Clarity Home Health

“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 interview and record review the agency failed to ensure its Emergency Preparedness Plan was reviewed and updated at least annually as evidenced by not having the plan reviewed and updated since 07/12/2021. This deficient practice had the potential to affect any of the 98 active patients. Findings: A review of the agency’s undated “Emergency Preparedness Planning” revealed the following, in part: II. Policies and Procedures: A. Director of Nursing and Administrator review the Emergency Preparedness Plan and training exercise annually and after each actual emergency. A review of the agency’s form titled, “Louisiana Model Home Health Agency Emergency Plan” Table of Review and Approval revealed the following: Date Reviewed 07/12/2021; Date Approved 07/30/2021. An interview was conducted with S1ADM on 05/07/2025 at 2:55 p.m. She confirmed she had no documented evidence she reviewed and updated the agency’s Emergency Preparedness Plan annually, but should have.”

“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 record review and interview the facility failed to update the Emergency Preparedness Policies and Procedures at least every two years. This deficient practice had the potential to affect ant of the 98 active patients. Findings: Review of the agency’s policy and procedure titled, “Emergency Operations Plan,” revealed a revision date of 04/2022. An interview was conducted with S1ADM on 05/07/2025 at 2:55 p.m. S1ADM confirmed the Emergency Operations Plan Policy and Procedure was not updated sine 04/2022, but should have been.”

“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 interview and record review the facility’s Emergency Preparedness Plan failed to include a training and testing program that was reviewed and updated at least every 2 years. This deficient practice had the potential to affect all 98 active patients. Findings: A review of the facility’s Emergency Preparedness Plan revealed it was last reviewed on 07/12/2021. Further review of the Emergency Preparedness Plan revealed the following, in part: IV. Training: D. Emergency Preparedness training will be conducted annually. E. Documentation of the training on the Emergency Operations Plan and annual Emergency Preparedness training will be maintained by Human Resources. F. Knowledge of the Emergency Preparedness will be shown by return demonstration, and participation in the facility Testing Program. The agency had no documented evidence of an Emergency Preparedness Training or testing program was conducted. An interview was conducted with S1ADM on 05/07/2025 at 2:55 p.m. She confirmed the agency did not perform Emergency Preparedness training or conduct a testing program at least every 2 years, but should have.”

“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 record review and interview, agency failed to ensure existing staff, including contract staff, providing services received initial training in Emergency Preparedness policies and procedures, had training at least every 2 years, and documentation of training was maintained with demonstration of staff knowledge of emergency procedures. The agency failed to have documented evidence of Emergency Preparedness training for 7 (S2ADON, S3LPN, S5RN, S6CNA, S7CNA, S8ST and S9OT) 9 (S1ADM, S2ADON, S3LPN, S4PTA, S5RN, S6CNA, S7CNA, S8ST and S9OT) personnel records reviewed. This deficient practice had the potential to affect all 98 active patients. Findings: Review of the agency’s policy titled, “Emergency Operations Plan” with a revised date of 04/2022 revealed, in part: 7. Other preparation activities include: Staff orientation and ongoing training, on orientation and annually. 16. Staff will be presented the emergency operations plan during orientation… Ongoing staff education will occur annually as part of an exercise or in response to an actual emergency. Review of S2ADON’s personnel file revealed a hire date of 06/27/2022. S2ADON’s last EP (Emergency Preparedness) training was completed upon hire on 06/27/2022. Review of S3LPN’s personnel file revealed a hire date of 07/19/2021. S3LPN’s last EP training was completed upon hire on 07/19/2021. Review of S5RN’s personnel file revealed a hire date of 06/16/2022. S5RN’s last EP training was completed upon hire on 06/16/2022. Review of S8ST’s personnel file revealed a hire date of 02/21/2022. Further review of S8ST’s file revealed no documented evidence she completed EP training. Review of S9OT’s personnel file revealed a hire date of 09/02/2022. S9OT’s last EP training was completed upon hire on 09/02/2022. An interview was conducted on 05/07/2025 at 2:55p.m. with S1ADM. She confirmed she was responsible for training employees and confirmed EP training with staff was only completed upon hire. She further confirmed S8ST was a contract employee, and she was unaware S8ST needed EP training.”

