Adventhealth Home Health

“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 staff interview and policy review, the Home Health Agency failed to develop, maintain, review and update the emergency preparedness plan to include an all hazards approach, ensuring shared duties with sister agency’s locations and administrative staff were updated when changes occurred and failed to ensure staff received required emergency preparedness training. The findings include: Based on record review and interview, the facility failed to develop and maintain an Emergency Preparedness Program (EP), that was reviewed and updated on an annual basis. (Refer to EP 0004) Based on record review and staff interviews, the facility failed to establish and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach. In the event of a disaster or other emergency, this would leave the facility and its occupants vulnerable to the hazards of the event. (Refer to EP 0006) Based on record review and interview, the provider failed to ensure that 3 out of 17 (Staff members C and F and the Clinical Manager) staff participated in on-going training in the facility’s emergency preparedness plan. (Refer to EP 0037) Based on record review and interview, the provider failed to demonstrate it analyzed the agency’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revised the agency’s emergency plan, as needed. (Refer to EP 0039)”

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on clinical record reviews, interviews, and review of data reports it was determined that the Home Health Agency (HHA) failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) assessment to the CMS system within 30 days of the assessing clinician completing the assessment of the beneficiary, in order to allow for multi-level of quality assurance reviews of the OASIS data. The cumulative effect of these systemic practices resulted in the agency’s failure to ensure completed, encoded, locked and accurate OASIS data for each patient was transmitted to the CMS system which impacts the agency’s ability to establish accurate health goals, report accurate data for quality reports to CMS, and to determine accurate payment based on the patient’s health status. (Refer to G0372) The findings include: Based on record reviews, interviews, and review of data reports the agency failed to ensure that the Outcome and Assessment Information Set (OASIS) assessments were transmitted to the CMS (Center for Medicare Medicaid Services) system within 30 days of the assessment. (Refer to G0372)”

“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 the home health agency failed to maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This failure has the potential to affect all patients admitted to the home health agency. The findings include: Based on attempted record review and interview, the provider failed to demonstrate a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. (Cross Reference F0684).”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the facility failed to develop and maintain an Emergency Preparedness Program (EP), that was reviewed and updated on an annual basis. The findings include: On 3/3/26 at approximately 1:00 PM an interview was conducted with the Administrator during which he was asked to provide a copy of the agency’s Federal emergency plan. He responded that there was not a Federal requirement for Emergency preparedness and that there was only a state component. He offered that they only had state requirements for emergency preparedness. On 3/5/26 at approximately 8:30 AM the visiting administrator provided a binder titled Comprehensive Emergency Management Plan (CEMP) offering that the binder had all the federal components for emergency preparedness along with the state requirements. She stated they put them all into the one binder and in one policy. Review of the Policy titled “Comprehensive Emergency Management Plan (CEMP)” Effective date 2/1/26; Emergency Management Plan – Heartland; Last review dates 2/1/26. The policy states “AdventHealth Home Health agencies uphold full compliance with s 400.492. Florida statutes, 59A8.027, and the Florida Administrative Code, and maintain a comprehensive emergency preparedness program that meets all federal requirements outlined in the CMS State Operations Manual, Appendix Z, as well as the Home Health Conditions of Participation 484.102.” Further review of the policy revealed on page 23 of 36, under Memoranda of Understanding Between Adventhealth Home Care agencies .” This Memorandum of Understanding (MOU) establishes a collaborative partnership between Adventhealth Home Care Agencies (The Parties) to ensure operation integrity of the agency Comprehensive Emergency Medical Plan. The MOU is not legally binding on the parties, but rather is a voluntary agreement based on the belief and commitment of the undersigned agencies that as a result of any community emergency or disaster regardless of cause, which exceed the effective response capabilities of an agency an affected agency may request assistance from the other agencies that are parties hereto as more generally described below. This document is intended to augment, not replace, each agencies disaster plan. Each agency shall have full and absolute discretion to determine the extend if any, to which it wishes to provide another agency under this MOU. On page 25 of 36 under Terms of Understanding. The term of this MOU is for one year, from the effective date of this agreement and will automatically be renewed. The agreement will be reviewed on periodic basis to ensure that it is fulfilling its purpose and to make any necessary revisions. Any Party may terminate this MOU upon 30 days written notice without penalty or liabilities.” Under this statement there is a list of Administrators for 5 separate locations within the MOU. The dates next to the 5 administrators were all 2/3/2022 and upon further review it was revealed that all 5 administrators were no longer working for the agency. Further review of the policy failed to reveal the inclusion of an All-hazard approach within the 36 page policy, the agency had included in the CEMP binder a brochure titled “Highlands County All Hazards Guide” however nothing within the policy referenced this document or an all hazard approach, there was no documentation to support that staff had reviewed this guide or that it was included in the development or updating of the policy. On 3/5/26 at approximately 8:45 AM, a follow up interview was conducted with the visiting administrator who was shown the list of administrators in the policy under the MOU. She verified the administrators had changed and that since this was signed the 5th location in Brooksville, FL had closed in 2025. She stated she was not aware this had not been updated and that it should have been during the annual reviews.”

