboration and cooperation with local, tribal, regional, and federal officials in 1 of 1 EPP reviewed. Findings include: Record review of policy and procedure titled “EPP for Home Health Care and Hospice” dated 04/10/2023 revealed “Procedure: 6. Calumet County Home Health Care Agency EPP will include: Collaboration with the local emergency manager, local public health, regional healthcare coalition and other community partners in planning efforts, including a clear understanding of Calumet County’s Home Health Care role and responsibilities in the county’s comprehensive management plan.” This plan failed to outline agency specific details related to how the agency would collaborate with the local, tribal, regional, and federal officials as part of the overall EPP program and no further information was provided within the agency’s Emergency binder. Record review findings were reviewed and confirmed with Quality and Infection Control Coordinator B and Home Health Supervisor B on 03/18/2024 at 4:00 PM. During an interview with Quality and Infection Control Coordinator B on 03/19/2024 at 12:55 PM, when asked if anything additional was found for EPP policies specific to collaboration and coordination with local, tribal, regional, and federal officials, Quality and Infection Control Coordinator B replied, “No, I cannot find anything specific.””

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure agency specific Emergency Preparedness policies and procedures were developed based on the agency risk assessment in 1 of 1 Emergency plans reviewed. Findings include: Record review of policy and procedure titled “EPP (Emergency Preparedness Plan) for Home Health Care and Hospice” dated 04/10/2023 revealed “Procedure: 4. The plan is based on and includes a documented, agency-based and community-based risk assesmsent utilizing an all-hazards approach.” Record review on 03/19/2024 of agency document “All-Hazards Risk Assessment” dated 2023 revealed the top 2 alerts for risks for this agency were “1. Inclement weather 2. Tornado.” Review of this agency’s Emergency binder contained no agency-specific policies and procedures related to the risks identified for the All-Hazards Risk Assessment. During an interview with Quality and Infection Control Coordinator B on 03/18/2024 at 2:50 PM, when asked about the agency’s all-hazards risk assessment and any policies and procedures specific to risks, Quality and Infection Control Coordinator B replied, “I am newer to this position. I will see what I can find.” During an interview with Quality and Infection Control Coordinator B on 03/19/2024 at 12:55 PM, when asked if anything additional was found for agency specific policies for the risks identified specific to inclement weather and tornado, Quality and Infection Control Coordinator B replied, “No, I cannot find anything specific to those certain risks.””

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to contain agency-specific EPP (Emergency Preparedness Plan) details for systems of medical documentation in the event of an emergency in 1 of 1 Emergency plans reviewed. Findings include: Record review of policy and procedure titled “EPP for Home Health Care and Hospice” dated 04/10/2023 revealed this plan failed to outline agency specific details related to the agency’s system for medical documentation in the event of an emergency, and no further information was provided within the agency’s Emergency binder. During an interview with Quality and Infection Control Coordinator B on 03/18/2024 at 2:50 PM, when asked about the agency’s system of medical documenation in the event of an emergency and that the agency’s EPP does not have anything specific in the plan, Quality and Infection Control Coordinator B replied, “We don’t have a policy specific on the system of medical documentation. We have paper copies if we need and a generator on-site to run our laptaps, but no, I cannot find anything specific in our policies.””

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to outline agency-specific EPP (Emergency Preparedness Plan) details for providing primary and alternate means of communication in the event of an emergency in 1 of 1 Emergency plans reviewed. Findings include: Record review of policy and procedure titled “EPP for Home Health Care and Hospice” dated 04/10/2023 revealed this plan failed to outline agency specific details related to providing primary and alternate means of communication in the event of an emergency, and no further information was provided within the agency’s Emergency binder. Record review findings were reviewed and confirmed with Quality and Infection Control Coordinator B and Home Health Supervisor B on 03/18/2024 at 4:00 PM. During an interview with Quality and Infection Control Coordinator B on 03/19/2024 at 12:55 PM, when asked if anything additional was found for EPP policies specific alternate means of communication, Quality and Infection Control Coordinator B replied, “No, I cannot find anything specific.””