“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 record review and interviews the agency failed to participate in a full-scale exercise that is community-based every two years or analyze the agency’s response to and maintain documentation of all drills, tabletop exercises, emergency events, and revised the emergency plan, as needed. This deficient practice had the ability to affect any of the 98 active patients. Findings: Review of the agency’s “Emergency Preparedness Planning,” revealed the following, in part: V. Testing: A. The agency will participate in a full scale exercise that is community-based or when a community-based exercise is not available, an individual, facility based exercise annually. D. After full scale exercises, the agency should analyze the response, identify areas for improvement and update the Emergency Operations Plan. Review of the facility’s Emergency Preparedness Binder and Emergency Plan revealed no documented evidence the agency participated in a full-scale exercise that is community-based every two years or analyzed the agency’s response to and maintained documentation of all drills, tabletop exercises, emergency events, and revised the emergency plan, as needed. An interview was conducted on 05/07/2025 at 2:55 p.m. with S1ADM. She confirmed she did not conduct any community-based exercises or full scale exercises with staff. She confirmed she implemented the Emergency Operations Plan in January 2025 for the “ice storm”, but did not have documented evidence the agency analyzed the response from the activation, but should have.”

“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 record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s policy titled, “Reporting of OASIS Information”, with a revision date of 05/2022, revealed the following, in part: Policy: The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items as required by CMS and State guidelines. Procedure: 2. Agency must encode and have the capability of transmitting OASIS data for each patient within thirty (30) days of completing any required OASIS data set collection. Review of the agency’s OASIS Final Validation Report, with a submission date of 01/09/2025, revealed 2 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after the date on the record. Review of the agency’s OASIS Final Validation Report, with a submission date of 01/14/2025, revealed 3 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after the date on the record. On 05/08/2025 at 8:25 a.m., interview was conducted with S1ADM. She reviewed the above OASIS validation reports and confirmed 2 of the records were submitted late, more than 30 days after completion.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain documentation the Governing Body conducted ongoing monitoring of the agency’s Quality Assurance and Performance Improvement (QAPI) program for quality improvement and patient safety. Findings: Review of the Agency’s policy titled, “Patient Safety Program”, with a revision date of 05/2022, revealed the following, in part: Policy: Agency leaders ensure implementation of a patient safety program. Procedure: 9.The Administrator and QA designee will provide an annual report to the Governing Body regarding actions taken to improve patient safety (in response to actual occurrences or proactively) and on process or system failures. Review of the Agency’s QAPI documentation and Governing Body Annual Meeting Minutes dated 03/24/2025, revealed no documented evidence the Governing Body conducted ongoing monitoring of the Agency’s QAPI program. On 05/08/2025 at 11:15 a.m., an interview was conducted with S1ADM. S1ADM stated she was responsible for the agency’s QAPI program. She reviewed the Governing Body Annual Meeting Minutes dated 03/24/2025 and confirmed there was no documented evidence of the Governing Body’s involvement in the agency’s QAPI program. She stated she reviewed the QAPI binder with the Governing Body members during the meeting, but had no documented evidence it was reviewed.