“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 staff interviews, the facility failed to establish and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach. In the event of a disaster or other emergency, this would leave the facility and its occupants vulnerable to the hazards of the event. The findings include: Review of the Policy titled “Comprehensive Emergency Management Plan (CEMP)” Effective date 2/1/26; SOP SW HC 105 an Emergency Management Plan – Heartland; Last review dates 2/1/26. The 36 page policy states “AdventHealth Home Health agencies uphold full compliance with s 400.492. Florida statutes, 59A8.027, and the Florida Administrative Code, and maintain a comprehensive emergency preparedness program that meets all federal requirements outlined in the CMS State Operations Manual, Appendix Z, as well as the Home Health Conditions of Participation 484.102.” Further review of the policy revealed on page 23 of 36, under Memoranda of Understanding Between Adventhealth Home Care agencies .” This Memorandum of understanding (MOU) establishes a collaborative partnership between Adventhealth Home Care Agencies (The Parties) to ensure operation integrity of the agency Comprehensive Emergency Medical Plan. The MOU is not legally binding on the parties, but rather is a voluntary agreement based on the belief and commitment of the undersigned agencies that as a result of any community emergency or disaster regardless of cause, which exceed the effective response capabilities of an agency an affected agency may request assistance from the other agencies that are parties hereto as more generally described below. This document is intended to augment, not replace, each agencies disaster plan. Each agency shall have full and absolute discretion to determine the extend if any, to which it wishes to provide another agency under this MOU. On page 25 of 36 under Terms of Understanding. The term of this MOU is for one year, from the effective date of this agreement and will automatically be renewed. The agreement will be reviewed on periodic basis to ensure that it is fulfilling its purpose and to make any necessary revisions. Any Party may terminate this MOU upon 30 days written notice without penalty or liabilities.” Under this statement there is a list of Administrators for 5 separate locations within the MOU. The dates next to the 5 administrators were all 2/3/2022 and upon further review it was revealed that all 5 administrators were no longer working for the agency. Further review of the policy failed to reveal the inclusion of an All-hazard approach within the 36 page policy, the agency had included in the CEMP binder a brochure titled “Highlands County All Hazards Guide” however nothing within the policy referenced this document or the all hazards approach, there was no documentation to support that staff had reviewed this guide or that it was included in the development or updating of the policy. On 3/3/26 at approximately 1:00 PM an interview was conducted with the Administrator during which he was asked to provide a copy of the agency’s Federal emergency plan. He responded that there was not a Federal requirement for Emergency preparedness and that there was only a state component. He offered that they only had state requirements for emergency preparedness. On 3/5/26 at approximately 8:30 AM the visiting administrator provided a binder titled Comprehensive Emergency Management Plan (CEMP) offering that the binder had all the federal components for emergency preparedness along with the state requirements. She stated they put them all into the same binder.”

