Caring Nurses of Michigan, 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 record review and interview, the Agency failed to provide documented evidence to ensure the Emergency Preparedness plan had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients currently serviced by this Agency in the event of an actual event (E0004); failed to ensure an Emergency Preparedness plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been reviewed and updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency (E0006); failed to develop and establish written Emergency Preparedness policies and procedures that were based on the Emergency Preparedness plan, risk assessment and communication plan that had been updated at least every 2 years, resulting in the agency’s inability to implement appropriate emergency actions and the potential for poor outcomes for all staff and patients currently serviced by this agency in the event of a disaster (E0013); failed to develop and maintain an Emergency Preparedness communication plan that complied with Federal, State and local laws, that had been updated and reviewed at least every 2 years, resulting in the potential for staff to not be able to communicate effectively in the event of an actual disaster or emergency (E0029); facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency (E0030); failed to develop an Emergency Preparedness testing and training program based on the Emergency Preparedness plan, that had been reviewed and updated at least every 2 years, resulting in the potential for staff not being properly trained or prepared in the event of an actual emergency or disaster (E0036); and, failed to provide initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers as appropriate, and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services (E0037). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by this agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §484.102, Emergency Preparedness.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on document review and interview, it was determined the home health agency failed to include any performance improvement activities that tracked adverse patient events, analyze potential causes, and formulate preventive actions (See G 654); failed to document the quality improvement projects from April 2022 through March 2025, and document the reasons for conducting these projects and the measurable progress achieved each year (See G 658); and failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section (See G 660). The cumulative effect of these systemic problems resulted in the Agency’s inability to ensure the provision of quality health care for all the patients the Home Health Agency has served for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“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 record review and interview, the Agency failed to provide documented evidence to ensure the Emergency Preparedness plan had been reviewed and updated at least every 2 years, resulting in lack of direction for Agency personnel in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients currently serviced by this Agency in the event of an actual event. Findings include: On 3/20/25 at 11:55 a.m., the Administrator was asked for permission to review the agency’s Emergency Preparedness documentation. During the review, it was noted that the agency had no completed plan accessible and available for review. On 3/26/25 at 11:30 a.m., the Administrator provided an additional binder which contained an undated Emergency Preparedness plan that was undated. A previous plan was noted to be dated 2020. There was no documented evidence that showed the agency had developed an Emergency Preparedness plan that had been reviewed/updated at least every 2 years, in accordance with the requirements of this section. These findings were reviewed with and confirmed by the Administrator during an interview on 3/26/25 at 2:30 p.m.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure an Emergency Preparedness plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, that had been reviewed and updated at least every 2 years, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 3/20/25 at 11:55 a.m., and 3/26/25 at 11:30 a.m., the Administrator was asked for permission to review the agency’s Emergency Preparedness documents. During the initial review, the Risk Assessment was noted to be undated and only included “Naturally Occurring Events” such as, Hurricane, Pandemic, Flood, Infection, Severe Thunderstorm, Snowstorm, Extreme Temperatures, Terrorism and Wildfires. All risks were noted to be Community-based. There were no Facility-based risks identified or included. On 3/26/25 at 11:30 a.m., the Administrator provided the additional Emergency Preparedness binder for review. The Risk Assessment contained in the additional binder was dated 2020. There was no documented evidence that the agency’s Emergency Preparedness plan was based on a facility and community-based risk assessment from an all-hazards approach, that had been reviewed and updated at least every 2 years, as per this requirement. These findings were reviewed the Administrator during an interview on 3/26/25 at 2:30 p.m. who responded, “No, I thought the Risk Assessment was dated 2024.” Upon further review by the Administrator, it was confirmed that the provided documents had not been reviewed/updated.”

“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 agency failed to develop and establish written Emergency Preparedness policies and procedures that were based on the Emergency Preparedness plan, risk assessment and communication plan that had been updated at least every 2 years, resulting in the agency’s inability to implement appropriate emergency actions and the potential for poor outcomes for all staff and patients currently serviced by this agency in the event of a disaster. Findings include: On 3/26/25 at 11:30 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that there was no Emergency Preparedness policy available for review that had been reviewed/updated at least every 2 years, as per this requirement. During the review, the Administrator was asked to distinguish which of the presented and reviewed documents was the agency’s Emergency Preparedness policy and replied, “It’s in the binder. It’s all the policy.” No policy could be discerned from this review. These findings were reviewed with and acknowledged by the Administrator at the time of discovery.”

“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 record review and interview, the facility failed to develop and maintain an Emergency Preparedness communication plan that complied with Federal, State and local laws, that had been updated and reviewed at least every 2 years, resulting in the potential for staff to not be able to communicate effectively in the event of an actual disaster or emergency. Findings include: On 3/20/25 at 11:55 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that there was no communication plan available for review. On 3/26/25 at 11:30 a.m., the Administrator presented an additional binder titled, Emergency Preparedness which contained an undated Emergency Preparedness Communication plan. There was no documented evidence to support that the Communication plan had been reviewed and updated at least every 2 years, as per this requirement. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:30 p.m.”