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, interviews, and record review, the agency failed to ensure staff followed accepted standards of infection control practices for 1 (#1) of 4 (#1, #2, #3 and #4) patients observed during home visits. The agency staff failed to practice proper hand hygiene while providing wound care for Patient #1. Findings: Review of the agency’s policy titled, “Hand Hygiene Policy and Compliance Program”, revision date of May 2022 revealed the following, in part: Policy: Hand hygiene will be done by all employees to reduce the transfer of microbes to patient and to prevent the growth of microorganisms on the nails, hands and forearms. Procedure: 3. Bacteriostatic gel is the preferable hand hygiene method. When using bacteriostatic gel, the procedure is as follow: Place adequate amount on the hands. Using friction, clean between fingers, around and under nails, palms, and back of hands until hands are completely dry. Review of Centers for Disease Control and prevention (CDC) guidelines titled, “Clinical Safety: Hand Hygiene for Healthcare Workers” dated 02/27/2024 revealed the following, in part: Know when to wear and change gloves: If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings. Always clean your hands after removing gloves. Review of Patient #1’s Clinical Record revealed he began receiving services with the Home Health Agency on 02/11/2025 and had a current Certification Period of 04/13/2025 through 06/11/2025. Patient #1 had diagnoses, which included Pressure Ulcer of Right Heel Stage 3, Pressure- Induced Deep Tissue Damage and Encounter for Change or Removal of Non-surgical Wound Dressing. A home visit was conducted with Patient #1 on 05/05/2025 at 1:00 p.m. with S2ADON present. S2ADON provided wound care to Patient#1’s right and left heels as per Physician’s Orders from 04/29/2025. She removed soiled dressings from both feet and cleansed wounds on right and left foot with wound cleanser and gauze. She removed the soiled gloves and without performing hand hygiene donned clean gloves. She then applied bandage to the right foot with petroleum non adherent gauze, antibacterial foam dressing and wrapped the right heel with two abdominal pads, gauze wrap and compression wrap. She removed gloves, applied hand sanitizer, did not produce friction with her hands, and while hands were still saturated with sanitizer when she donned clean gloves. She applied bandage to the left heel with antibiotic ointment, petroleum no adherent gauze, and antibacterial foam dressing and wrapped the left heel with two abdominal pads, gauze wrap and compression wrap. She removed her gloves, applied hand sanitizer, did not produce friction with her hands which remained saturated with sanitizer when she donned clean gloves to assess resident’s skin on his buttock On 05/05/2025 at 2:00 p.m., an interview was conducted with S2ADON. S2ADON confirmed she should perform hand hygiene between glove changes and should use friction to dry hands when using hand sanitizer, but she did not. On 05/05/2025 at 9:00 a.m., an interview was conducted with S1ADM. She confirmed she expected staff to practice appropriate hand hygiene at all times. She stated staff should use friction of hands to dry hands when using hand sanitizer and hand hygiene should be performed between all glove changes.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 3 (#1, #2 and #4) of 4 (#1, #2, #3, and #4) patients reviewed with home visits. Findings: Review of the agency’s policy titled, “Medication Reconciliation” with a revision date of 05/2022, revealed the following, in part: Policy: The Agency will reconcile patient’s medications at time of admission and on an ongoing basis. Procedure: 1. At time of admission, the admitting RN, PT or SLP will create and document a complete list of medications that patient is taking at home, including dose, route and frequency. 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication… Patient #1 Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/12/2025 and had a current Certification Period of 04/13/2025 to 06/11/2025. Patient #1 had diagnosis which included Unspecified Dementia with Other Behavioral Disturbance. Patient #1 was ordered to receive Skilled Nursing Visits twice weekly. On 05/05/2025 at 1:00 p.m., a home visit was conducted with Patient #1, S2ADON, and Patient #1’s caregiver were present in the home. Patient resided in an Assisted Living Facility. The Assisted Living Facility was responsible for administering Patient #1’s medications. