Marion County Home Care Services

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on a review of the Emergency Preparedness Plan (EPP), agency documents, and an interview, it was determined that the Home Health Agency (HHA) failed to comply with the regulatory requirements specified in §484.102, §485.68, §485.542, and §485.727. Specifically, the HHA did not establish and maintain a comprehensive emergency preparedness program that meets all applicable Federal, State, and local emergency preparedness requirements. The emergency preparedness program must include, but is not limited to, an all-hazards approach as required by the relevant regulations. The cumulative effect of this deficient practice has the potential to place patients and staff at risk for harm during an emergency or disaster. Findings Include: 1.The Home Health Agency (HHA) failed to develop and maintain a comprehensive emergency preparedness program that complies with all applicable Federal, State, and local emergency preparedness requirements. The emergency preparedness plan was not reviewed and updated annually as required. Additionally, the plan lacked strategies for addressing identified emergency events, such as power failures, natural disasters, and other emergencies affecting the facility’s ability to provide care. It also did not adequately address the patient/client population, including at-risk individuals, or detail the types of services the facility can provide in an emergency, continuity of operations, delegations of authority, and succession plans. Furthermore, there was no documented process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials, nor was there evidence of the facility’s efforts to contact these officials or participate in integrated response planning. (Refer to E-0004, E-0007, E-0009) 2. The Home Health Agency (HHA) failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment, and communication plan. The policies and procedures were not reviewed and updated annually as required. Specifically, the policies and procedures did not address the following: plans for each patient during natural or man-made disasters, including as part of the comprehensive patient assessment; procedures for informing State and local emergency preparedness officials about patients in need of evacuation due to an emergency; procedures to follow up with on-duty staff and patients to determine needed services during service interruptions and to inform State and local officials of any staff or patients that cannot be contacted; a system of medical documentation that preserves patient information, protects confidentiality, and secures the availability of records; and the use of volunteers and other emergency staffing strategies to address surge needs during an emergency. (Refer to E-0017, E-0019, E-0021, E-0023, E-0024) 3. The Home Health Agency (HHA) failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws. The plan lacked necessary elements such as names and contact information for relevant individuals and entities, contact information for emergency preparedness staff and other sources of assistance, primary and alternate means for communication, methods for sharing patient information, and means of providing information about the facility’s needs and occupancy. Additionally, the plan was not reviewed and updated at least annually. (Refer to E-0029, E-0030, E-0031, E-0032, E-0033, and E-0034) 4. The Home Health Agency (HHA) failed to develop, maintain, and annually review and update a comprehensive emergency preparedness training and testing program based on its emergency plan, risk assessment, policies and procedures, and communication plan. The training and testing program did not meet the required standards. Specifically, the HHA did not ensure that all new and existing staff, service providers, and volunteers received initial and annual training in emergency preparedness policies and procedures, nor was there adequate documentation or demonstration of staff knowledge of emergency procedures. Additionally, the HHA did not conduct the required exercises to test the emergency plan annually. The required exercises, including unannounced staff drills, full-scale or tabletop exercises, and analysis of responses to drills and actual emergency events, were not conducted or documented properly. Furthermore, if the HHA is part of a healthcare system with multiple separately certified facilities and has elected to participate in a unified and integrated emergency preparedness program, it failed to ensure that the program met all requirements. This includes demonstrating active participation in the program’s development, addressing each facility’s unique circumstances, ensuring compliance, and including a unified and integrated emergency plan with documented community-based and individual facility-based risk assessments, integrated policies and procedures, and coordinated communication and training programs. (Refer to E-0036, E-0037, E-0039, E-0042)”

