Emmanuel Home Health, Inc.

“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 review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan every 2 years. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 02/10/25 at 2:15 PM. The Plan lacked a date of when it was last updated or revised. 2. During an interview with the Administrator, Clinical Supervisor and Biller on 02/11/25 at 1:10 PM, it was stated that the Emergency Preparedness Plan has not been updated since 2021. During the same interview, the above finding was confirmed.”

“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 review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach, every two years. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 02/10/25 at 2:15 PM. The plan lacked documentation of Hazard Vulnerability Assessments for the years 2022, 2023 and 2024. 2. During an interview with the Administrator, Clinical Supervisor and Biller on 02/11/25 at 1:10 PM, the above finding was confirmed. .”

“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 the review of the Agency’s Error Summary report and staff interview, it was determined that in the last 12 months, the Agency failed to submit 202 of 458 reports on time. Finding include: 1. The Agency’s Error Summary report for 02/01/24 thru 01/30/24, was reviewed on 02/10/25 at 11:50 AM. The report included error # -3330. The report included 44.10% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator, on 02/11/25 at 12:00 PM.”

“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 the clinical records reviewed and staff interview, it was determined in 4 of 7 (Pts. #4, 3, 6 and 7) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 2. Pt. #3 was admitted to the home health services on 06/20/24 with the diagnosis of: Encounter for Orthopedic. The clinical record was reviewed on 02/11/25. The clinical record contained a POC dated 12/27/24, that required the SN to assess the patient’s heart rate and blood glucose, 2 times a week for 9 week and notify the Physician or heart rates below 60. The SN visit note dated 02/03/25 lacked documentation that the Physician was notified of the heart rate of 52. 3. Pt. #6 was admitted to the home health services on 10/03/22 with the diagnosis of: Encounter for Change. The clinical record was reviewed on 02/11/25. The clinical record contained a POC dated 05/25/24, that required the SN to assess the patient’s pain and blood glucose, 1 time a week for 9 week. The SN visit note dated 06/27/24 lacked the pain and blood glucose assessment. 4.Pt. #7 was admitted to the home health services on 10/02/24 with the diagnosis of: Type 2 Diabetes Mellitus was reviewed on 02/11/25. The clinical record contained a POC dated 12/01/24, that required the SN to assess the patient’s blood glucose and weight, 1 time a week for 9 week. The SN visit note dated 01/22/25 lacked the blood glucose and weight assessment. 5. The above findings were confirmed, during the interview with the Director of Nursing, on 02/11/25 at 11:30 AM and on 02/13/25 at 11:00 AM, with the Director of Nursing. Findings include: 1.Pt. #4 was admitted to home health services on 01/06/25 with the diagnosis of Encounter for Change or Removal of Non-surgical Wound Dressing. The clinical record was reviewed on 02/10/25. The record included a Physician order dated 01/10/25 which included the documentation, “Please refer patient to MSW for assistance with Medicare Part D enrollment.” The record lacked documentation of an MSW evaluation or visit.”