Horizon 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 record review and interview, it was determined the agency failed to conduct the required full‑scale emergency preparedness exercises as required. This deficient practice had the potential to compromise the agency’s ability to respond effectively during an actual emergency, placing patients and staff at risk for harm due to an untested and insufficiently practiced emergency preparedness plan. Findings include: Review of the agency’s emergency drill documentation showed the following exercises were conducted: • On 5/22/26, the agency conducted a test of the emergency call tree. • On 5/15/26, the agency conducted an office fire drill. • On 7/30/25, the agency conducted a test of the emergency call tree. • On 4/11/25, the agency conducted an office fire drill. • On 2/11/25, the agency conducted a ransomware drill. • On 11/01/24, the agency conducted an active‑shooter drill in the office. None of the above exercises demonstrated a full‑scale test of the emergency preparedness plan, nor did they allow staff to practice implementing all components of the plan. The last documented full‑scale exercise was conducted on 7/24/24, during which the disaster plan was implemented in response to widespread power outages. There was no full scale or tabletop exercises to test the emergency plan since the actual emergency in July 2024. During an interview with the Administrator on 9/2/26 at 1:17 PM, the Administrator agreed the disaster drills completed in 2025 and 2026 were not comprehensive enough to fully test the agency’s emergency preparedness plan. The agency failed to sufficiently test the emergency plan.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, home visit observation, record review, and interview, it was determined the agency failed to ensure that the medication profile was accurate and reflected the medications the patient was actually taking for 1 of 7 patients (Patient #18) whose home visits were observed. Failure to ensure the medication profile was accurate created the potential for medication errors and unidentified drug interactions. Findings include: An agency policy titled, “Medication Profile,” undated was reviewed and stated, “Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medication and new and/or discontinued medications.” This policy was not followed. An example includes: Patient #18 was a 49 year old male admitted to the agency on 1/02/26 with a primary diagnosis of quadriplegia. Additional diagnoses included bladder dysfunction and hyperlipidemia. He received SN and aide services. During a home visit to Patient #18 on 9/02/26 at 10:24 AM, Patient #18’s medications were reviewed with him. The medication list included a multivitamin, which he stated he was not taking. The medication list also included a “magic bullet” rectal suppository to be taken daily; however, he stated he takes the suppository four days per week. The medication list further included Vitamin C 500 mg extended‑release capsules, which the patient stated he was not taking. The agency failed to ensure the medication profile was accurate.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 3 of 18 patients (Patient #4, #6 and #7) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: 1. Patient #4 was an 72-year-old female admitted to the agency 9/16/24 with the primary diagnosis of major depressive disorder. Additional diagnosis listed as “level 3 symptoms poorly controlled, patient needs frequent adjustments in treatment and dose monitoring” included encephalopathy syndrome, hypotension, COPD, and dysphagia. In the last year, she received only psych nurse services and is still on services. Her record, including the POC, for the certification period 7/08/26 to 9/05/26 was reviewed as were visit notes for 2026. Patient #4’s medical record documented on 3/03/26 that she had an increase in intrusive thoughts about dying and the narrative on 4/17/26 stated, “demonstrates increased pessimistic and reports increase of intrusive negative thoughts, some thoughts of death and dying, denies suicidal ideation, plan or intent.” Patient #4’s medical record for each note included, “skilled reason for home health services: depression, suicidal ideation, hopelessness, anxiety with panic, insomnia, PTSD, labile BP and chronic pain.” Patient #4’s POC did not contain any measurable goals or interventions related to suicidality including no documentation of safety planning or referrals to additional psychiatric or therapeutic services. The DCS was interviewed 09/02/26 beginning at 11:00 AM. She confirmed Patient #4s POC did not include measurable interventions or goals directly related to her suicidal ideation including quantative assessment or safety planning. 