“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 record review and interview, it was determined that the facility failed to develop and maintain an Emergency Preparedness communication plan that included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency, resulting in the lack of effective communication in the event of an actual emergency. Findings include: A review of the agency’s Emergency Preparedness documents was conducted on 3/20/25 on 11:55 a.m., and again on 3/26/25 at 11:30 a.m. During the review, a document titled, “Caregiver Roster” listed 10 caregivers/disciplines with titles such as Skilled Nursing, Physical Therapy, Occupational Therapy and Medical Social Worker. The list of disciplines was dated 4/20/22. During the survey, the Administrator was asked to provide a current list of all staff employed by this agency, and replied, “I’ll have to type one up and add the dates of hire.” Upon review of the provided employee list, none of the employees, with the exception of the Administrator and Clinical Manager/Director of Nursing from the previous list were included in the current list. The employee list had not been updated since 4/2022. Additionally, there was no contact information for the patients, patient’s physicians, entities providing services under arrangement, or volunteers as appropriate. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:20 p.m.”

“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 record review and interview, the Agency failed to develop an Emergency Preparedness testing and training program based on the Emergency Preparedness plan, that had been reviewed and updated at least every 2 years, resulting in the potential for staff not being properly trained or prepared in the event of an actual emergency or disaster. Findings include: On 3/26/25 at 11:30 a.m., the Agency’s Emergency Preparedness documents were reviewed. During the review, it was noted that the Testing/Training program had not been reviewed or updated since 2022. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:30 p.m.”

“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, it was determined the Agency failed to provide initial and ongoing training in Emergency Preparedness policies and procedures to all new and existing staff, including contract employees and volunteers as appropriate, and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: The agency’s Emergency Preparedness documents were reviewed on 3/26/25 at 11:30 a.m. Upon review, there was no documented evidence that all staff, including contracted staff, had received initial and ongoing training in Emergency Preparedness policies and procedures, as per this requirement. These findings were reviewd with and acknowledged by the Administrator during an interview on 3/26/25 at 2:20 p.m.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled disciplines provided care and services in accordance with the Physician ordered visit frequency for 3 (P-2, P-4, P-7) patients, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning and unmet care needs. Findings include: P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/25/25, record review noted the Plan of Care (POC) on 5/22/24 had ordered SN (Skilled Nursing) services to be provided at 1W3 (once a week x 3 weeks) which was provided on 5/22/24, 5/28/24, and 6/5/24. Further review found SN was involved in P-7’s care on 6/26/24 (OASIS transfer) to hospital, a resumption of care visit on 6/28/24, and a SN only discharge visit on 7/1/24. Record review found no order authenticating any type of visit frequency provided by SN after completion of the 1W3 visit order. This finding was reviewed and acknowledged by the Administrator during an interview on 3/26/25 at 3:12 PM. P-2: The patient’s Start of Care (SOC) was 2/26/25 with diagnoses that included Mononeuropathies and Low Back Pain. During the record review on 3/21/25 at 1:41 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) services at a frequency of 1x/wk. x 5 wks. The record revealed the SN missed the scheduled visit on 3/12/25 and documented, “Several calls made. No return call. Will continue to reach out.” There was no documented evidence that the SN made any further attempts to honor the visit frequency. Additionally, the SN missed the weekly scheduled visit on 3/21/25. The missed visit note documented, “Son left message to that [sic] scheduled appt had to be cancelled this morning.” There was no evidence that the SN made any attempts to honor the ordered visit frequency. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:45 p.m. P-4: The patient’s SOC was 2/4/25 with diagnoses that included Displaced Tri-Malleolar Fracture of Rt. Lower Leg, Diabetes Mellitus and Hypertension. During the record review on 3/25/25 at 1:10 p.m., it was noted that the patient was ordered to Physical Therapy (PT) services. The identified frequency was 2x/wk. The record revealed the PT missed 1 of 2 scheduled visits during the week of 2/9/25, and1 of 2 scheduled visits during the week of 3/2/25. There was no documented evidence that the PT attempted to reschedule the visits to honor the ordered visit frequency. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:25 p.m.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Performance Improvement Project (PIP)/activities, as part of the Agency’s Quality Assessment Performance Improvement (QAPI) program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions having the potential to negatively affect care provided to all 11 patients currently receiving services, resulting in the potential for substandard care and unmet care needs. Findings include: On 3/26/25, review of the Agency’s QAPI program found no evidence that a performance improvement project (PIP) was created since April 2022. Data generated from OASIS (Outcome and Assessment Information Set) was evidenced from the Agency’s medical record software. However, evidence of tracking adverse patient events, formulating cause analysis and the implementation of preventative actions was not found within the QAPI program. The above findings were reviewed and acknowledged during an interview with the Agency’s Administrator on 3/26/25 at 2:58 PM.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual quality improvement projects, the reasons for conducting these projects, and the measurable progress achieved on these projects since April 2022, resulting in the Agency’s inability to improve in patient care, health outcomes, patient safety, quality of care and the Agency’s performance. Findings include: On 3/26/25, review of the Agency’s QAPI program found no evidence that a performance improvement project (PIP) was created or active since April 2022. Subsequently, an interview was conducted with the Agency’s Administrator on 3/26/25 at 2:55 PM, who reviewed the findings and acknowledged no PIP’s have been started in the last 3 years.”

