Reliable Medical Services, 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 a review of the Agency’s Emergency Operations Plan and staff interview, it was determined that the Agency failed to review and update its Emergency Operations Plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 11/4/24, the Emergency Operations Plan was reviewed. The Plan included the date “May 2018” indicating, the date the Plan was last reviewed and updated. The Agency failed to review and update the Plan every 2 years. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, both confirmed the Agency last reviewed and revised the Emergency Operations Plan in May 2018.”

“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 a review of the Agency’s Emergency Operations Plan and staff interview, it was determined the Agency failed to review and update the risk assessment biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 11/4/24, the Emergency Operations Plan dated “May 2018” was reviewed. The Plan contained the “Hazard Vulnerability Assessment” (risk assessment) form. The Agency failed to review and update the risk assessment every 2 years. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, both confirmed the Agency last reviewed and revised the risk assessment in May 2018.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Operations Plan and staff interview, it was determined the Agency failed to review and update the Emergency Operations policies and procedures biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 11/4/24, the Emergency Operations Plan dated “May 2018” was reviewed. The Plan contained the Emergency policies and procedures. The Agency failed to review and update the Emergency Operations Plan policies and procedures every 2 years. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, both confirmed the Agency last reviewed and revised the Emergency Operations Plan policies and procedures in May 2018.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on a review of the Agency’s Emergency Operations Plan and staff interview, it was determined the Agency failed to review and update the Emergency Operations communication plan biennially. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 11/4/24, the Emergency Operations Plan dated “May 2018” was reviewed. The Plan contained the communication plan. The Agency failed to review and update the Emergency Operations communication plan every 2 years. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, both confirmed the Agency last reviewed and revised the Emergency Operations communication plan in May 2018.”

“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 a review of the Agency’s Emergency Operations Plan and staff interview, it was determined the Agency failed to conduct staff training biennially, relative to the Emergency Operations Plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan dated “May 2018” was reviewed on 11/4/24. The Plan contained documentation the Agency last provided staff training on “Oct. 8, 2020”. As of 11/4/24, the Agency failed to provide staff training pertaining to the Agency’s Emergency Operation Plan every 2 years. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, the Administrator confirmed staff were last trained on the Emergency Operations Plan on 10/8/20.”

“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 Operations Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Operations Plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Operations Plan dated “May 2018” was reviewed on 11/4/24. The Plan lacked documentation that the Agency conducted any testing exercises after “May 3 2018”. 2. During an interview with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, the Administrator confirmed the Agency failed to conduct the required testing of its Emergency Operations Plan.”

“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 Error Summary report and staff interview, it was determined in 1 of 2 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 8/2023 to 7/2024, was reviewed on 11/6/24 at 9:30 AM. The report included error # -3330 for 1 of 2 late submissions, 50% of the OASIS reports submitted, were more than 30 days after the M0090. 2. During an interview with the Administrator and the QA Nurse/Alternate Director of Nursing on 11/7/24 at 9:30 AM, it was confirmed that the error occurred.”

