Accord Home Health Services, Inc.

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on the Agency’s Emergency Preparedness Plan review and staff interview, the Agency failed to include current contact information in the communication plan. Findings include: The Agency’s Emergency Preparedness Plan was reviewed on 03/03/26. The Emergency Preparedness Plan lacked the names and contact information for current Agency staff, physicians, volunteers, and entities providing services under arrangement. 2. During an interview with the Director of Nursing (DON) on 03/04/26 at 9:30 AM, the DON confirmed the above finding.”

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to conduct a full-scale exercise to ensure the effectiveness of the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 03/03/26. The Emergency Preparedness Plan included tabletop exercises for 2024 / 2025 and lacked evidence of conducting any full-scale exercise or implementation of the Emergency Preparedness Plan since August 2023. 2. During an interview with the Director of Nursing (DON) on 03/04/26 at 9:30 AM, the DON confirmed the above finding.”

“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 the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 17 of 156 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 03/02/25 to 03/02/26, was reviewed on 03/02/26. The report documented 17 of 156 (10.90%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing on 03/04/26 at 1:30 PM, the Director of Nursing confirmed the above finding.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on home visit observation, interviews during the home visits, clinical record reviews, and staff interviews, in 2 of 7 (Pts. # 1 and 7) clinical records reviewed, the Agency failed to ensure the Plan of Care (POC) included the patients’ current medications and that services/treatments were provided according to the POC. Findings include: 1. Pt. # 1 was admitted to home health services on 07/28/25 with the Diagnosis of Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 03/02/26. The clinical record included a Plan of Care (POC) for the certification period of 01/24/26 to 03/24/26, included the following medications: “….Amlodipine besylate 5 mg oral tablet….Ascorbic Acid 500 mg oral tablet….Atorvastatin calcium 80 mg oral tablet….Cholestyramine sugar-free 4 gm powder for oral suspension….Ergocalciferol 1.25 mg (50,000 unt) oral capsule….Ferrous Sulfate 324 mg (iron 65 mg) delayed release oral tablet….Metoprolol Succinate 50 mg 24hr extended release oral tablet….Oxybutynin Chloride 5 mg 24 hr extended release oral tablet….” A home visit was conducted for Pt. #1 with the Visiting Nurse on 03/02/26 at 2:30 PM. It was observed that during review of medications, Pt. # 1 stated that he was taking an over the counter antidiarrhea medication as needed. The following medications were observed at the Pt.’s home: 1 bottle of “Aspirin 81 mg”, 1 bottle of “Amlodipine 10 mg”, 1 bottle of “Vitamin 200 IU” and 1 box of “Imodium 2 mg”. During an interview with Pt. #1 at 2:45 PM, Pt. confirmed that he was no longer taking some of the medications on the Agency’s current medication list “for a long time” and stated that he was only taking the medications observed at home. The clinical record lacked the patient’s current medications in the POC, or a modification of the orders to the POC. 2. Pt. # 7 was admitted to home health services on 07/31/25 with the Diagnosis of Radiculopathy. The clinical record was reviewed on 03/03/25. The clinical record included a Plan of Care (POC) for the recertification period of 11/28/25 to 01/26/26, the required Skilled Nursing (SN) frequency of 1 visit every 2 weeks for 9 weeks. The clinical record lacked SN visits which were 1 visit every 2 weeks/14 days as ordered. The dates of the SN visits were 12/10/25, 12/19/25 (9 days later), 01/10/26 (21 days later), 01/17/26 (7 days later) and 01/26/26 (9 days later). The clinical record lacked a modification order to the SN frequency or documentation as to why POC was not followed. 3. During an interview with the Director of Nursing on 03/04/26 at 10:25 AM, the Director of Nursing confirmed the above findings.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical records review and staff interview, in 6 of 7 (Pts. #2,1,5,7,3 and 4) clinical records reviewed the Agency failed to ensure documentation entered into the clinical record was complete. 