Affiliated Home Health Care

“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, agency staff failed to establish and maintain an emergency preparedness program in 1 of 1 emergency preparedness program reviewed. Findings include: Requested review of agency’s emergency preparedness program on 11/7/2023 at 9:30 a.m. Received binder with templates of required items for an emergency preparedness program but nothing specific to the agency. There was no documentation of an all-hazards risk assessment, emergency preparedness policies and procedures, a communication plan and no documentation of any testing and training of an emergency preparedness program. An interview was conducted with agency Vice President A on 11/7/2023 at 10:15 a.m. regarding the agency’s emergency preparedness plan. Vice President A stated he/she remembered printing the template and discussing it but was unsure if it was made specific to the agency.”

“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: Based on record review and interview, agency staff failed to document and maintain an infection control program, including processes and procedures for tracking and surveillance of infections in 1 of 1 infection control program reviewed. Findings include: The agency staff failed to maintain an agency-wide infection control program that maintained a method for identifying infections and communicable disease problems. See tag G684.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure at least one additional therapeutic service was provided or arranged for in 1 of 1 Home Health Agency Survey Report reviewed. Findings include: The agency staff failed to provide or arrange for at least one other therapeutic service in addition to skilled nursing. See tag G982.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, agency staff failed to individualize patient goals based on each patient’s need in 5 of 7 patient record reviews completed (Patients #1, #2, #4, #5, #6). Findings include: Review of policy titled “The Physician’s Role” not dated revealed in part, “a) Plan of care is a written plan developed with the participation of professional staff and the patient, in consultation with and authorized by the physician that supports the patient’s medical, nursing, and social needs in the home setting and serves as the basis of care delivery.” Review of Patient #1’s “Home Health Certificate and Plan of Care” dated 9/20/2023 revealed Patient #1 was being seen twice daily by skilled nursing for flushing of patient’s suprapubic foley catheter (a tube inserted into the bladder to allow drainage of urine) and to change the foley catheter every 3-4 weeks. There was no documentation of any patient goals related to the catheter or urinary status. Review of Patient #2’s “Home Health Certificate and Plan of Care” dated 10/16/2023 revealed Patient #2 was being seen twice daily by skilled nursing for wound care to an open wound on the lower leg. There was no documentation of any patient goals related to the wound or skin integrity. Review of Patient #4’s “Home Health Certificate and Plan of Care” dated 10/8/2023 revealed Patient #4 was being seen daily for tracheostomy (a tube inserted into the throat to assist with breathing) care. There was no documentation of any patient goals related to the patient’s tracheostomy or respiratory status. Review of Patient #5’s “Home Health Certificate and Plan of Care” dated 10/29/2023 revealed Patient #5 was being seen daily for ileostomy (an opening in the stomach) care. There was no documentation of any patient goals related to the patient’s ileostomy or gastrointestinal status. Review of Patient #6’s “Home Health Certificate and Plan of Care” dated 8/8/2023 revealed Patient #6 was being seen 3 times per week for wound care to toe fractures on left foot. There was no documentation of any patient goals related to the wound or fracture status. An interview was conducted on 11/7/2023 at 10:15 a.m. with Vice President A to review the above findings. Vice President A stated “We do struggle with that.””

“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: Based on record review and interview, the agency staff failed to maintain and document an infection control program in 1 of 1 Infection Control Program reviewed; and failed to ensure that the agency’s Infection Control Program was an integral part of the agency’s Quality Assurance Performance Improvement (QAPI) program in 1 of 1 QAPI Program reviewed. Findings include: Review of binder labeled “Infection Control” revealed “Guidelines for Standard Precautions and Infection Control” not dated. There was no documentation of any surveillance or tracking/trending of infections for patients and staff. An interview was conducted on 11/7/2023 at 10:15 a.m. with Vice President A regarding the agency’s infection control program. When asked about documentation of their Infection Control Program to show goals of prevention, surveillance, control, and integral part of the QAPI program, Vice President A stated that he/she has no documentation of infection control concerns/program and no meeting minutes that indicate infection control concerns are a part of the agency’s QAPI.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview the agency failed to provide at least one other therapeutic service in addition to skilled nursing in 1 of 1 CMS (Centers for Medicare & Medicaid Services) Home Health Agency Survey Report reviewed. Findings include: Review of form titled (CMS 1572) “Home Health Agency Survey Report” completed by the provider revealed in part, “11. Services Provided: 01-Skilled Nursing provided by HHA (Home Health Agency) staff...08-Infusion Services provided by HHA staff.” Further review revealed in part, “12. Staffing-List full-time equivalents (not hours): Registered Nurses-9. Licensed Practical Nurses-0. N/A (Not applicable) for Physical Therapists, Physical Therapy Assistants, Occupational Therapists, Occupational Therapy Assistants, Speech-Language Pathologists, Social Workers, Social Work Assistants, Home Health Aides. Staff Under Arrangement: N/A for all disciplines listed.” A telephone interview was conducted on 11/9/2023 at 12:43 p.m. with Vice President A regarding the above completed form. When asked what procedure is followed when a referral for services other than skilled nursing is received, Vice President A stated that this happens mainly with referrals from a hospital. If a patient is under insurance, that insurance company may allow the agency to provide the skilled nursing while also paying for the patient to attend outpatient therapy. If the patient is not under insurance and requires multiple disciplines for care, the agency informs the referral source that they are unable to accept the referral and the hospital contacts another HHA.”