“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 provider failed to ensure that 3 out of 17 (Staff members C and F and the Clinical Manager) staff participated in on-going training in the facility’s emergency preparedness plan. The findings include: On 3/5/26 at approximately 8:45 AM an interview was conducted with the visiting administrator who provided copies of the Emergency Preparedness in Home Health transcript for 2025. She offered that the agency had been unable to find evidence that three of their staff members had completed the required annual training. Staff member C, Social Worker with a date of hire of 4/4/2016 Staff member F, Occupational Therapy Care Manager with a date of hire of 11/30/2005 Clinical Manager with a date of hire of 1/6/2020. Review of the Policy titled “Comprehensive Emergency Management Plan (CEMP)” Effective date 2/1/26; Emergency Management Plan – Heartland; Last review dates 2/1/26. The policy states “AdventHealth Home Health agencies uphold full compliance with s 400.492. Florida statutes, 59A8.027, and the Florida Administrative Code, and maintain a comprehensive emergency preparedness program that meets all federal requirements outlined in the CMS State Operations Manual, Appendix Z, as well as the Home Health Conditions of Participation 484.102.” Under item III, page 22 of 36 “Information, training and exercise” “The Agency will: a. Provide to all staff members, mandatory training/education on the Agency’s Emergency Management Plan during initial orientation and annual training.””

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate it analyzed the agency’s response to and maintained documentation of all drills, tabletop exercises, and emergency events, and revise the agency’s emergency plan, as needed. The findings include: Review of the CEMP binder found a document titled Emergency Management After Action Report. Evaluation completed for: “Actual Event XX drill” dated 7/15/25, and signed by the current Administrator. The Location was noted to be “Enterprise Wide – but affected WFD – Heartland”. Summary of Event On 7/15/25 Hurricane Drill; Plan Evaluation had no comments and no notes or comments under the Preparedness Activities (List and Evaluate); Response Activities (List & Evaluate); Recovery Activities (List & Evaluate): all fields were blank. On 3/5/26 at approximately 8:45 PM, an interview was conducted with the visiting administrator who stated that the Drill Evaluation was not complete and did not contain all the information. She verified this was the only drill conducted in 2025. The last active drill was in 2024 related to hurricane Milton. Review of the Policy titled “Comprehensive Emergency Management Plan (CEMP)” Effective date 2/1/26; Emergency Management Plan – Heartland; Last review dates 2/1/26. The policy states “AdventHealth Home Health agencies uphold full compliance with s 400.492. Florida statutes, 59A8.027, and the Florida Administrative Code, and maintain a comprehensive emergency preparedness program that meets all federal requirements outlined in the CMS State Operations Manual, Appendix Z, as well as the Home Health Conditions of Participation 484.102.” Under item III, page 22 of 36 “Information, training and exercise” “The Agency will: a. Provide to all staff members, mandatory training/education on the Agency’s Emergency Management Plan during initial orientation and annual training.””