5. Pt. #3 was admitted to home health services on 02/10/26 with the Diagnosis of Parkinson’s Disease. The clinical record was reviewed on 03/02/26. The clinical record included a document titled “Advance Beneficiary Notice of Non-Coverage” signed by Pt #3 on admission. The document was incomplete; it lacked description of the items or services will not be covered. 6. Pt # 4 was admitted to home health services on 02/18/26 with the Diagnosis of Depression Unspecified. The clinical record was reviewed on 03/03/26. The clinical record included a document titled “Advance Beneficiary Notice of Non-Coverage” signed by Pt #4 on admission. The document was incomplete; it lacked description of the items or services will not be covered. 7. During interviews with the Director of Nursing on 03/04/26 between 9:30 AM and 12:00 PM, findings of clinical records having incomplete documents was confirmed. 2. Pt. # 1 was admitted to home health services on 07/28/25 with the Diagnosis of Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 03/02/26. The clinical record included an Advance Beneficiary Notice of Non-coverage (ABN), signed by Pt. #1 and dated at the SOC. The document lacked description of specific items/supplies not covered by Medicare. 3. Pt. # 5 was admitted to home health services on 01/30/26 with the Diagnosis of Hemiplegia following Cerebral Infarction. The clinical record was reviewed on 03/03/26. The clinical record included an Advance Beneficiary Notice of Non-coverage, undated and signed by Pt. #5. The document lacked description of specific items not covered by Medicare. 4. Pt. # 7 was admitted to home health services on 07/31/25 with the diagnosis of Radiculopathy. The clinical record was reviewed on 03/03/25. The clinical record included an Advance Beneficiary Notice of Non-coverage (ABN), signed and dated at the SOC. The document lacked description of specific items/supplies not covered by Medicare. Findings include: 1. Pt.#2 was admitted to home health services on 08/30/25 with a Diagnosis of Quadriplegia. The clinical record was reviewed on 03/03/26. The Advance Beneficiary Notice of Non-Coverage (ABN) form, signed by Pt.#2 and dated at the SOC, lacked documentation of specific supplies not covered by Medicare.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on clinical record reviews, home visit observation and staff interview, in 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. and/or patients’ representatives were informed in advance of the disciplines to provide care/service and frequency of visits provided by each discipline. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 03/02/26 and included a form titled: “Admission Consent form” which lacked documentation of what services/disciplines are to be provided and their frequencies. 2. The following clinical records were reviewed from 03/02/26 to 03/04/26 and lacked documentation of the services/disciplines to be provided and the visit frequencies. Pt. #1 Start of Care (SOC) 07/28/25 Pt. #2 SOC 08/30/25 Pt. #3 SOC 02/10/26 Pt. #4 SOC 02/18/26 Pt. #5 SOC 01/30/26 Pt. #6 SOC 03/28/25 Pt. #7 SOC 07/31/25 3. The following home visits were conducted on 03/02/26 for Pt. #1 and on 03/03/26 for Pts. #2 and 3. During the home visits, the Pt. admission folders were observed, which included the “Admission Consent form.” The forms lacked documentation indicating the Pts. /patients’ representatives were notified of the services/disciplines to provide service, and the frequency of visits in writing. 4. During interviews with the Director of Nursing on 03/03/26 between 9:30 AM to 12:00 PM, the Director of Nursing confirmed the above findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, in 1 of 2 (Pt. #7) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conducted Home Health Aide supervision every 14 days. Findings include: 1. Pt. # 7 was admitted to home health services on 07/31/25 with the Diagnosis of Radiculopathy. The clinical record was reviewed on 03/03/26. The clinical record included Home Health Aide (HHA) visit notes 1 time a week, for the certification period of 11/28/25 to 01/26/26. The clinical record included HHA supervisory notes dated 11/28/25 and 12/10/25. As of 03/03/26, the record lacked documentation of HHA supervision by the RN after 12/10/25. 2. During an interview with the Director of Nursing on 03/04/26 at 10:25 AM, the Director of Nursing confirmed the above findings.”