Riderwood Village, Inc.

“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 review of administrative records and interviews with staff, the agency failed to maintain a comprehensive and updated emergency preparedness program that complies with federal requirements, as evidenced by: 1) failure to develop, review, and update the agency’s Emergency Plan every 2 years; 2) failure to review and update emergency preparedness policies and procedures every 2 years; 3) failure to develop a structured communication process delineating roles, responsibilities, and authority for staff communication during emergencies; and 4) failure to maintain an active and effective staff training program for emergency preparedness procedures. Failure to maintain an up-to-date effective emergency preparedness program impacted the agency’s ability to effectively respond to emergencies and ensure the safety of staff, patients, and operations, and resulted in a finding of the agency being out of compliance with the Condition of Participation for Emergency Preparedness. The findings include: 1) The agency failed to develop, review, and update the agency’s Emergency Plan every 2 years. Cross reference to tag E-0004. 2) The agency failed to review and update emergency preparedness policies and procedures every 2 years. Cross-reference to tag E-0023. 3) The agency failed to develop a structured communication process delineating roles, responsibilities, and authority for staff communication during emergencies. Cross-reference to tag E-0032. 4) The agency failed to maintain an active and effective staff training program for emergency preparedness procedures. Cross-reference to tag E-0036.”

“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 administrative records, the facility failed to develop and maintain an up-to-date comprehensive emergency preparedness plan. The facility did not provide evidence of required reviews or updates to ensure the plan reflected current operations, personnel, and risks. This failure compromised the agency’s ability to adequately plan and respond to emergencies, placing patients, staff, and operations at risk. The findings include: A review of administrative records on December 11, 2024 determined that there was no documented evidence that the facility maintained comprehensive emergency preparedness plans for the years 2021, 2022, or 2023. The absence of these plans indicates that plan reviews and updates were not conducted in accordance with regulatory requirements. Additionally, during a review of Emergency Plan for 2024, the surveyors identified the following information: Page 36 of 75 instructed staff to contact the Erickson Living (EL) Incident Command Center using Appendix G. However, Appendix G was an incomplete employee contact list and did not provide sufficient information for effective communication during an emergency. Page 36 of 75 referred to Appendix F for employee contact purposes; Appendix F, labeled “Patient Census,” was blank and not relevant to its intended purpose. Page 37 of 75 referenced an employee call tree for emergency communication, but no call tree was provided or available for review. The emergency preparedness plan for 2024 was identified as a template last updated in October 2022, as evidenced by multiple references in the document, including the Hazard Vulnerability Risk Assessment section. The plan had not been reviewed or updated every two years, failing to comply with requirements. Page 10 of the emergency preparedness plan referenced an Emergency Preparedness Planning Committee and listed committee members, including the Resident Life Director, CHH Home Care Administrator, and CHH Clinical Manager. Interviews with staff and review of pertinent documents determined that these individuals were current leaders of another entity, Charlestown Senior Living. On page 46 (Appendix A), the Emergency Management Committee members were listed as leaders for Riderwood. However, surveyors determined that these individuals were current leaders at Charlestown Senior Living, further indicating that the plan did not accurately reflect Riderwood’s current staff or structure.”

“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: The facility failed to review and update its emergency preparedness policies and procedures within the required two-year timeframe to ensure compliance with federal regulations and effective emergency management. The facility did not provide evidence that the policies and procedures were reviewed or updated, resulting in outdated documentation that did not reflect current risks, resources, or operational changes. The findings include: During a review of administrative records, it was revealed that the Emergency Preparedness Plan policy had a version date of June 2021. No documentation was provided to demonstrate that the policy had been reviewed or updated since that time, exceeding the required two-year review interval.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on review of administrative records, the agency failed to develop a structured communication process delineating roles, responsibilities, and authority for staff communication during emergencies. The absence of a defined communication hierarchy compromises the agency’s ability to effectively disseminate critical information and coordinate staff actions during emergencies. The findings include: A review of the emergency preparedness plan on December 11, 2024, revealed: The plan contained a list of employee names and contact numbers but did not include a structured process delineating how communication should occur during emergencies. Page 37 of the plan referenced an employee call tree as a tool for communication, but no documented call tree or process for communication was provided. There was no documentation addressing the roles, responsibilities, and authority of staff in initiating or executing communication during emergencies.”

“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 administrative records and staff interviews, it was determined that the agency failed to develop and maintain a comprehensive training and testing program that ensured staff preparedness for emergency situations. The absence of proper documentation, debriefs, and evidence of participation in training undermined the effectiveness of the emergency preparedness program and increased the risk of staff not following the approved procedures in the event of an emergency. The findings include: A review of the agency’s training and testing program on December 11, 2024, revealed incomplete and insufficient documentation for annual fire drills and tabletop exercises as described below: 2021: Documentation included a fire alarm system testing letter dated July 5, 2021, and a handwritten fire drill checkbox report. These documents lacked sign-in sheets or other evidence of staff attendance, as well as debrief reports. 2022: Documentation included a fire alarm system testing letter dated July 5, 2022, and a tabletop exercise from corporate packet for a trespasser and workplace violence scenario. No sign-in sheets, staff signatures, or debrief reports were provided. 2023: Evidence included a fire alarm system testing letter dated June 22, 2023, and a tabletop exercise from corporate dated September 2023. Both lacked sign-in sheets, staff signatures, and debrief reports. 2024: Evidence included a fire alarm system testing letter dated October 14, 2024, and a tabletop exercise from corporate dated October 30, 2024. Neither included sign-in sheets, staff signatures, or debrief reports. An interview with the Administrator on December 11, 2024, at 4:45 p.m., revealed the tabletop exercises were sent by corporate and not conducted on-site with staff. Staff interviews conducted onsite on December 11, 2024, revealed significant gaps in training: Staff #1 stated they did not participate in the October 2024 fire drill, despite being listed on the attendance sheet. They noted no formal emergency preparedness training. Staff #2 was unaware of the emergency preparedness plan and had no knowledge of evacuation meeting points. They stated they had not participated in any drills or training in 2024. Staff #3 recalled fire alarm maintenance but had not participated in any emergency preparedness training or reviewed the emergency preparedness plan.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on records reviewed from December 1, 2023, to December 8, 2024, the agency failed to ensure timely submission of OASIS assessments to the CMS system. The findings include: A review of the agency’s Error Report 3330 revealed that 322 OASIS assessments were submitted late, exceeding the 30-day submission requirement.”

“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 of care, it was determined that the agency failed to follow accepted standards of practice and maintain infection control precautions during a home health visit for Patient #10. These deficiencies increase the risk of infection and compromise patient safety. The findings include: During direct observation of a licensed practical nurse (LPN) conducting a home health visit on 12/13/24 for Patient #10, the following infection control breaches were noted: The LPN failed to sanitize his/her hands between glove changes before proceeding with patient care. Clean and dirty barriers were not maintained, resulting in the overlap and commingling of clean and dirty supplies. The LPN touched his/her pockets while wearing gloves, compromising cleanliness. The LPN accessed a bag of clean supplies while wearing dirty gloves. A dirty blood pressure cuff and used gauze were placed directly on the patient’s chair and table without the use of a dirty barrier.”