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when comparing the Assisted Living Facility’s Medication Profile to Patient #1’s Current Medication Profile provided by the Home Health Agency: Azelastine HCL nasal 0.1% 1 ML 1 spray each nostril daily was listed on the medication profile, but the patient was only receiving this medication as needed as of 03/18/2025. Melatonin 3mg 1 tablet by mouth at bed time was on the medication profile, but patient was only receiving this medication as needed as of 02/03/2025. Dipyridamole 25mg 1 tablet in the a.m. and 1 tablet in the p.m. was listed on the medication profile, but the patient was receiving Dipyridamole 25mg/ Aspirin 200mg one tablet by mouth in the a.m. and 1 tablet by mouth in the p.m. Patient was receiving Loratadine 10 mg one tablet by mouth daily with a start date of 04/29/2025, which was not listed on medication profile. Patient was receiving Rexulti 1mg 1 tablet daily with a start date of 02/25/2025, which was not listed on the medication profile. Patient was receiving Zinc Oxide Butt Baste each diaper change, which was not listed on the medication profile. On 05/05/2025 at 2:00p.m., an interview was conducted with S2ADON. She reviewed the medication list from the Assisted Living Facility, and Patient #1’s medication profile and confirmed the medication profile did not match what Patient #1 was receiving, but should have. Patient #2 Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 05/01/2025 and had a current Certification Period of 05/01/2025 to 06/29/2025. Patient #2 had diagnosis which included After Care following Joint Replacement Surgery. Patient #2 was ordered to receive Physical Therapy Visits twice weekly for one week, three times weekly for one week, and twice weekly for one week. On 05/05/2025 at 2:41 p.m., a home visit was conducted with Patient #2, his spouse, and S4PTA present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Patient was receiving Polyethylene glycol (Miralax) one cap full mixed with water every morning with a start date of 05/01/2025 was present in the home and not on the medication profile. On 05/05/2025 at 2:55 p.m., an interview was conducted with S4PTA. S4PTA confirmed patient was taking the Polyethylene glycol and confirmed it was not on the medication profile, but should have been. Patient #4 Review of Patient #4’s Clinical Record revealed she began receiving services from the Home Health Agency on 04/17/2025 and had a current Certification Period of 04/17/2025 to 06/15/2025. Patient #4 had diagnoses, which included Acute Respiratory Failure with Hypoxia, Pneumonia, Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory Infection, and Malignant Neoplasm of Lower Lobe Right Bronchus or Lung. Patient #4 was ordered to receive Skilled Nursing Visits once weekly for one week, twice weekly for one week, and once weekly for two weeks. Patient #4 was ordered to receive Physical Therapy Visits once weekly for one week and twice weekly for three weeks. On 05/06/2025 at 10:15 a.m., a home visit was conducted with Patient #4 with S5RN and the patient’s family member present in the home. Patient #4’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #4’s Current Medication Profile provided by the Home Health Agency: Fentanyl Transdermal 100 mcg/hour 2 patch(es) apply one patch every 72 hours was on the medication profile and the patient was taking Fentanyl Transdermal 12 mcg/hour 1 patch(es) apply two patches every 72 hours; Fluticasone Furoate Inhalation 100 mcg/ACT one puff inhalation daily was on the medication profile and the patient was taking Fluticasone Furoate Inhalation 200 mcg/62.5 mcg/25 mcg one puff inhalation daily; Naloxone 4 mg take one spray intranasal times one dose was present in the home and not on the medication profile; and CBD (Cannabidiol) oil 2mg THC (Tetrahydrocannabinol) plus 50 mg CBD per dropper take one drop as needed was present in the home and not on the medication profile. On 05/06/2025 at 10:30 a.m., an interview was conducted with Patient #4 and her family member. Patient #4’s family member confirmed she had been on the same dose of the Fentanyl patch since admitting to home health. Patient #4 stated she had taken the 200 mcg dose of Fluticasone Furoate inhaler since prior to her admitting to home health. The Naloxone was observed with a filled date of 04/17/2025, and Patient #4’s family member stated it was ordered by Palliative Care. Patient #4’s family member stated Patient #4 had been taking the CBD oil with THC daily prior to admitting to home health and was currently taking it on days she had doctor appointments. Patient #4 stated she took a dose of the CBD oil on Monday 04/28/2025, prior to going to her doctors’ appointment. On 05/06/2025 at 11:00 a.m., an interview was conducted with S5RN. She reviewed the medication list and confirmed the medications the patient was taking and the home health medication list did not match and should have. On 05/07/2025 at 12:30 p.m., an interview was conducted with S1ADM. She stated each patients’ medications should be reconciled on every OASIS visit and anytime there were medication changes. She stated each clinician should be reviewing the patient’s medication list on every visit. She was made aware of the medication discrepancies identified during Patient #4’s home visit on 05/06/2025. She confirmed the medications the patient was taking and the home health medication list should match. On 05/08/2025 at 10:11a.m., an interview was conducted with S1ADM. She was made aware of the medication discrepancies identified during Patient #1 and #2’s home visits on 05/05/2025. She confirmed the medications Patient #1 and Patient #2 were taking should match the home health medication list, and they did not.