“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 record review and interview, it was determined the Governing Body (GB) failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that incorporated performance improvement activities that addressed priorities for improved quality of care, and patient safety with measures that quantified intended improvements, resulting in the potential to negatively affect the quality and safety of care to all 11 patients currently receiving services. Findings include: On 3/26/25, during review of the Agency’s QAPI program, no evidence was found that indicated the GB had any involvement in the QAPI program during the last 3 years. At 3:05 that day, a request was made to the Administrator (Adm-1) to review the GB meeting minutes to ascertain if the meeting minutes incorporated aspects of the QAPI program. Review of the submitted GB meeting minutes noted the last involvement the GB had over Agency operations of any kind occurred on 3/28/2022. This finding was reviewed and acknowledged by Adm-1 on 3/26/25 at 3:11 PM. The Agency failed to have its GB provide the required oversight and guidance concerning all aspects of the Agency’s QAPI program.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to include any aspects of analyzing/evaluating collected infection control data, and the formulation of improvement actions aimed at mitigating potential breakdown in infection control, resulting in the potential spread of infections between patient care staff and the Agency’s 11 patients currently admitted. Findings include: On 3/26/25, the Agency’s “Infection Control” binder was reviewed and noted the Agency’s efforts to track the following information: patient’s name, type of infection, antibiotic and resolution of infection. A total of ten patient infections were noted from July 2024 through December 2024, with a 12-month unduplicated patient census at 56 patients. However, further review of found no evidence or efforts to evaluate collected data to ascertain potential root causes, if the occurrence rate of infections fell within acceptable parameters, and no evidence of infection control actions used to mitigate the degree or number of infections experienced among the Agency’s patients was found. The findings above were reviewed and acknowledged by the Administrator during an interview on 3/26/25 at 3:10 PM.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on observation and interview, the Agency failed to ensure that SN (skilled nursing) appropriately notified the physician of all relevant aspects concerning a SCIC (significant change in condition) in 1 (P-6) of 1 home visits made with SN, out of a total sample of 7 records reviewed, resulting in the physician having an incomplete picture of the patient’s needs and the potential for a poor outcome. Findings include: P-6: The start of care date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease (COPD), osteoarthritis, and hypertension. On 3/21/25, a scheduled survey home visit with SN was conducted at 9 AM through 9:50 AM. At 9:08 AM, the SN (RN-1) was observed recording vital signs. P-6’s oxygen reading was low at 87% on room air and RN-1 instructed P-6 to do deep breathing exercises which increased the oxygen level to 95%. It was observed RN-1 then documented on her notes one oxygen reading, which was 95%. Then RN-1 took P-6’s blood pressure (BP) on the right arm with a reading of 98/50 mm/Hg. Then P-6’s daughter who was present during the home visit described how her mother almost fell the day before from getting very dizzy after standing up. RN-1 then called the physician’s office notifying that P-6 had a low BP of 98/50 mm/Hg., and if any interventions/orders were needed. The physician was unavailable to take the call, and the office instructed RN-1 to await a call back from the physician. RN-1 failed to report to the physician significant findings of P-6’s resting oxygen level of 87%. In addition, RN-1 failed to report the near reported fall with dizziness experienced by P-6 when standing up the day prior and failed to incorporate any orthostatic blood pressures (BP when standing up) prior to notifying the physician’s office. No return call from the physician was noted upon completion of the home visit. The above observations and findings were reviewed and acknowledged by the Administrator during an interview on 3/21/25 at 2:50 PM.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that the individuals who furnished Home Health Aide services on its behalf, met the competency evaluation requirements of this section by ensuring the subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section were evaluated by a Registered Nurse who observed the Aide’s performance of the required tasks with a patient/pseudo-patient in 2 of 2 Home Health Aide personnel records reviewed, resulting in the potential for the provision of substandard care and unmet care needs Findings include: On 3/26/25 at 12:00 p.m., a review of the Home Health Aide (HHa) personnel files revealed the following: HHa #1: Date of Hire was 2/28/22. A document titled, “Certified Home Health Aide Self-Evaluation & Skills Checklist” documented, “To the new applicant: Please provide information related to current practice or prior experience as a Home Health Aide by completing your experience in a category..., Leave the shaded columns to the right..., These areas will be completed by the Nurse preceptor.” HHa #1 checked off the following topics as “Have Performed”: Temperature, pulse, respiration, blood pressure, bed bath, weight, shower/tub bath, sponge bath, nail care, skin care, oral care, dentures, shampoo, shave, pericare, foot care, urinal bedpan, bedside commode, dangle, bed to chair, chair to standing, range of motion passive/active, assistive devices: cane, crutches, wheelchair, Positioning; body alignment, support with turning, rights, advance directives, dry dressing, ace bandage; Needs practice: Urostomy bag care, gastrostomy site care, record intake/output, urinary catheter care, bag technique, exposure plan...” The document was signed and dated by HHa #1 on 2/28/22 (Date of Hire). There were no additional signatures on the form. The section to be completed by the Nurse, titled, “Demonstrate, Document and RN Initial” were all left blank. There was no clear evidence that any of the above tasks were directly observed by a Registered Nurse, either on an actual or pseudo-patient. Further, there was no documented evidence that a competency evaluation had been conducted by a Registered Nurse Prior to the provision of care. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:30 p.m. HHa #2: Date of Hire was 8/19/24. A document titled, “Home Health Aide Sills Checklist” dated 8/30/24 documented, “Complete this competency assessment by checking either the independent box meaning that you feel confident in your skills in that area or select “needs instruction.” HHa #2 checked off the following topics: Communication skills, aide care plan, aide documentation, proper body mechanics; Assessment process: blood pressure pulse, temperature, respiration, pain signs of UTI, weight, pressure areas; Personal Care skills were all left blank. The documentation read, “Ongoing, no patient to observe.” Infection Control: handwashing, bag technique, protective equipment, exposure plan, equipment care. The document was dated 8/30/25 and signed by a nurse. There was no indication if any of the above tasks were performed under observation by a nurse or with an actual or pseudo patient. Additionally, the listed tasks did not include all the specified areas of this requirement. These findings were reviewed with the Administrator during the above interview on 3/26/25 at 2:30 p.m.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 1 (HHa #1) of 2 Home Health Aides employed by this agency, who’s personnel file was reviewed, received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 3/26/25 at 12:00 p.m., a review of the agency’s Home Health Aide (HHa) personnel files were reviewed and revealed the following; HHa #1: Date of Hire was 2/28/22. A document titled, “HHA Training Videos” included topics such as, Patient rights, infection control aide training, OSHA MIOSHA safety advance directives, bag technique, personal care, nutrition, therapeutic communication and standard precautions. There was no amount of time allocated for the videos; therefore, it could not be discerned if the 12-hours of annual in-services requirement had been met. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:30 p.m.”