“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 Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to comply with the requirement to develop and maintain a comprehensive emergency preparedness program, as specified under §484.102. Review of the agency’s Emergency Preparedness Program (EPP) revealed that there was no documented date of review or revision for the emergency preparedness plan. During an interview on 08/07/24 between 9:30 AM and 11:30 AM, the Administrator confirmed that there was no documentation of a review date for the emergency preparedness plan.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan that addresses the patient/client population, as required by §484.102. Review of the agency’s Emergency Preparedness Program (EPP) revealed that there was no policy or statement within the plan addressing the patient or client population, including the types of services the facility can provide during an emergency, and continuity of operations with delegations of authority and succession plans. During an interview on 08/07/24 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place to ensure that the emergency preparedness plan addressed the patient/client population, including emergency services and continuity of operations.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials, as required by §484.102. Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/24, failed to include policies or procedures for documenting efforts to contact emergency preparedness officials and participating in collaborative planning efforts. There was no policy or procedure in place addressing the required cooperation with emergency preparedness officials. During an interview on 08/07/24 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no documented policies or procedures to ensure cooperation and collaboration with emergency preparedness officials. There was no evidence of annual contact with the local emergency preparedness agency to confirm the facility’s needs in emergencies.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and implement policies and procedures to address patient care during natural or man-made disasters, including the requirement for individual patient plans as part of the comprehensive patient assessment, as required by §484.102(b)(1). Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/24, revealed that the policies and procedures did not include individual disaster plans for each patient as part of the comprehensive patient assessment. During an interview on 08/07/24 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place for addressing patient needs during a disaster or for including individual patient plans in the comprehensive patient assessment.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and implement procedures to inform State and local emergency preparedness officials about patients needing evacuation due to an emergency, based on their medical and psychiatric conditions and home environment. Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/2024, revealed that the policies and procedures did not address the requirement to inform State and local emergency preparedness officials about patients in need of evacuation during emergencies. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place for informing officials about patients needing evacuation in emergency situations.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined that the Home Health Agency (HHA) failed to establish and implement procedures for following up with on-duty staff and patients to determine services needed during an emergency interruption. Additionally, the HHA did not have procedures in place to inform State and local officials about any on-duty staff or patients that could not be contacted. Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/2024, revealed that the policies and procedures did not address the required follow-up procedures for staff and patients or the notification process for State and local officials as outlined in the regulatory text. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place for follow-up with staff and patients during emergency interruptions or for informing State and local officials about any uncontacted individuals.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined that the Home Health Agency (HHA) failed to establish and implement policies and procedures for maintaining a system of medical documentation. Specifically, the agency did not have a system in place to preserve patient information, protect confidentiality, or secure and maintain the availability of records. Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/2024, revealed that the policies and procedures did not address the required system of medical documentation for preserving patient information, protecting confidentiality, and ensuring the availability of records. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place addressing the requirements for maintaining medical documentation as outlined in the regulatory text.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined that the Home Health Agency (HHA) failed to develop and implement policies and procedures for the use of volunteers and emergency staffing strategies. Specifically, the agency did not have documented procedures for integrating State and Federally designated health care professionals to address surge needs during an emergency. Review of the agency’s Emergency Preparedness Program (EPP), last revised by the facility on 08/07/2024, revealed that the policies and procedures did not address the use of volunteers and emergency staffing strategies, including the integration of State and Federally designated health care professionals to address surge needs. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place for utilizing volunteers or integrating designated health care professionals during emergencies.”

“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 review of the Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined that the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws. Specifically, the agency did not have a documented communication plan, and there was no evidence of any review or updates. Review of the agency’s Emergency Preparedness Program (EPP) revealed that no communication plan was documented, and there was no record of any reviews or updates. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures in place for developing, maintaining, or reviewing the required emergency preparedness communication plan.”

“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 review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined that the Home Health Agency (HHA) failed to include required contact information in their emergency preparedness communication plan as mandated by §484.102(c). Specifically, the facility did not have a documented communication plan that included names and contact information for staff, entities providing services under arrangement, patients’ physicians, and volunteers. Review of the agency’s Emergency Preparedness Program (EPP) revealed that there was no documented communication plan, and there was no record of review or updates. The EPP did not include any contact information for the required entities. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures for maintaining the required contact information for staff, service entities, physicians, and volunteers.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to include required contact information in their emergency preparedness communication plan, as mandated by §484.102(c). Specifically, the facility did not have a documented communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness staff, or other sources of assistance. Review of the agency’s Emergency Preparedness Program (EPP) revealed that there was no documented communication plan, and there was no record of review or updates. The EPP did not include any contact information for the required emergency officials or sources of assistance. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures for maintaining the required contact information for emergency preparedness staff and other necessary assistance sources.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and maintain methods for sharing patient information and medical documentation with other health providers to maintain continuity of care. Additionally, the facility did not have a means for releasing patient information during an evacuation or for providing information about the general condition and location of patients as required by 45 CFR 164.510. Review of the agency’s Emergency Preparedness Program (EPP) revealed that there was no documented policy or procedure for sharing patient information and medical documentation with other health providers, releasing patient information during an evacuation, or providing information about the general condition and location of patients. The EPP was last revised on [EPP Date of Last Annual Reviewed/revised/updated] but lacked the required details. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed that there were no policies or procedures for methods to share patient information and medical documentation or for ensuring compliance with patient information release during an evacuation.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to include a means of providing information about its occupancy, needs, and ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. Review of the agency’s Emergency Preparedness Program (EPP), last revised on [EPP Date of Last Annual Reviewed/revised/updated], revealed a lack of policies or procedures for providing information regarding the facility’s occupancy, needs, and ability to offer assistance to relevant authorities. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed there were no documented policies or procedures for sharing information about the facility’s occupancy, needs, and assistance capabilities.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness training and testing program as required. Specifically, the program was not reviewed and updated at least every 2 years, and there was no documentation of the required training and testing activities. Review of the agency’s Emergency Preparedness Program (EPP), last revised on [EPP Date of Last Annual Reviewed/revised/updated], revealed a lack of policies or procedures for developing, maintaining, reviewing, and updating the emergency preparedness training and testing program. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed there were no documented policies or procedures for the emergency preparedness training and testing program, including its development, maintenance, review, and updating.”