“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 a review of clinical records, Agency policy, and staff interviews, it was determined that in 5 of 7 (Pts. #3, 4, 6, 2, and 7) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete and correct. 5. Pt. #7 was admitted to home health services on 6/10/24 with a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. The clinical record was reviewed on 11/6/24. The form “Beneficiary-Elected Home Health Transfer” was signed by the Pt. and dated on 6/10/24 but lacked the name of the home health agency that the Pt. #7 was transferred from. 6. The Agency Policy “Patient Information – Timeliness and Accuracy of Entries in the Clinical Record” was reviewed on 11/6/24 and required, “Each entry into the patient record must be current, accurate…Patient records should: Be factual, consistent and written in a way that the meaning is clear...” 7. During an interview with the Administrator and the QA Nurse on 11/6/24 at 11:00 AM and on 11/7/24 at 9:30 AM and 10:30 AM, it was stated that the forms should be accurately completed. During the same interviews, the above findings were confirmed. 4. Pt. #2 was admitted to home health services on 6/4/24 with a diagnosis of Polyosteoarthritis, Unspecified. Upon review of the clinical record on 11/4/24, the form titled, “Advance Beneficiary Notice of Non-coverage (ABN)” completed by the SN and dated 6/4/24, for the designated “SN” service, lacked reasoning for non-payment per Medicare, and the estimated cost for those services. CMS guidelines require the agency to complete the form, including all applicable sections, before obtaining the Pt./representative’s signature. . Findings include: 1. Pt. #3 was admitted to the home health services on 10/12/24 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/4/24. The clinical record contained an undated form titled, “Notice of Medicare Non-Coverage”. The undated form was signed by Pt. #3. The form lacked the effective date that home health services will end, as required by the Centers for Medicare & Medicaid Services (CMS) form. The form titled, “Advance Beneficiary Notice of Non-coverage (ABN)” completed by the SN and dated 10/12/24, lacked the reason Medicare may not pay for “Nursing” services, and the estimated cost for that service. The undated form titled, “Discharge Instructions” completed by the SN, signed by the SN and Pt. #3. During an interview with the QA Nurse/Alternate Director of Nursing on 11/6/24 at 11:00 AM, the QA Nurse/Alternate Director of Nursing stated the SN should not instructed the Pt. to sign this form. This form is only used when the Pt. is being discharged from the Agency. Pt. #3 is currently receiving SN services. 2. Pt. #4 was admitted to home health services on 3/8/24 with the diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 11/6/24. The clinical record contained the form titled, “Beneficiary Elected Home Health Transfer”, signed by the Pt. and dated 3/8/24. The form lacked the name of the previous home health agency that will no longer provide service, as required by the Agency’s form. 3. Pt. #6 was admitted to the home health services on 1/10/24 with the diagnosis of Gout, Unspecified. The closed clinical record was reviewed on 11/4/24. The closed clinical record contained the OASIS-E SOC form dated 1/10/24, and the OASIS-E Discharge form dated 2/14/24, both forms were completed by the SN and contained documentation Pt. #6 was not a diabetic. Yet, the SOC OASIS form dated 1/10/24 included a random blood sugar result of 168 mg/dl. The SN visit note dated 1/17/24 included a random blood sugar result of 138 mg/dl. It was unclear whether Pt. #6 was a diabetic. During an interview with the QA Nurse / Alternate Director of Nursing on 11/6/24 at 11:00 AM, the QA Nurse / Alternate Director of Nursing stated Pt. #6 is not a diabetic, the “nurse may have mixed it up”. The form titled, “Advance Beneficiary Notice of Non-coverage (ABN)” was completed by the SN and dated 1/10/24. The form lacked the service(s) that Medicare will no longer pay, reason Medicare may not pay, and the estimated cost of the service.”

“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 a review of the Pt. admission folder, clinical records review, observation during home visits, and staff interviews, it was determined in 7 of 7 (Pts. #1, 2 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the frequency of visits provided by each discipline. Findings include: 1. The Pt. admission folder was reviewed on 11/4/24. The folder contained the “Authorization and Agreement For Home Health Services” form that included the section, “Services and Frequency Of Visit Verification: I have been given written verification of the type, frequency and duration of all disciplines of services that will participate in my plan of care.” 2. The following clinical records were reviewed on 11/4/24, 11/6/24, and required the following services at the SOC: Pt. #1. SOC 7/16/24 - SN and PT. Pt. #2. SOC 6/4/24 - SN and PT. Pt. #3. SOC 10/12/24 - SN. Pt. #4. SOC 3/8/24 - SN. Pt. #5. SOC 9/13/23 - SN and PT. Pt. #6. SOC 1/10/24 – SN, PT and OT. Pt. #7. SOC 6/10/24 - SN. The clinical records lacked documentation that the Pt./representative was provided in writing, the visit frequency of the disciplines to provide service. 3. Home visits were conducted on the following Pts. on 11/4/24 and 11/6/24: Pt. #1. SOC 7/16/24. Pt. #2. SOC 6/4/24. Pt. #3. SOC 10/12/24. During the home visits, the Pt. admission folders were observed and lacked documentation of the visit frequency of the disciplines that provided service. 4. During interviews with the Administrator, and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, and 11/6 or 11/7/24 from 9:30 AM to 10:30 AM, the Administrator confirmed the Agency failed to ensure the Pt./representative was informed in writing of the frequency of visits provided by each discipline.”