“Basis and Scope CFR(s): §484.80(h)(1)(iv) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the skilled discipline made an annual onsite observation visit at the patient’s residence to observe the care being provided, by 1 (HHa #1) of 2 Home Health Aides employed by this agency, who’s personnel file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: On 3/26/25 at 12:00 p.m., a review of the Home Health Aide (HHa) personnel files revealed the following: HHa #1: Date of Hire was 2/28/22. There was no documented evidence in HHa #1’s personnel file that the skilled discipline made an annual onsite visit in 2023 at the patient’s place of residence to observe and ensure adequate provisional of care. A document titled “Home Health Aide Skills Checklist” dated 6/21/24 instructed the Aide to “Complete this competency assessment by checking either the independent box meaning that you feel confident in your skills in that area or select “needs instruction.” There was no indication if this checklist was to be considered an annual onsite visit as there was no indication if any of the tasks were performed in the patient’s place of residency. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:30 p.m.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to have an active Governing Body (GB) that met at least annually, assumed the responsibility for the Agency’s overall management and operations, all services provided, the fiscal operations, and review of the Agency’s budget and operations plans, resulting in the potential to adversely affect the quality of care to all 56 patients admitted within the last 12 months. Findings include: On 3/26/25, during review of the Agency’s QAPI program, no evidence was found that indicated the GB had any involvement in the QAPI program during the last 3 years. At 3:05 that day, a request was made to the Administrator (Adm-1) to review the GB meeting minutes to ascertain the extent of involvement the GB had in providing oversight concerning business and patient care operations. There was no documented evidence the GB met at least annually for the last 3 years (March 2022 through March 2025), was responsible for the overall management and operations of the Agency, and developed a budget and operations plan that was reviewed annually. Further review of the submitted GB meeting minutes revealed the last involvement the GB had over Agency operations of any kind, occurred on 3/28/2022. This finding was reviewed and acknowledged by Adm-1 during an interview on 3/26/25 at 3:11 PM. The Agency failed to adhere to its policy referenced below in ensuring its GB provided the required oversight and guidance concerning all aspects of business and patient care operations during the last 3 years. Agency Policy: “Governing Body” B-100 pg. 1 stated, “To ensure clients are provided with appropriate, quality services. The duties and responsibilities of the Governing Body shall include: Adopt and periodically review the agency’s bylaws or an acceptable equivalent. Oversee the management and financial affairs of the agency. This shall include participation in preparing the annual operating budget and capital expenditure plan with final approval granted. Review and approve agency Mission, Goals, Objective and Purpose every 36 months.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the Agency terminating on-going care for 2 (P-1, P-7) of 2 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-1: The patient’s start of care was 10/29/24 with diagnoses that included Non-Pressure Ulcer and Diabetes Mellitus. During the clinical record review on 3/20/25 at 1:50 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The patient was discharged from the agency’s services on 12/16/24. There was no documented evidence that the patient was provided the “Notice of Medicare Provider Non-Coverage” prior to being discharged from the agency. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:20 p.m. P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/21/25, record review noted the patient was discharged from SN (skilled nursing) on 7/1/24. Evidence that P-7 was provided the “Notice of Medicare Provider Non-Coverage” prior to being discharged from SN services was not found in the medical record. Additional review noted P-7 was discharged from the Agency by PT (physical therapy) services on 7/17/24. Evidence that P-7 was provided the “Notice of Medicare Provider Non-Coverage” prior to being discharged from the Agency was not found in the medical record. The findings above were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 3:12 PM. The Agency failed to give in advance as required, the patient the opportunity to agree or disagree with the termination of care being provided at the time.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Registered Nurse performed the initial start of care comprehensive assessment within 48 hours of the date of the referral to ascertain immediate care needs and establish homebound status for 1 (P-2) record in which both Nursing and Physical Therapy services were ordered, from a total sample of 7 records reviewed, resulting in the potential for unidentified unmet care needs. Findings include: P-2: The patient’s start of care (SOC) was 2/26/25 with diagnoses that included Mononeuropathies, Low back pain and Difficulty walking. The referral for home care was dated 2/6/25 and ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the record review on 3/21/25 at 1:41 p.m., it was noted that the SN conducted the Initial Comprehensive Assessment on 2/26/25, which was 20 days after the date of the referral. A Physician’s Order dated 2/26/25 stated, “Patient’s SOC was delayed per patient request.” There was no documented evidence that the SN attempted to conduct the SOC assessment prior to 2/26/25, and there was no documented evidence that the patient requested a later start date or refused services. Additionally, there was no documented evidence that the Physician had been made aware that care had not begun within 48 hours of the date of the referral. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:45 p.m.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure Activity of Daily Living needs were adequately met in the patient’s home for 3 (P-1, P-2, P-3) of 3 patients assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 10/29/24 with diagnoses that included Non-Pressure Ulcer and Diabetes Mellitus. During the record review on 3/20/25 at 1:50 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment revealed the patient required assistance with grooming, toileting and dressing. The section regarding Supportive Assistance, was void of an available, willing caregiver. There was no documented evidence that the agency offered or provided a Home Health Aide to assist with grooming. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:20 p.m. P-2: The patient’s SOC was 2/26/25 with a diagnosis of Mononeuropathies and Low Back Pain. During the record review on 3/21/25 at 1:41 p.m., it was noted that section M1800 of the Comprehensive Assessment revealed the patient required assistance with grooming, toileting and dressing. There was no documented, willing caregiver available to provide assistance. Additionally, there was no documented evidence that the agency offered or provided a Home Health Aide to assist with grooming needs. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:45 p.m. P-3: The patient’s SOC was 2/20/25 with diagnoses that included Strain Abductor, Falls and Sprain Sacroiliac Joint. During the clinical record review on 3/21/25 at 3:30 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment revealed the patient required assistance with grooming, toileting and dressing. There was no documented, willing or available caregiver to provide assistance. Additionally, there was no documented evidence that the agency offered to provide Home Health Aide services to assist with grooming. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:15 p.m.”