“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 Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness training program as required. Specifically, there was no documented evidence of initial or ongoing training, and the facility did not provide training at least every 2 years. Additionally, there was no documentation or demonstration of staff knowledge of emergency procedures. Review of the agency’s Emergency Preparedness Program (EPP), last revised on [EPP Date of Last Annual Reviewed/revised/updated], revealed that the training program did not include policies or procedures for conducting and documenting the required emergency preparedness training. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed there were no documented policies or procedures for the required initial and ongoing training, nor was there evidence of demonstrated staff knowledge of emergency procedures.”

“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 review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to meet the emergency preparedness testing requirements. Specifically, the HHA did not conduct the required annual exercises to test the emergency plan, nor was there documentation or analysis of any drills or tabletop exercises. Additionally, there was no evidence of participation in community-based exercises or facility-based functional exercises, as required. Review of the agency’s Emergency Preparedness Program (EPP), last revised on [EPP Date of Last Annual Reviewed/revised/updated], failed to include policies or procedures for conducting and documenting the required emergency plan exercises. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed there were no documented policies or procedures for the required emergency preparedness testing, including drills, tabletop exercises, or community-based exercises.”

“Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.542(f), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system’s coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This Standard is not met as evidenced by: Based on review of Emergency Preparedness Plan (EPP), agency documents, and interview, it was determined the Home Health Agency (HHA) failed to comply with the requirements for an integrated emergency preparedness program as specified in §484.102(e). Specifically, the HHA did not demonstrate active participation in the development of a unified and integrated emergency preparedness program, nor did it include the required risk assessments, integrated policies, or comprehensive training and testing programs. Review of the agency’s Emergency Preparedness Program (EPP), last revised on [EPP Date of Last Annual Reviewed/revised/updated], failed to include policies or procedures for the unified and integrated emergency preparedness program requirements, including the development of the program, risk assessments, and compliance verification. During an interview on 08/07/2024 between 9:30 AM and 11:30 AM, the Administrator confirmed there were no documented policies or procedures for the integration and coordination of emergency preparedness across the healthcare system, including unified planning, risk assessments, and compliance verification.”