“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 record review and interview, the agency failed to ensure that an emergency preparedness training program was developed for agency staff in 1 of 1 Emergency plans reviewed. Findings include: Record review of policy and procedure titled “Emergency Preparedness Training and Education of Staff “ dated 04/10/2023 revealed “Procedure: 1. Emergency Preparedness training and education will be available during orientation of all new staff. 2. Existing staff will receive Emergency Preparedness training at least annually.” Review of this agency’s Emergency binder contained no information on education provided to agency staff for Emergency Preparedness. Record review of personnel records for continuing employees Registered Nurse D (date of hire 02/23/2022), Registered Nurse E (date of hire 03/20/2023), Aide F (date of hire 06/30/2005), Aide G (date of hire 03/08/2022), and Aide H (date of hire 06/05/2014) revealed no specific ongoing education or training for Emergency Preparededness. During an interview with Quality and Infection Control Coordinator B on 03/19/2024 at 12:55 PM, when asked if any additional proof of Emergency Preparedness training was found for all agency staff, Quality and Infection Control Coordinator B replied, “No, I am not able to find anything in meetings minutes that we’ve done training for all staff.””

“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 record review and interview, the agency RN (Registered Nurse) failed to provide supervision to the LPN (Licensed Practical Nurse) in 1 of 3 patients (Patient #7) receiving LPN care in a total of 7 patient records reviewed. Findings include: Review of agency policy and procedures titled “Provision of Care and Record Management, Clinical Supervision” dated 12/01/2018 revealed, “Procedure: 8. LPNs will be supervised at least every 30 days by a RN in the patient’s home with or without the LPN present.” Record review of Patient #7’s Plan of Care dated 01/08/2024 to 03/05/2024 revealed “SN (Skilled Nurse) 3 times per week.” Review of SN visits provided during 01/08/2024 to 03/05/2024 revealed a LPN provided patient care on 01/19/2024, 01/24/2024, 02/02/2024, 02/22/2024, and 02/26/2024. Documentation of an RN visit on 01/22/2024 revealed the RN supervised the LPN care. There was no further evidence in RN visit documenation past 01/22/2024 that the LPN care was supervised per policy. During an interview with Home Health Supervisor A on 03/18/2024 at 4:00 PM, findings were reviewed for Patient #7. During an interview with Home Health Supervisor A on 03/19/2024 at 12:55 PM, when asked if there was proof of additional LPN supervisory visits found, Home Health Supervisor A replied, “No, we couldn’t find documentation on those.””

“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 agency RN (Registered Nurse) failed to supervise the HHA (Home Health Aide) no less than every 14 days in 1 of 3 patients (Patient #7) receiving HHA services in a total of 7 patient records reviewed. Findings include: Review of agency policy and procedures titled “Provision of Care and Record Management, Clinical Supervision” dated 12/01/2018 revealed, “Procedure: 9. Home Health Aide will be supervised at least every 14 days by a RN.” Record review of Patient #7’s Plan of Care dated 01/08/2024 to 03/05/2024 revealed “SN (Skilled Nurse) 3 times per week. HHA 1 time per week.” HHA services began on 01/09/2024 and visits were conducted weekly from 01/09/2024 to 03/05/2024. Record review of Patient #7 SN visit note documentation revealed HHA supervision was documented 01/10/2024 and then not until 01/31/2024 (7 days past due date of 01/24/2024). SN visit note documentation of HHA supervision was documented 02/07/2024 and no further HHA supervision was documented (was due 02/21/2024). During an interview with Home Health Supervisor A on 03/18/2024 at 4:00 PM, findings were reviewed for Patient #7. When asked how often the HHA should be supervised and agency expectations, Home Health Supervisor A replied, “Every 14 days.” During an interview with Home Health Supervisor A on 03/19/2024 at 12:55 PM, when asked if there was proof of additional Aide supervisory visits found, Home Health Supervisor A replied, “No, we couldn’t find documentation on those.””