“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 record review and interview, the Agency failed to ensure its procedure to perform a comprehensive review was sufficient within accepted standards of professional practice in determining any potential adverse medication effects such as: side effects, drug interactions, and duplicate drug therapy in 1 (P-7) of 7 records reviewed for medication safety, out of a total sample of 7 records reviewed, and failed to perform a medication reconciliation during a post-hospital resumption of care (ROC) visit in 1 (P-7) of 1 record reviewed with a ROC from a total of 7 sampled records, resulting in the potential for unrecognized adverse effects due to significant medication interactions and duplications that could negatively affect all 11 current patients. Findings include: P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/25/25, record review of the Comprehensive Assessment under “Drug Regimen Review” documented, “No issues found during review” and “Medication Follow-up” was left blank. Subsequent review of the 20 medications listed on P-7’s Plan of Care noted several high-risk classifications (narcotic, CNS (central nervous system) depressants, and anti-psychotics) all together which usually creates significant drug to drug interactions at the highest level (severe/major). Verification of potential significant interactions was performed through a professional on-line pharmaceutical resource “Drugs.com” which noted the following: 5 major or severe level drug to drug interactions, 53 moderate interactions, and 5 therapeutic duplications. During an interview on 3/25/25 at 11:40 AM., the Administrator was asked for the specific drug-drug interactions the Agency’s software generated during P-7’s initial drug review. The Administrator was unable to provide evidence of specific drug to drug interactions, even at minor (lowest) levels. Even though a documented drug review took place, it was determined the Agency’s procedure for checking drug interactions and duplicative drug therapies was insufficient and posed a potential risk for poor outcomes concerning optimal patient care. No physician notification as of 3/26/25 was found in the medical record concerning potential drug-drug interactions or duplicative therapies. In addition, P-7 was transferred to the hospital on 6/25/24 and had a resumption of care to the Agency on 6/28/24. Record review found no evidence that a medication reconciliation review had taken place to ensure any medication changes that occurred during the hospitalization would be accounted for and checked for any potential safety concerns. The findings above were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 3:16 PM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Medication Profile” C-600 pg.1 stated, “To identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, and contraindicated medications. The RN or Therapist shall promptly report any problems to the physician. RN/PT must Notify MD within 24 hours of MAJOR INTERACTION and will document properly with an order.””

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure SN (skilled nursing) documented on the comprehensive assessment the primary caregivers’ willingness, ability, their availability and scheduled hours and days to provide care for patients in 2 (P-6, P-7) of 7 total records reviewed, resulting in a potential for poor hygiene and patient injury during routine daily activities when no caregiver is available to assist the patient. Findings included: P-6: The start of care date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease, osteoarthritis, and hypertension. On 3/25/25, record review of the Comprehensive Assessment (dated 3/4/25) documented under “Availability of Assistance” regular night-time with other person(s) in the home and “patient resides with daughter.” The Comprehensive Assessment documented that P-6 needs assistance/supervision with all routine daily activities. The comprehensive assessment failed to include documented information regarding the primary caregivers’ willingness, ability, their availability, and scheduled hours and days to provide care for this patient. There were no further documents found in the record that included this information. P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/26/25, record review of the Comprehensive Assessment (dated 5/22/24) documented under “Availability of Assistance” that “No specific Caregiver available short time assistance provided by Friends.” (sic) The Comprehensive Assessment documented that P-7 needs assistance/supervision with all routine daily activities due to ambulation difficulty, limited range of motion of neck/shoulders, poor balance and falls. The comprehensive assessment failed to include documented information regarding any individual(s) willingness, ability, their availability, and scheduled hours and days to provide care for this patient. There were no further documents found in the record that included this information. The findings above were reviewed and acknowledged by the Administrator during an interview on 3/26/25 at 3:15 PM.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the comprehensive assessment was updated and revised within 48 hours of the patient’s return home post discharge from a hospital for 1 (P-7) of 1 record reviewed in which care had been resumed following hospitalization, resulting in unaddressed clinical needs the delay of home health services and the potential for declining health status for this patient. Findings include: P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/25/25, record review noted P-7 was transferred to the hospital on 6/25/24 for a hernia repair and had a resumption of care (ROC) to the Agency on 6/28/24. Further record review revealed that P-7 had a foley catheter, which was evidenced by an order on 7/5/24 (7 days after ROC visit) that documented, “Patient went to the MD for removal of Foley Cath.” Additional review of the ROC assessment performed by SN (Skilled Nursing) found no evidence of P-7’s foley catheter being acknowledged or assessed by SN on 6/28/24. The findings above were reviewed with and acknowledged by the Administrator (Adm-1) during an interview on 3/26/25 at 3:16 PM. Adm-1 noted this did not meet Agency expectations or its policy referenced below. Agency Policy: “Comprehensive Client Assessment” C-150 (undated) pg. 1 stated, “To accurately reflect the current health status of the client... To identify client’s medical, nursing, rehabilitative, social and discharge planning needs.