“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 a review of clinical records, and staff interviews, it was determined that in 3 of 7 (Pts. #3, 4, and 5) clinical records reviewed, the Agency failed to fully assess patients’ Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. 3. Pt. #5 was admitted to home health services on 6/4/24 with the diagnosis of Bilateral Primary Osteoarthritis of the Knee. The clinical record was reviewed on 11/6/24. The clinical record included the form “Influenza Vaccination Verification, Pneumonia Vaccination Verification…” The form was signed and dated 6/4/24 by the Pt. and the SN and, required the SN to put a mark on the space provided before a statement that applies, but all the spaces were left blank. 4. During an interview with the Administrator and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, the QA Nurse/Alternate Director of Nursing stated, if the Pt. do not recall the date they were vaccinated, the SN is required to “check the doctor’s notes or contact the doctor’s office” to obtain those dates. 5. During an interview conducted with the Administrator and the QA Nurse/Alternate Director of Nursing on 11/6/24 at 11:00 AM and on 11/7/24 at 9:30 AM, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to home health services on 10/12/24 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/4/24. The clinical record contained the form titled, “Influenza Vaccination Verification Pneumonia Vaccination Verification…” The Vaccination form was completed by the SN and dated 10/12/24. The form had a checkmark placed next to “I already had my vaccination __Influenza __Pneumonia”. The form required the SN to enter the dates the Pt. received the Influenza and Pneumonia vaccines; these sections were left blank. During an interview with the Administrator and QA Nurse/Alternate Director of Nursing on 11/4/24 at 3:40 PM, the QA Nurse/Alternate Director of Nursing stated, if the Pt. do not recall the date they were vaccinated, the SN is required to “check the doctor’s notes or contact the doctor’s office” to obtain those dates. During the same interview, the above findings were confirmed. 2. Pt. #4 was admitted to home health services on 3/8/24 with the diagnosis of Spondylosis without Myelopathy or Radiculopathy, Lumbar Region. The clinical record was reviewed on 11/6/24. The clinical record contained the form titled, “Influenza Vaccination Verification Pneumonia Vaccination Verification…” The Vaccination form was signed by the SN and dated 3/8/24. The SN was required to place a checkmark next to an entry that indicate whether the Pt. had the vaccines, requested the vaccines or refused the vaccines. The form was left blank.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined that for 3 of 7 (Pts. #1, 5 and 7) clinical records reviewed, the Agency failed to ensure that the PsOC were updated. Findings include: 1. Pt. #1 was admitted to home health services on 7/16/24 with the diagnoses of but not limited to, Chronic Systolic Heart Failure and Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 11/6/24. The clinical record included a SN visit note dated 10/25/24 that included, “Pt. reports having burning pain and itching to left occipital calf. SN assessed area and noted opening of skin… measurement: length 4.5 cm, width 4.5 cm, depth 0.02 cm… treatment performed: SN cleanse area with normal saline, send photograph to md office (awaiting orders), apply dry dressing, Abd pad, kerlix and secure with tape.” The clinical record also included a SN visit note dated 11/1/24 which included, “SN cleansed area with normal saline, wound cleanser, alerted md, applied dry 4 x 4 absorbent pad, kerlix and ace bandage…. measurement: length 4.5 cm, width 4.5 cm, depth 0.02 cm… treatment performed: SN cleanse area with normal saline, send photograph to md office (awaiting orders), apply dry dressing, and kerlix and ace bandage.” The record lacked documentation that the SN followed up with the Physician an order for treatment of the left calf wound. 2. Pt. #5 was admitted to home health services on 6/4/24 with the diagnosis of Bilateral Primary Osteoarthritis of the Knee. The clinical record was reviewed on 11/6/24. The clinical record included SN visit notes dated 9/10/24 and 9/17/24, that included documentation Pt. #5 had an indwelling urinary catheter. The record lacked documentation that nurse obtained a physician order for the care of the indwelling urinary catheter. 3. Pt. #7 was admitted to home health services on 6/10/24 with the diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery. The clinical record was reviewed on 11/6/24. The clinical record included the following SN visit notes: 7/22/24, Blood Pressure- 93/54, 7/29/24, Blood Pressure- 100/56. During an interview conducted with E#1 (QA Nurse/Alternate Director of Nursing) on 11/7/24, at 9:30 AM, E#1 stated that the Physician is aware that Pt. #7’s diastolic blood pressure is below 60 and so the diastolic blood pressure range in POC should have been updated, so that the SN should not be reporting it to the Physician when it is below 60. The record lacked a physician order updating the POC for the change in diastolic blood pressure parameters. 4. During an interview with E#1 on 11/7/24, at 10:00 AM, it was stated that if there are changes in the Pt. care or treatment, the PsOC should be updated as soon as there is a change... and it is done by obtaining physician orders for the care or treatment and labeling the order as “addendum to the POC” to reflect the update. During the same interview, the above findings were confirmed.”