2. Patient #6 was an 70-year-old female admitted to the agency 8/17/26 with a primary diagnosis of other visual disturbances. Additional diagnosis with a “level 2 symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring” included hyperosmolality and hypernatremia, type 2 diabetes and unspecified mental disorder. She received PT services until discharged 8/25/26 for suicide attempt and psychiatric hospital admission. Her record, including the POC, for the certification period 8/17/26 to 8/25/26 was reviewed. Patient #6’s POC for the certification period 8/17/26 to 8/25/26 did not contain any goals related to hyperosmolality and hypernatremia, type 2 diabetes and unspecified mental disorder. The DCS was interviewed 09/02/26 beginning at 11:00 AM. She confirmed Patient #6’s POC did not include interventions or goals related to her nursing or mental health diagnosis. 3. Patient #7 was an 84-year-old male admitted to the agency 7/08/26 with the primary diagnosis of sepsis. He received PT, OT and ST services beginning 7/06/26 and continues to receive services. His record, including the POC, for the certification period 7/08/26 to 9/05/26 was reviewed. Patient #7’s POC for the certification period 7/08/26 to 9/05/26 did not contain any measurable goals or interventions related to sepsis. The DCS was interviewed 09/02/26 beginning at 11:00 AM. She confirmed Patient #7s POC did not include measurable interventions or goals directly related to sepsis. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs and health decline or mental health crisis.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to coordinate care delivery and involve additional disciplines (such as skilled nursing, psychiatric nursing, social work, or therapy) to address complex diagnoses, safety concerns, and comprehensive care assessments for 3 of 18 patient records reviewed (Patients #4, #6, and #7). Failure to ensure care was coordinated and a multidisciplinary team was included in the care of patients had the potential for unmet patient needs. Findings include: 1. Patient #4, a 72-year-old female, was admitted on 9/16/24 with a primary diagnosis of Major Depressive Disorder and secondary diagnoses including encephalopathy syndrome, hypotension, COPD, and dysphagia with “level 3 symptoms poorly controlled, needing frequent adjustments in treatment and dose monitoring.” She was receiving only psychiatric nurse services during the certification period of 7/08/26 to 9/05/26. Patient #4’s medical record review revealed documented depression on 3/03/26 (increase in intrusive thoughts about dying) and 4/17/26 (“demonstrates increased pessimistic and reports increase of intrusive negative thoughts, some thoughts of death and dying”). Additionally, visit notes consistently listed reasons for services as depression, suicidal ideation, hopelessness, anxiety with panic, insomnia, PTSD, labile BP, and chronic pain. Despite severe clinical depression and complex medical diagnoses (dysphagia, COPD, labile BP), the agency failed to coordinate additional disciplines—such as MSW for crisis/safety planning or outpatient psychiatric referrals—to safely manage her suicidal ideation and co-occurring medical conditions. In an interview on 9/02/26 at 11:00 AM, the DCS confirmed the agency failed to involve additional displines or coordiante care across a multidisciplinary group for Patient #4’s suicidal ideation and complex needs. 2. Patient #6, a 70-year-old female, was admitted on 8/17/26 with a primary diagnosis of visual disturbances and secondary diagnoses including hyperosmolality/hypernatremia, type 2 diabetes, and an unspecified mental disorder (“level 2 symptoms controlled with difficulty, affecting daily functioning”). The agency assigned PT services only. During her admission (8/17/26 to 8/25/26), the agency failed to coordinate skilled nursing or psychiatric care disciplines to evaluate or monitor her diabetes, hypernatremia, or psychiatric diagnosis. On 8/25/26, Patient #6 was discharged following a suicide attempt and psychiatric hospital admission. In an interview on 9/02/26 at 11:00 AM, the DCS confirmed that care was not coordinated across disciplines (e.g., Nursing or MSW) to assess, treat, or establish goals for Patient #6’s underlying medical and mental health diagnoses prior to the crisis. 3. Patient #7, an 84-year-old male, was admitted on 7/08/26 with a primary diagnosis of sepsis and was assigned PT, OT, and ST services. Review of the Patient #7’a record for the certification period 7/08/26 to 9/05/26 showed that despite a high-risk primary diagnosis of sepsis, the agency failed to coordinate with Skilled Nursing to perform systemic physical assessments, monitor vital signs/infection markers, or establish care plans related to sepsis management. In an interview on 9/02/26 at 11:00 AM, the DCS confirmed that care was limited to rehabilitation therapy and was not coordinated with nursing disciplines to assess or manage Patient #7’s primary sepsis diagnosis. The agency’s failure to coordinate interdisciplinary care delivery to assess, monitor, and address critical medical and psychiatric conditions could have resulted in unmanaged patient safety risks and directly contributed to unaddressed mental health crises. ,,”