Epic Home Care, Inc.

“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 review of Agency staff list, review of Agency’s Emergency Preparedness Plan, review of In-service documents, staff interview, in 3 of 5 (Employees # 1, 3, and 6) Employees reviewed, the Agency failed to conduct initial staff training related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s staff list, the Agency’s Preparedness plan and In-service documents were reviewed on 04/01/26. As of 04/01/26, the Agency’s Emergency Preparedness Plan lacked documentation of Emergency Preparedness initial training for the following Employees: Employee # 1 (Licensed Practical Nurse / Date of Hire (DOH)12/05/25). Employee # 3 (Registered Nurse / DOH 12/17/25). Employee # 6 (Licensed Practical Nurse / DOH 09/02/25). 2. During an interview with the Administrator and Director of Nursing on 04/01/26 at 11:00 AM, the Administrative staff confirmed the above findings.”

“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./ Pts. representative were informed in advance 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 03/30/26 and included a form titled: “Patient Consent for Home Health Services” which included a section for what services / disciplines are to be provided and their proposed visit frequencies. 2. The following clinical records were reviewed from 03/30/26 to 04/01/26 and lacked documentation of the services/disciplines and proposed visit frequencies. Pt. #1 Start of Care (SOC) 05/23/25. Pt. #2 SOC 08/25/25. Pt. #3 SOC 02/17/26. Pt. #4 SOC 11/20/25. Pt. #5 SOC 05/13/25. Pt. #6 SOC 07/18/24. Pt. #7 SOC 01/19/25. 3. The following home visits were conducted on 03/31/26 for Pts. #1, 2 and 3. During the home visits, the Pt. admission folders were observed, including the “Patient Consent for Home Health Services” and lacked documentation of services/disciplines and proposed visit frequencies. 4. During staff interviews with the Administrator and Director of Nursing on 04/01/26 between 11:00 AM to 1:30 PM , the Director of Nursing confirmed the above findings.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on clinical record reviews, policy review, and staff interviews, for 4 of 7 (Pts. #2, 3, 4, and 5) clinical records reviewed, the Agency failed to conduct complete assessments of patients’ Pneumonia vaccination status. Findings include: 1.The following clinical records were reviewed from 03/31/26 to 04/01/26, and the records lacked documentation that the Pneumonia vaccination was assessed. Pt. #2 SOC 08/25/25 lacked Pneumonia vaccination assessment. Pt. #3 SOC 02/17/26 lacked Pneumonia vaccination assessment. Pt. #4 SOC 11/20/25, lacked Pneumonia vaccination assessment. Pt. #5 SOC 05/13/25, lacked Pneumonia vaccination assessment. 2. The Agency Policy titled: “Flu and Pneumonia Protocol for Patient” was reviewed on 04/01/26 and required: “ 1. The agency requires clinicians to submit patient screening at the end of each calendar year.” 3. “Clinicians will ask patients to fill out a consent form either to consent to vaccination or decline vaccination.” 4. “If patient consent to have vaccination, clinician will assist patient in getting a flu or pneumonia shot either at Physician’s office or Pharmacy.” 3. During staff interviews with the Administrator and Director of Nursing on 04/01/26 at 11:00 AM and 1: 00 PM, the above findings were confirmed.”

“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 interviews, in 3 of 4 (Pts. # 1, 2 and 3) clinical records reviewed, wherein the Pt. received HHA services, the Agency failed to ensure the RN conducted HHA supervision every 14 days. 2. Pt. #2 was admitted to Home Health services on 08/25/25 with diagnosis of Cirrhosis of the Liver. The clinical record was reviewed on 03/30/26. The clinical record included documentation the HHA provided service 2 times a week from 01/08/26 to 03/28/26. The HHA supervisory notes dated 02/02/26, 03/02/26, 03/09/26, 03/15/26, and 03/22/26, were signed by the Licensed Practical Nurse (LPN). The record lacked a supervisory note for the week of 02/16/26. As of 04/02/26, the record lacked documentation for supervisory visit notes conducted by a Registered Nurse. 3. Pt. #3 was admitted to Home Health services on 02/17/26 with diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 03/31/26. The clinical record included documentation the HHA provided service 2 times a week from 02/17/26 to 03/24/26. The HHA supervisory notes dated 03/03/26, 03/10/26, and 03/24/26, were signed by the Licensed Practical Nurse (LPN). As of 04/02/26, the record lacked documentation for supervisory visit notes conducted by a Registered Nurse. 4. During staff interviews with the Administrator and Director of Nursing on 04/01/26 at 11:00 AM and 1:00 PM, it was confirmed the Agency failed to ensure the RN conducted Home Health Aide supervision every 14 days. Findings include: 1. Pt. # 1 was admitted to Home Health Services on 05/23/25 with the diagnosis of Chronic Atrial Fibrillation. The clinical record was reviewed on 03/31/26. The clinical record included documentation that the Home Health Aide (HHA) provided service, 2 times a week from 02/01/26 to 03/15/26. The clinical record included HHA supervisory notes by the Licensed Practical Nurse (LPN) on 02/09/26, 02/16/26, 03/02/26 and 03/15/26. As of 04/01/26, the record lacked documentation of Home Health Aide supervision by the Registered Nurse from 02/01/26 to 04/01/26.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records and staff interviews, in 2 of 2 (Pts. # 6 and 7) closed/discharged clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. Findings include: 1. Pt. # 6 was admitted to Home Health Services on 07/18/24 with the diagnosis of Other Spondylosis with Radiculopathy. The clinical record was reviewed on 03/31/26. The record included a discharge summary indicating Pt. # 6 was discharged from the Agency on 05/13/25. The discharge summary lacked documentation of date that it was sent to the Physician. 2. Pt . #7 was admitted to Home Health Services on 01/19/25 with the diagnosis of Cerebral Infarction. The clinical record was reviewed on 04/01/25. The record included a discharge summary indicating Pt. # 7 was discharged from the Agency on 03/17/25. The discharge summary lacked documentation of date that it was sent to the Physician. 3. During an interview with the Administrator and Director of Nursing on 04/01/26 at 11:00 AM, the Administrative staff confirmed the above findings.”