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 6 (P-1, P-2, P-3, P-5, P-6, P-7) records from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-5: The start of care (SOC) date for home care was 2/14/25, with diagnoses which included alcoholic polyneuropathy, cirrhosis of liver without ascites, and diabetes type-2. On 3/21/25, record review of the POC ordered SN (Skilled Nursing) 1W3 (once a week x three weeks) and PT (Physical Therapy) to evaluate and treat. During a scheduled home visit with PT services on 3/21/25, it was observed P-5 had 4 unsecured rugs (2 partially on top of each other, 1 having a curled-up corner) located between the front door entrance and his recliner in the living room where P-5 spends most of his time during the day (per patient interview at 3:20 PM.) Further record review noted the PT evaluation of 2/19/25 had documented “No hazards identified” and the “Unsecured floor coverings” was left blank. Subsequently, the POC had no safety interventions or education to be provided to P-5 to help mitigate further falls already experienced per his medical history. The PT evaluation documented that P-5 could ambulate 10 feet (wheeled walker) with moderate assistance and had “Poor endurance with unsafe maneuvering of weight bearing and increased assistance for ambulation... general body weakness, instability and imbalance” for functional impairment. In addition, review of P-5’s Plan of Care SN goals found no evidence that any had been written yet to help guide/motivate P-5’s medical diagnosis noted above. P-6: The SOC date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease, osteoarthritis, and hypertension. On 3/25/25, record review noted the PT evaluation dated 3/6/25, failed to include any goals for P-6. This was further verified on the next PT visit on 3/11/25, which documented under “Goal Summary” that “No goals have been assigned to this patient.” In addition, review of the SN goals found that 12 of 12 listed goals were not written in measurable terms to track for potential improvements. P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/26/25, record review found no evidence that any SN patient care goals had been written within the Plan of Care. This was further verified on the SN discharge visit on 7/1/24, which documented under “Goal Summary” that “No goals have been assigned to this patient.” The findings above for P-5, P-6, and P-7 were reviewed and acknowledged by the Administrator during an interview on 3/26/25 at 3:15 PM. P-1: The patient’s start of care (SOC) was 10/29/24 with diagnoses that included Non-Pressure Chronic Ulcer and Diabetic Mellitus. During the record review on 3/20/25 at 1:50 p.m., it was noted that the Plan of Care (POC) contained Congestive Heart Failure (CHF) management including reportable weight parameters and documented, “weight check, edema management...” Further review of the clinical record revealed the patient had no diagnosis of CHF. Additionally, there were no documented Skilled Nursing goals. The agency failed to ensure the POC addressed the identified needs of the patient. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:20 p.m. P-2: The patient’s SOC was 2/26/25 with diagnoses that included Mononeuropathies and Low Back Pain. During the record review on 3/21/25 at 1:41 p.m. it was noted that the patient complained of pain levels 7/10 during the course of care. The Initial Comprehensive Assessment documented, “Pt. (patient) has pain to BLE (Bilateral Lower Extremities) r/t (related to) OA (Osteoarthritis). The POC was void of reportable parameters in which to notify the Physician and had no goals related to pain. The POC did not address the identified needs of the patient. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:45 p.m. P-3: The patient’s SOC was 2/20/25 with diagnoses that included Strain Abductor, Falls and Sprain Sacroiliac Joint. During a review of the record on 3/21/25 at 3:30 p.m., it was noted that the patient complained of pain at levels of 6/10 - 7/10 throughout the course of care. The POC was void of pain parameters in which to notify the Physician. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:15 p.m.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its skilled disciplines provided care and services only as ordered by the Physician for 2 (P-2, P-6) patients, from a total of 7 sampled records reviewed, resulting in the potential for the provision of substandard care, unnecessary treatment and unmet care needs. Findings include: P-6: The SOC date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease (COPD), osteoarthritis, and hypertension. On 3/2525, record review noted the following order effective 3/6/25: “Patient with DX (diagnosis) of COPD patient gets SOB (short of breath) monitor SPO2 (oxygen levels) pre post therapy every visit.” (sic) The Plan of Care ordered skilled disciplines to notify the physician of oxygen levels less than 92%. Further review of PT (Physical Therapy) visit notes revealed on 3/11/25, that P-6’s oxygen level had dropped to 89% post-therapy with no documentation noted if the patient was short of breath at the time. No evidence was found in the medical record that the physician was notified of P-6’s low oxygen level as instructed. Additional record review revealed an OT (Occupational Therapy) evaluation on 3/12/25. The evaluation documented that P-6 endurance was poor and becomes SOB with ambulation. However, no documentation was found that OT had obtained P-6’s oxygen level as instructed per order on 3/11/25. The findings above were reviewed and acknowledged by the Administrator (Adm-1) during an interview on 3/26/25 at 3:15 PM. Adm-1 noted this did not meet Agency expectations or its policy referenced below. Agency Policy: “Care Plan” C-560 pg. 1 stated, “The Care Plan shall address the identified needs, changes in the client’s condition, and planned services to meet the client’s needs. To provide a means of evaluating the effective needs of intervention ...” P-2: The patient’s start of care was 2/26/25 with diagnoses that included Mononeuropathies and Low Back Pain. The Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the clinical record review on 3/21/25 at 1:41 p.m., a SN visit note dated 3/7/25 documented a random blood glucose (RBS) level of 157 taken by the SN during the visit. The section of the Initial Comprehensive Assessment titled “Endocrine” documented, “Is patient diabetic? No.” Upon further review, there was no Physician’s orders to check the patient’s blood sugar, and no sentinel event warranting the SN to check the patient’s blood sugar. The SN failed to provide services only as ordered by the Physician. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:45 p.m.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician’s verbal orders were appropriately authenticated, signed and dated by the nurse receiving the order and the ordering Physician in 1 (P-1) record of a patient discharged from the agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of unauthorized care. Findings include: P-1: The patient’s start of care was 10/29/25 with diagnoses that included Non-Pressure Ulcer and Diabetes Mellitus. During the clinical record review on 3/20/25 at 1:50 p.m., it was noted that the patient was discharged from the agency on 12/16/24. Further review of the record revealed Physician’s Orders dated 11/6/24 and 11/15/24. The Order dated 11/15/24 had not been signed by the nurse accepting the order. Additionally, neither of the orders had been authenticated, dated or signed by the Physician. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 1:20 p.m.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the clinical record was completed and included detailed Physical Therapy and Skilled Nursing notes for 1 (P-3) record with the ordered services, from a total of 7 sampled records reviewed, resulting in the potential for undocumented, unidentified health concerns, and unmet patient needs. Findings include: P-3: The patient’s start of care was 2/20/25 with diagnoses that included Strain Abductor, Falls and Sprain Sacroiliac Joint. During the clinical record review on 3/21/25 at 3:30 p.m., it was noted that the Plan of Care ordered Physical Therapy (PT) services to be provided at a frequency of 2x/wk. x 7 wks. During the review, it was noted that there were no visit notes available for review for the following dates: 3/11/25, 3/14/25, 3/18/25 and 3/21/25. Additionally, these notes were still not available for review by the survey’s exit on 3/26/25. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:15 p.m.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation and interview, it was determined the Administrator failed to ensure a Clinical Manager was available during all operating hours, resulting in the potential for lack of clinical and supervisory oversight of patient care services and unmet care needs for all 11 patients currently serviced by this agency. Upon arrival to the Agency on 3/20/25 at 9:13 AM., the door to the Agency was locked. A sign on the door revealed the Agency’s name, phone number, and suite location. A call was made at 9:14 AM to the listed number with no answer, and a message was left to call back as soon as possible for purposes of a Medicare recertification survey. A return call was noted by the Agency’s Administrator at 10:06 AM., who stated he would be coming in by 11 AM to open the Agency. From that time through time of survey exit (3/26/25 at 3:48 PM.), neither the Clinical Manager (CM-1) or the Alternate Clinical Manager (Alt-CM) had provided an Administrative clinical presence during the survey. In addition, the Administrator acknowledged during an interview on 3/26/25 at 3:32 PM., that CM-1 would be gone in the Philippines celebrating Easter until mid-April and the Alt-CM had just left to spend one week down in the Philippines also to celebrate Easter. It was confirmed by the Administrator at 3:34 PM., that the Agency would have no official clinical manager available for administrative duties or availability for patient care needs for at least the next week. The Agency failed to ensure that a Clinical Manager is available during all operating hours as required.”

“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, it was determined the Agency failed to ensure the clinical record was complete and appropriate, including physician orders, assessments, and evaluations for 2 (P-5, P-6) of 7 total records reviewed, resulting in no authentication of patient care orders, an incomplete evaluation of the patient’s health status, and the potential for unmet care needs. Findings include: P-5: The start of care (SOC) date for home care was 2/16/25, with diagnoses which included alcoholic polyneuropathy, cirrhosis of liver without ascites, and diabetes type-2. On 3/26/25, record review noted under “Orders” the following concerns: Physician order dated 2/14/25, regarding the visit frequency for SN (skilled nursing) and PT (physical therapy) was blank for 3 of 3 entries: “Clinician Signature/Date”, “Clinician Co-Signature/Date” and “Physician Signature/Date”. Physician order dated 2/26/25, regarding a missed PT visit was blank for 3 of 3 entries: “Clinician Signature/Date”, “Clinician Co-Signature/Date” and “Physician Signature/Date”. Additional blank authentication orders as the two examples above were found on 3/11/25, 3/12/25, and 4/5/25. This represents 5 of 5 written orders not authenticated. Further review of P-5’s prior admission to this Agency (2/16/24) found the same issue with an order written on 3.12.24 with the discontinuation of OT (Occupational Therapy), and a missed discharge planning visit dated 4/5/24. The clinical record also had an instance of false documentation. On 3/21/25, a home visit with PT services noted P-5’s home care admission packet which contained the patient consent for initial services and frequency was blank. When comparing this to the Agency’s hard/paper chart, another copy was found which had been altered to include the services (SN, PT) with visit frequencies. P-6: The SOC date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease, osteoarthritis, and hypertension. On 3/25/25, record review noted under “Orders” the following concerns: Physician order dated 3/7/25, regarding the visit frequency of an unidentified discipline was blank for 3 of 3 entries: “Clinician Signature/Date”, “Clinician Co-Signature/Date” and “Physician Signature/Date”. Another physician order dated 3/7/25, regarding P-5 being short of breath and to take oxygen level reading every visit was blank for 3 of 3 entries: “Clinician Signature/Date”, “Clinician Co-Signature/Date” and “Physician Signature/Date”. In addition, record review noted an OT evaluation was provided on 3/12/25. No order that authorized this service was found in the clinical record for P-6. The above findings were reviewed and acknowledged by the Administrator (Adm-1) during an interview on 3/26/25 at 10:52 AM. Adm-1 had no explanation of why there was two different versions of a patient consent (P-5) with no supporting documentation of the change.