Centerwell Home Health

“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 policy titled “CWHH EMERGENCY PREPAREDNESS PLAN (EPP),” facility document review, and staff interview, it was determined that the agency failed to maintain documentation of all the components of drills, tabletop exercises, and emergency events. Findings included: Review of CWHH “EMERGENCY PREPAREDNESS PLAN” [EPP] dated March 2018 revealed: Policy Statement The Emergent/ Preparedness Plan establishes procedures to prevent, prepare for, respond to, and recover from natural or man-made emergencies that may disrupt operations or patient care. All associates must be familiar with and adhere to the Emergency Preparedness Plan, which includes communication protocols, resource allocation, and coordination with local, state, and federal agencies. Policy •Each Home Health Agency (HHA) will maintain an Emergency Preparedness Plan (“EPP” ) in accordance with state and federal regulations following guidance in the Company ‘s Emergency Prepa redness Plan Job Aid available on the Company ‘s intranet resource site. •The HHA will adhere to applica ble state-specific stringent guidelines/ requirements rela ted to emergency preparedness. •An emergency/disaster is a natural or human-caused event that significant ly: odisrupts the environment of patient care (example: damage to the organizati on ‘s buildings and grounds due to severe winds, storms or earthquakes) odisrupts care, tr eatment and services to patients (examples: loss of utilities such as power , water or phone due to floods, civil disturbances, accidents or emergencies within the organiza ti on or in the community) oresults in a sudden , changed or increased demand s for the organization’s services (examples: bioterrorist attacks, building collapse, plane crash in the organization’s community) Each HHA will develop and maintain an EPP that must be reviewed, updated, and approved every two years. Each HHA performs and documents participation in annual Emergency Preparedness training and testing. Training and Emergency Preparedness Exercise- Associate, contracted Associate and per diem Associate will: receive emergency preparedness training at orientation to include their specific roles and responsibilities complete required education biannually (every two years) or participate in testing drills and exercises as scheduled by the HHA and directed by the Agency Administration When emergency preparedness policies and procedures are updated, the HHA must inform and train Associates on the updated policies/procedures. One emergency preparedness exercise is required annually, which may be either community-based full-scale exercise, or if not available, an individual facility-based functional exercise every other year. In the alternating year, the Agency Administrator may choose the emergency preparedness drill/exercise of their choice inclusive of a: second full-scale community-based functional exercise OR individual facility-based functional exercise OR a mock emergency/disaster event drill OR tabletop exercise/workshop that is a facilitator-led group discussion using a narrated clinically relevant emergency/disaster event scenario with problem statements, directed messages and/or prepared questions designed to challenge the agency’s EPP.Approved full-scale emergency/event exercises include:community-based exercise a facility-based exercise or an actual event that resulted in activation of the EPP, communication plan and coordination plan or tabletop exercise/workshop in which key personnel assigned emergency management roles discuss simulated emergency/disaster events. The HHA will participate in any required community emergency management drills as required by state regulation. Review of the agency’s binder titled “Safety Binder EPP” failed to reveal documentation of the components of tabletop drill dated 10/24/2025. The binder failed to reveal 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. The binder failed to reveal the participants of the tabletop drill. The binder revealed an emergency preparedness event dated 12/10/2025 related to information systems failure. The binder failed to reveal documentation that the emergency preparedness event on 12/10/2025 disrupted patient care. The binder failed to reveal signatures for the emergency event and the tabletop drill. Review of document titled “Branch Director Assignments” dated 12/11/25, revealed the agency’s electronic medical record (EMR) was down with no direct impact to hands-on patient care. The document failed to reveal participants in the emergency event. Review of document titled “Severe Weather/Tornado Evaluation Form” dated 10/24/25, failed to reveal 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. The document failed to reveal participants in the tabletop drill. On 06/09/ 2026 at 11:30 AM, an office interview was conducted with the Clinical Manager (CM), who confirmed her responsibility for the agency’s disaster plan. The CM stated she was unable to locate documentation of the facilitator-led group discussion using a narrated clinically relevant emergency/disaster event scenario with problem statements, directed messages and/or prepared questions designed to challenge the agency’s emergency preparedness plan of the tabletop drill performed on 10/24/2025. The CM confirmed the agency failed to document the required components of the tabletop drill. The CM further revealed that the emergency preparedness event dated 12/10/2025 was sent to the facility from their corporate office regarding an information system failure. She confirmed that it did not disrupt patient care. The CM was unable to provide documentation for the participants in the drill.”

“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 review of policy titled “03-05: Patient Assessments, OASIS Data Collection” review of the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings included: Review of the policy titled “OASIS Date Collection” reviewed 9/2025, revealed that OASIS date items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 03/2025 – 02/2026 ran on 06/05/2026 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview was conducted with the Administrator on 06/10/2026 at 1:00 PM. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments. The Administrator revealed the agency had identified an issue with untimely OASIS submissions and were currently investigating processes to correct the error.”