“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 observation, record review, and staff interview, the home health agency skilled staff failed to ensure the patient’s right to participate in, be informed about, and consent or refuse care in advance of and during treatment, with respect to the disciplines that will furnish the care and the frequency of visits for 7 (Patients 1 - 7) of 7 sample patients. The home health agency’s failure to ensure the patient’s right to consent to frequency of services placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review or Patient 1’s Admission Consent dated 07/29/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 1’s plan of care indicated PT (Physical Therapy) visits to be 1 time per week for 4 weeks, OT (Occupational Therapy) visits to be 1 time per week for 4 weeks, and Home Health Aide (HHA) visits to be 1 time per week for 9 weeks. Review of Start of Care Assessment visit dated 07/29/24 lacked documentation, by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Observation during Patient 1’s home visit on 08/07/24, showed the home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 2 Review of Patient 2’s Admission Consent dated 01/25/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 2’s plan of care indicated SN (Skilled Nurse) 1 time per week for 9 weeks, PT (Physical Therapy) 1 time per week for 8 weeks, and ST (Speech Therapy) 1 time per week for 9 weeks. Review of Start of Care Assessment visit dated 01/25/24 lacked documentation, by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Observation during Patient 2’s home visit on 08/07/24, showed the home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 3 Review of Patient 3’s Admission Consent dated 02/12/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 3’s plan of care indicated PT (Physical Therapy) 1 time per week for 5 weeks, and Home Health Agency (HHA) 1 time per week for 9 weeks. Review of Start of Care Assessment visit dated 02/12/24 lacked documentation, by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Observation during Patient 3’s home visit on 08/07/24, showed the home folder documents provided by the home health agency lacked evidence of visit frequencies being provided to the patient. Patient 4 Review of Patient 4’s Admission Consent dated 06/10/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 4’s plan of care indicated PT (Physical Therapy) 1 time per week for 2 weeks, then 2 times per week for 7 weeks. Review of Start of Care Assessment visit dated 06/10/24 lacked documentation, by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Patient 5 Review of Patient 5’s Admission Consent dated 06/26/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 5’s plan of care indicated SN (Skilled Nurse) 1 time per week for 3 weeks, Home Health Aide (HHA) 1 time per week for 4 weeks, and PT (Physical Therapy) to evaluate the patient for services. Review of Start of Care Assessment visit dated 06/26/24 lacked documentation by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Patient 6 Review of Patient 6’s Admission Consent dated 07/02/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 6’s plan of care indicated SN (Skilled Nurse) 2 times per week for 1 week, then 1 time per week for 3 weeks, and PT/OT (Physical Therapy/Occupational Therapy) to evaluate the patient for services. Review of Start of Care Assessment visit dated 07/02/24 lacked documentation by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. Patient 7 Review of Patient 7’s Admission Consent dated 04/15/24 lacked evidence of a visit frequency for the service disciplines providing care. Review of Patient 7’s plan of care indicated PT (Physical Therapy) 2 times per week for 4 weeks, then 1 time per week for 4 weeks and OT (Occupational Therapy) to evaluate the patient for services. Review of Start of Care Assessment visit dated 04/15/24 lacked documentation by the Start of Care RN (Registered Nurse), of informing the patient of visit frequencies that would be provided by each service discipline. There was no documentation to support the patient had given consent to any visit frequencies. During an interview on 08/08/24 at 9:05 AM, Staff A, Agency Director, confirmed agency failed to ensure patients were informed about and consented to visit frequencies for each discipline.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review, observation, and staff interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining visit schedules that included frequency of visits by HHA personnel for 7 (Patients 1 - 7) of 7 Patients. The home health agency’s failure to ensure the patients received written instruction regarding planned visits, placed all patients currently on services at risk for unmet needs, care and services. Findings Include: Review of Patient records 1 through 7 lacked documented evidence by agency professional staff to confirm the agency developed or delivered written instructions outlining visit frequencies to the patients or caregivers. Observation during home visit with Patient 1 on 08/07/24, showed there were no written instructions regarding visit frequency or home health agency (HHA) instructional documents found in the home. Observation during home visit with Patient 2 on 08/07/24, showed there were no written instructions regarding visit frequency or home health agency (HHA) instructional documents found in the home. Observation during home visit with Patient 3 on 08/07/24, showed there were no written instructions regarding visit frequency or home health agency (HHA) instructional documents found in the home. During an interview on 08/08/24 at 4:00 PM, Staff A, Agency Director, confirmed that the agency had not given the patients written information regarding the frequency of agency visits.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review, observation, and staff interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining medication schedule instructions, that included medication name, dosage, frequency, and which medications would be administered by the HHA personnel for 7 (Patients 1 - 7) of 7 Patients. The home health agency’s failure to ensure the patients received written instructions regarding medication administration placed all patients currently on service at risk for adverse medication outcomes, and unmet needs. Findings Include: Review of Patient records 1 through 7 lacked documented evidence by agency professional staff regarding to confirm the agency developed or delivered written instructions outlining medication instructions to the patients or caregivers Observation during home visit with Patient 1 on 08/07/24, showed there were no written instructions regarding the patient medication list or home health agency (HHA) instructional documents found in the home. Observation during home visit with Patient 2 on 08/07/24, showed there were no written instructions regarding the patient medication list or home health agency (HHA) instructional documents found in the home. Observation during home visit with Patient 3 on 08/07/24, showed there were no written instructions regarding the patient medication list or home health agency (HHA) instructional documents found in the home. During an interview on 08/07/24 at 3:45 PM, Staff A, Agency Director, confirmed that the agency had not given the patients written information regarding their medications.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on record review, observation, and staff interview, the Home Health Agency (HHA) failed to provide the patient and caregiver a copy of written instructions outlining wound care treatments and therapy home exercise program for 3 (Patients 1, 2, and 3.) of 7 Patients. The home health agency’s failure to ensure the patients received written instructions regarding treatments to be provided, placed all patients currently on service at risk for adverse outcomes and unmet needs. Findings Include: Patient 1 Review of Patient 1’s plan of care for Start of Care dated 07/29/24 showed a Primary Diagnosis of Chronic Obstructive Pulmonary Disease and indicated the patient was receiving wound care two times per week. Observation during Patient 1’s home visit on 08/07/24, review of home folder and documents provided by the agency lacked evidence of written instructions for the patient and caregiver explaining the wound care treatments being provided. Patient 2 Review of Patient 2’s plan of care for episode dated 05/24/24 through 07/22/24 showed the patient was receiving daily wound care which was provided by caregiver in the home. Observation during Patient 2’s home visit on 08/07/24, review of home folder and documents provided by the agency lacked evidence of written instructions for the patient and caregiver explaining the wound care instruction. Patient 3 Review of Patient 3’s plan of care for episode dated 06/11/24 through 08/09/24, showed the patient was receiving Physical Therapy services. Observation during Patient 3’s home visit on 08/07/24, review of home folder and documents provided by the agency lacked evidence of written instructions for the patient and caregiver explaining the home exercise plan. During an interview on 08/07/24 at 4:00 PM, Staff A, Agency Director, confirmed that the agency had not given the patients written information regarding the treatments to be provided in the home.”