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the Plan of Care (POC) included goals in 2 (P-5, P-6) of 7 total records reviewed, resulting in no plan to measure progress made (or lack of) concerning ordered interventions/treatments for improved quality patient measures. P-5: The start of care (SOC) date for home care was 2/14/25, with diagnoses which included alcoholic polyneuropathy, cirrhosis of liver without ascites, and diabetes type-2. On 3/25/25, record review of the POC ordered SN (skilled nursing) 1W3 (once a week x three weeks) and PT (physical therapy) to evaluate and treat. Further review of the POC noted a failure to incorporate any SN goals. This was further verified on the next SN visit on 2/20/25, which documented under “Goal Summary” that “No goals have been assigned to this patient.” P-6: The SOC date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease, osteoarthritis, and hypertension. On 3/25/25, record review noted the PT evaluation dated 3/6/25, failed to include any goals for P-6. This was further verified on the next PT visit on 3/11/25, which documented under “Goal Summary” that “No goals have been assigned to this patient.” In addition, the clinical record concerning the 3/11/25 visit note was incomplete. The only documentation for all therapy exercises were “Exercise 1: TE, Exercise 2: pendulum EX, Exercise 3: STM, Exercise 4: Isometric Ex.” (sic) The findings above were reviewed and acknowledged by the Administrator during an interview on 3/26/25 at 3:15 PM.”

“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 discharge summary was complete, provided the patient’s current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 3 (P-1, P-4, P-6) records where the patient was discharged from an agency service, and failed to forward a completed discharge from agency to the physician in 1 (P-7) of 2 closed records, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-6: The start of care date for home care was 3/4/25, with diagnoses which included chronic obstructive pulmonary disease, osteoarthritis, and hypertension. On 3/25/25, record review noted P-6 had the ordered service of OT (Occupational Therapy) provided on 3/12/25 for evaluation. Further record review found no evidence in the medical record of a discharge (DC) summary from OT service. Subsequently, the physician was unable to review findings from the evaluation that would be included in the DC summary. P-7: The patient was admitted to the Agency on 5/22/24 with diagnoses that included myocardial infarction (heart attack) diabetes type-2 with neuropathy (nerve damage) and hypertension. On 3/25/25, record review noted P-7 was discharged from the Agency on 7/17/24 with goals met by both SN (Skilled Nursing) on 7/1/24, and PT services on 7/17/24. However, additional review revealed the following concerns. SN failed to create any SN goals from admission through discharge. The SN visit with discharge summary on 7/1/24 documented under “Goal Summary” that “No goals have been assigned to this patient.” Further, PT (Physical Therapy) discharged P-7 without documented evidence that basic functional goals were assessed and met. For example, the PT evaluation on 5/23/24 documented the Tinetti (balance score) was to improve from 14/28 to 22/28 (a follow-up Tinetti score was not found in the medical record), strength would increase from 3-/5 to 3+/5 which was never achieved per medical record. A 7/15/24 PT visit note documented P-7 was able to ambulate 100 feet with contact guard assist, yet PT had no ambulation goals which addressed potentially alleviating home bound status. The DC summary from the Agency failed to include or document any functional measures concerning improvement in strength, balance, and ambulation. Subsequently, the physician was unable to determine if the patient’s functional needs for safety in relation to homebound status were met at discharge. No documented evidence was found in Agency records that verified when the DC summary was sent to the physician for review. The findings above were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 3:16 PM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Discharge Summary” C-760 (undated) pg. 1 stated, “The RN or Therapist will assure the treatment goals and the client’s expected outcomes have been met.” The policy language failed to include any timeline regarding when a Discharge Summary will be sent to the physician as required. Policy: Discharge Summary C-760 stated, “In all cases, a discharge summary will be completed for all clients discharged...” P-1: The patient’s start of care (SOC) was 10/29/24 with diagnoses that included Non-Pressure Ulcer and Diabetes Mellitus. During the clinical record review on 3/20/25 at 1:50 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The patient was discharged form SN services on 11/6/24. The SN Discharge Summary was void of a summary of care that detailed the course of care provided with responses and the overall health status of the patient at the time of discharge. Additionally, there was no documented evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at1:20 p.m. P-4: The patient’s SOC was 2/4/25 with diagnoses that included Displaced Tri-Malleolar Fracture of Rt. Lower Leg, Diabetes Mellitus and Hypertension. During the record review on 3/25/25 at 1:10 p.m., it was noted that the patient was ordered to receive SN and PT services. The patient was discharged from SN services on 2/27/25. The SN Discharge Summary dated 2/27/25 was void of a summary of care that detailed the course of care provided with responses, and the patient’s health status at the time of discharge. The summary documented, “Physician notified of discharge summary availability.” There was no documented evidence that the summary had been sent to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator during an interview on 3/26/25 at 2:20 p.m.”