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to assure communication with all physicians involved in the Plan of Care. The agency failed to ensure: 1.The Physician was notified and responded timely to Urinalysis and Urine Culture results for 1 (#6) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patient records reviewed.; and 2. The Physician was notified Physical Therapy and Occupational Therapy visits ordered on 04/24/2025 were not conducted until 05/05/2025 for 1 (#6) of 6 (#2, #3, #4, #6, #8, and #9) patient records reviewed with orders for Home Health Therapy services. Findings: Review of the Agency’s policy titled, “Coordination of Patient Care”, with a revision date of 05/2022, revealed the following, in part: Policy: Agency staff members regularly communicate through interdisciplinary means, to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care. Procedure: 3. Staff provides the physician with patient information on an ongoing basis regarding: Current condition and changes in condition or Plan of Care. Results of relevant laboratory tests. Review of the Agency’s policy titled, “Plan of Care-CMS #485 and Physician Orders”, with a revision date of 05/2022, revealed the following, in part: Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. 6. Care and services provided will be provided according to physician orders. 1. Review of Patient #6’s Clinical Record revealed she began receiving services from the agency on 03/07/2025 and had a Certification Period of 03/07/2025 to 05/05/2025. Patient #6 had diagnoses, which included Sepsis due to Enterococcus, Sepsis due to Pseudomonas, Pressure Ulcer of Sacral Region Stage 4, Urinary Tract Infection, and Encounter for Fitting and Adjustment of Urinary Device. Review of Patient #6’s Plan of Care for Certification Period 03/07/2025 to 05/05/2025 revealed she was to receive skilled nursing services once weekly for one week, three times weekly for seven weeks and once weekly for one week. Review of Patient #6’s Physician Order dated 04/07/2025 by S10LPN revealed the following, in part: Urinalysis (UA) and Culture and Sensitivity (C&S) for urine cloudy and bloody. Review of Patient #6’s Laboratory Results dated 04/07/2025 revealed the following, in part: Urinalysis received from a local lab on 04/08/2025 –Clarity, Slightly Cloudy, Range Clear; Hemoglobin Urine Moderate, Range Negative; WBC (White Blood Cell) 20-50, Range None 0-5; Blood 10-20, Range None seen, 0-1, 1-5; Urine Culture Indicated Yes; Nitrate Positive, Range Negative; Leukocyte Esterase Large, Range Negative; Bacteria Moderate, Range None Seen. Final Urine Culture results received from a local lab on 04/11/2025 – greater than 100,000 CFU/ML Gram Negative Rod; greater than 100,000 CFU/ML Second Gram Negative Rod; greater than 100,000 CFU/ML Presumptive Pseudomonas; and 50,000 to 100,000 CFU/ML Presumptive Enterococcus. Review of Patient #6’s Skilled Nurse Visit Notes, Physician Orders and Communicates Notes for Certification Period 03/07/2025 to 05/05/2025 revealed no documented evidence the physician was notified or the agency followed up regarding Patient #6’s Urinalysis and Urine Culture results from 04/11/2025 until 04/16/2025. On 05/07/2025 at 9:13 a.m., a telephone interview was conducted with S10LPN. He stated during his skilled nurse visit on 04/07/2025, Patient #6 had signs and symptoms of a Urinary Tract Infection. He verified Patient #6 had an indwelling urinary catheter. He stated he received an order for and collected a Urinalysis and Urine Culture on 04/07/2025. He stated once he delivered a patient’s lab, the agency’s office staff were responsible for reviewing the results, notifying the physician, and obtaining new orders. He confirmed he made skilled nursing visits with Patient #6 on 04/11/2025 and 04/14/2025, did not review Patient #6’s lab results or follow up with Patient #6’s physician. On 05/07/2025 at 10:05 