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record reviews, interviews, and review of data reports the agency failed to ensure that the Outcome and Assessment Information Set (OASIS) assessments were transmitted to the CMS (Center for Medicare Medicaid Services) system within 30 days of the assessment. The findings include: A review of the Home Health Agency Error Summary report for the previous calendar year (1/1/25 to 12/31/25) revealed an error code of -3330, which indicated the record was submitted more than 30 days after the assessment was completed, was noted to be 29.42%. For the “year to date” (1/1/26 to 3/9/26) the error rate was 22.10% and for the Fiscal Year to Date (10/1/25 to 3/9/25) the error rate was 21.49%. A record review for patient #7 revealed a start of care date (SOC) of 1/29/26, review of the OASIS Validation Report revealed an OASIS start date of 1/30/26 with a submission date of 3/3/26 – a total of 33 days from the SOC. A record review for patient #11 revealed a SOC of 5/5/25; Review of the OASIS Validation Report revealed an OASIS start date of 5/20/25 with a submission date of 6/30/25. Further review of the Validation Report revealed a second start of care date of 7/2/25 with a submission date of 8/12/25. There were two other Start of Care dates for this same admission a third date of 9/6/25 with a submission date of 10/8/25 and a fourth start of care date of 5/20/25 with a submission date of 6/25/25. A record review for patient #12 revealed a soc of 6/20/25 and a submission date of 7/29/25. Further review of the record revealed a second start of care date of 8/15/25 with a submission date of 9/25/25. A record review for patient #13 revealed a SOC of 6/23/25 with a submission date of 7/29/25; a second start of care date of 7/3/25 with a submission date of 8/13/25; a third start of care date of 8/5/25 with a submission date of 9/15/25; a forth start of care date of 6/30/25 with a submission date of 8/4/25. A record review for patient #14 revealed a SOC of 9/8/25 with an OASIS submission date of 10/15/25; a second start of care date of 9/17/25 with an OASIS submission date of 10/21/25 and a third start of care date of 9/11/25 with a submission date of 10/21/25. On 3/5/26 at approximately 4:01 PM an interview was conducted with the visiting Administrator. She stated that they were not aware the percentage of late OASIS submission were so high and offered that in Quarters 2 & 3 they had 30% growth and the quality team had to absorb this which caused the delays and issues with submission timeliness. She stated that they were aware of the average days to lock was 30 to 40 days so they knew they had to get this down. She stated the company had engaged their Clinical Managers to review and lock OASIS. But it wasn’t enough due to the growth. She reported that they look at late documentation and coding on a daily basis (Monday through Friday). Reporting that Resumption of Cares (ROCs ) can cause OASIS data to be submitted late which can also result in two OASIS data submissions in the same certification period. She was shown dates for late submission for residents #12 and #13 and she stated that it must have been a change in payor. When she was asked why all the subsequent submissions would also be late she stated she wasn’t sure why this would occur. She verified that the Coding team reviews the OASIS data, then the quality review team reviews the assessments, after this it goes back to the clinicians who finalize the requested changes. The billing team are the ones who submit the OASIS data but they do not do a quality review they just submit. She agreed this is a concern. On 3/5/26 at approximately 9:26 AM, a follow-up interview was conducted with the Director of Quality; the Administrator, the visiting administrator and the clinical manager during which the issue with late OASIS submission was discussed. The Director of Quality explained that they had collaborated with a contractor for quality assurance reviews of their OASIS submissions. This collaboration resulted in delays due to duplications of work as both teams were reviewing the OASIS items. They had a meeting last month to address the locking of the plans of care to adjust the goal in submission of OASIS to be less than 10 days from the assessment to the submission to the contractor for review.”

“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 provider failed to demonstrate a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The findings include: On 3/4/26 at approximately 4:00 PM, the visiting administrator provided a copy of the Policy Infection Control Plan with an effective date of 5/7/25 and a review date of 5/7/25. At this time she stated that this was all they had. When asked to clarify if they tracked and trended infections or had training the response was that this was all they had and there was nothing further to provide the surveyor. She verified they are not tracking or trending infections at the agency. On 3/5/26 at approximately 9:26 AM, during the Quality Assurance Performance Improvement review with the Director of Quality, Administrator, Clinical Manager and the visiting Administrator clarification was obtained to clarify that the only document available for review for the home health agency’s infection control program was the policy, “Infection Control Plan”. No further information was provided to the survey team. Review of the policy titled “Infection Control Plan” with an effective date of 5/7/25 and a review date of 5/7/25 revealed, “Each home health agency will implement an infection control plan specific to the care setting.” “The Infection Control Plan (ICP) will identify risks for the acquisition and transmission of infectious agents on an ongoing basis. The agency’s risks of infection will vary based on the agency’s geographic location, the community environment, the types of programs/services provided, and the characteristics and behaviors of the population served. The risk assessment will be an ongoing process as the risks change over time. The ICP Risks may include wound infections; hand hygiene compliance; flu vaccination compliance; foley catheter infections; infections of IV (intravenous) site; respiratory infections; surgical site infections and GI (gastrointestinal) infections.” The policy goes on to state “Surveillance of all reported infections: each agency will track all reported patient infections that include but are not limited to: wound/skin infections; catheter related UTIs (Urinary Tract Infections); Upper respiratory infections; GI infections; other type of reported infections.””