a.m., an interview was conducted with S3LPN. She reviewed Patient #6’s Clinical Record and verified Patient #6 had an indwelling urinary catheter. She stated on 04/07/2025, S10LPN collected a UA C&S for Patient #6 due to her urine was cloudy and bloody. She stated on the morning of 04/08/2025, she received the UA and preliminary urine culture results and faxed them to Patient #6’s physician’s office. She stated on 04/09/2025, the updated preliminary urine culture results were faxed to Patient #6’s physician’s office. She stated on 04/11/2025, the final urine culture resulted and was faxed to Patient #6’s physician’s office. She stated the UA C&S results were attached in the clinical record for the clinicians to review. She stated the clinician should check with the patient and caregiver on the next scheduled visit, after a lab was collected, to see if any new medications were started. She stated on 04/16/2025, S11RN notified the agency to resend the lab results to Patient #6’s physician’s office. She stated she did not communicate with Patient #6’s physician from 04/11/2025 until 04/16/2025. She confirmed there was no documented evidence S10LPN contacted the physician in regards to the lab results and should have. She confirmed Patient #6’s urine culture results should have been followed up on prior to 04/16/2025. On 05/07/2025 at 10:26 a.m., a telephone interview was conducted with Patient #6’s Power of Attorney. He stated on 04/07/20205, Patient #6 had signs and symptoms of a Urinary Tract Infection during S10LPN’s visit. He stated S10LPN took a urine sample from Patient #6 during his visit. He stated on 04/11/2025, S10LPN made a visit and he asked the nurse about the urine results. He stated S10LPN said the agency was still waiting on the physician to give orders. He stated after almost a week, he had not heard from the agency or the physician’s office. He stated on 04/16/2025, S11RN made a home visit and contacted the physician’s office about the lab results. He stated the physician’s office reported they had not received the results. On 05/07/2025 at 11:10 a.m., a telephone interview was conducted with S11RN. She stated on 04/07/2025, S10LPN collected a UA C&S on Patient #6 for signs and symptoms of a Urinary Tract Infection. She stated on 04/16/2025, she made a visit to Patient #6 and she had not been prescribed any antibiotics. She stated she reviewed the lab results in Patient #6’s clinical record and the agency office staff had faxed the results to the physician. She stated she called Patient #6’s physician’s office during her visit and the physician’s office staff reported the lab results had been misplaced and requested the results be refaxed. She stated she knew from the culture results Patient #6 had a Urinary Tract Infection and needed to be treated with antibiotics. She stated the agency’s office staff were responsible for obtaining the lab results and faxing them to the physician. She stated both nurses seeing the patient and the agency office staff were responsible for following up to ensure orders were received from the physician. She stated the physician should have been contacted prior to 04/16/2025 to obtain orders for Patient #6’s Urinary Tract Infection. On 05/07/2025 at 11:30 a.m., an interview was conducted with S1ADM. She reviewed Patient #6’s Clinical Record and stated on 04/07/2025 a UA C&S was ordered and collected by S10LPN. She stated on 04/08/2025 and 04/09/2025, the UA and preliminary urine culture results were received and faxed to Patient #6’s physician. She stated the final urine culture results were received and faxed to the physician’s office on 04/11/2025. She stated during a visit on 04/16/2025, S11RN contacted Patient #6’s physician’s office who reported the lab results were misplaced or they did not receive them. She stated the agency’s office nurses should follow up on lab results with the provider to ensure new orders were received. She stated the clinician in the home should also follow up with the patient and ask if any new medications were started. She stated the agency staff assumed since the lab results were faxed three times with confirmations the physician’s office had received and reviewed the results. She confirmed Patient #6’s urine culture results were positive for a Urinary Tract Infection and warranted a follow up with the patient’s physician for new orders. She confirmed the agency’s office staff and S10LPN should have contacted the physician’s office to ensure orders were received for Patient #6’s Urinary Tract Infection. She confirmed there was no documented evidence S10LPN or the agency’s office nurses communicated or followed up with Patient #6’s physician regarding the Urinary Tract Infection from 04/11/2025 until 04/16/2025. 2. Review of Patient #6’s Clinical Record revealed she was admitted to a local hospital on 04/21/2025. Further review revealed a physician’s resumption of care order dated 04/24/2025 to arrange home health, which included Physical Therapy, Occupational Therapy, and Skilled Nurse to evaluate and treat. Review of Patient #6’s Skilled Nurse Visits revealed a resumption of care visit on 04/25/2025. Further review revealed Physical Therapy and Occupational Therapy Evaluation visits were conducted on 05/05/2025. Review of Patient #6’s Physician Orders and Communications Notes revealed there was no documented evidence the patient’s physician was notified of the delay in the Physical Therapy and Occupational Therapy evaluations. On 05/07/2025 at 11:30 a.m., an interview was conducted with S1ADM. She stated Patient #6 was discharged home from a local hospital on 04/24/2025 with an order for Physical Therapy, Occupational Therapy, and Skilled Nurse to evaluate and treat. She confirmed a resumption of care visit was made for Patient #6 on 04/25/2025 by S2ADON. She stated the Physical Therapy and Occupational Therapy evaluations were completed on 05/05/2025. She stated the agency tried to complete all therapy evaluations within 24 to 48 hours, but due to scheduling issues it could be up to a week before an evaluation was completed. She confirmed there was no documented evidence the delay was communicated to the physician and a new order obtained and there should have been.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to provide services as ordered by the physician in the Plan of Care for 1 (#3) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patient records reviewed. The agency failed to ensure the skilled nurse obtained a weight for Patient #3 on each home visit. Findings: Review of the agency’s policy titled, “Plan of Care-CMS #485 and Physician Orders”, with a revision date of 05/2022, revealed the following, in part: Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. 6. Care and services provided will be provided according to physician orders. Review of Patient #3’s Clinical Record revealed he began receiving services from the agency on 04/02/2025. Patient #3 had diagnoses, which included Chronic Diastolic Congestive Heart Failure, Peripheral Vascular Disease, and Chronic Kidney Disease. Review of Patient #3’s Plan of Care for Certification Period 04/02/2025 to 05/31/2025 revealed he was to receive skilled nursing services once weekly for nine weeks. Further review of Patient #3’s Plan of Care revealed the following, in part: Notify physician of: Weight greater than 180 pounds (lbs.) or less than 199 lbs. Review of Patient #3’s Skilled Nurse Visit Notes for Certification Period 04/02/2025 to 05/31/2025, dated 04/08/2025, 04/15/2025, 04/22/2025, and 05/01/2025 revealed no documented weights. On 05/07/2025 at 12:15 p.m., an interview was conducted with S1ADM. She reviewed Patient #3’s Clinical Record and confirmed the patient had diagnoses of Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease. S1ADM stated if a weight parameter was entered on a patient’s Plan of Care, the nurses were expected to obtain the patient’s weight on every visit. She stated if a patient was not weighed, the nurse should document the reason the weight was not obtained in the narrative or comments section of the Skilled Nurse Visit’s Notes. S1ADM reviewed the above mentioned Skilled Nurse Visit Notes for Patient #3 and confirmed there were no documented weights or documentation of the reason the patient was not weighed and there should have been.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, record review, and interviews the agency failed to ensure the accuracy of skilled nurse documentation as evidenced by inaccurate documentation found on the Skilled Nurse Visit note dated 05/05/2025 for Patient #1 out of a total of 10 sampled patients. This deficient practice had the potential to affect any of the 98 active patients. Findings: Review of the agency’s policy titled “Medical Record Content” with a revised date of 05/2022 revealed the following, in part: Policy: The Agency will provide an accurate medical record of past and current findings for every patient seen by the Agency. Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 02/12/2025 and had a current Certification Period of 04/13/2025 to 06/11/2025. Patient #1 had diagnosis which included Pressure Ulcer of Right Heel Stage 3, Pressure- Induced Deep Tissue Damage of Left Buttock, and Change or Removal of Nonsurgical Wound Dressing. A home visit was conducted with Patient #1 on 05/05/2025 at 1:00 p.m. with S2ADON present. S2ADON provided wound care to Patient#1’s right and left heels as per Physician’s Orders. There was no observation of S2ADON conducting wound measurements for patient #1 during the home visit on 05/05/2025. Review of Patient #1’s Skilled Nurse Visit note per S2ADON dated 05/05/2025 1:00p.m. – 1:30 p.m. revealed the following, in part: Wound #1- Left Heel; Length: 3.5cm, Width: 3.2cm, Depth: 0 cm Wound #2- Right Lateral Heel; Length: 1.3cm, Width: 0.7cm, Depth: 0.3cm On 05/07/2025 at 12:05 p.m., an interview was conducted with S2ADON. She confirmed she had not measured Patient #1’s wounds during the skilled nurse visit performed on 05/05/2025. Therefore, she should have removed those measurements in her charting, she further confirmed this was inaccurate documentation. On 05/08/2025 at 10:32 a.m., an interview was conducted with S1ADM. She confirmed that she expected staff to complete documentation in the patient’s clinical record timely and accurately. She confirmed that wound measurements documented during a skilled nurse visit that were not obtained during the visit was considered inaccurate documentation.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient’s clinical record contained pertinent current findings in accordance with accepted professional standards for 1 (#6) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) patient records reviewed. The agency failed to ensure there was documentation of a completed Post Hospital Order in Patient #6’s Clinical Record. Findings: Review of the Agency’s policy titled, “Plan of Care-CMS #485 and Physician Orders”, with a revision date of 05/2022, revealed the following, in part: Policy: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. 6. Care and services provided will be provided according to physician orders. Review of the Agency’s policy titled, “Medical Record Content”, with a revision date of 05/2022, revealed the following, in part: Policy: The Agency will provide an accurate medical record of past and current findings for every patient seen by the Agency. Procedure: 2. Medical record content will contain the following documentation: Updated orders as obtained. Review of Patient #6’s Clinical Record revealed she began receiving services from the agency on 03/07/2025 and had a Certification Period of 03/07/2025 to 05/05/2025. Further review revealed she was admitted to a local hospital on 04/21/2025 and a resumption of care visit was made by S2ADON on 04/25/2025. Review of Patient #6’s Physician Orders for Certification Period of 03/07/2025 to 05/05/2025 revealed a task for a Post Hospital Order was scheduled to S2ADON on 04/25/2025, but was not started. On 05/07/2025 at 11:30 a.m., an interview was conducted with S1ADM. She stated Patient #6 was discharged home from a local hospital on 04/24/2025. She confirmed a resumption of care visit was made for Patient #6 on 04/25/2025 by S2ADON. She stated the Post Hospital Order should have been completed within five days after the resumption of care visit. She stated on 05/02/2025, after the resumption of care was coded, the Post Hospital Order should have been completed. She stated when Patient #6’s resumption of care came back from the coder on 05/02/2025, S2ADON was on vacation. S1ADM confirmed she should have completed Patient #6’s Post Hospital Order on 05/02/2025 and sent the order to the physician to review and sign.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge summary was sent to the patients primary care practitioner within 5 business days of the patient’s discharge from the agency for 1 (#10) of 3 (#8, #9, and #10) discharged patient records reviewed. Findings: Review of Patient #10’s Clinical Record revealed he began receiving services from the Home Health Agency on 03/01/2025, had a Certification Period of 03/01/2025 to 04/29/2025, and was discharged from the agency on 04/29/2025. Further review revealed no documented evidence the completed discharge summary was sent to Patient #10’s primary care practitioner. On 05/07/2025 at 3:30 p.m., an interview was conducted with S1ADM. She reviewed Patient #10’s Clinical Record and confirmed Patient #10 was discharged from the agency on 04/29/2025. She confirmed the completed discharge summary was not sent to Patient #10’s primary care practitioner.”