Excellacare Skilled Services

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness (EP) plan that must be reviewed, and updated, resulting in lack of direction for Agency personnel (See E 0004); failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years that included guidance for EP strategies based on documented facility and community based risk assessments from an all hazards approach (See E 0006); failed to develop and maintain an EP communication plan that is to be utilized during an actual or simulated emergency event, and is updated every 2 years (See E 0029); failed to show evidence of EP training and testing of its EP program that is based on the emergency plan, risk assessment(s), policies, procedures, and its communication plan (See E0036); and failed to perform testing of their EP program as required at the community and/or facility levels (See E 0039). The cumulative effect of these systemic problems could potentially have a negative effect on all 4 patients currently serviced by the agency in the event staff are not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, 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 policy review and interview, it was determined the home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program, (G-642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, (G-644); failed to document the quality improvement projects and document the reasons for conducting these projects and the measurable progress achieved each year (G-658). 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 serves 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 develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in no directions for agency personnel in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all 4 patients currently serviced by this agency in the event of an emergency or disaster. Findings include: On 12/10/25 through 12/11/25, review of the agency’s Emergency Preparedness (EP) binder revealed no evidence that the agency’s Administrator (Adm-1) had reviewed and updated the EP plan within the last 3 years. Also, the agency’s Governing Body meeting minutes were reviewed for the last 3 years, no documented evidence was found that the EP plan had been reviewed and updated as required. The above findings were reviewed with and acknowledged by the agency’s administrator during an interview on 12/11/25 at 2:55 PM.”

“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 develop and update an Emergency Preparedness (EP) plan within the last 3 years that utilized and incorporated a facility and community-based all-hazards risk assessments, resulting in the potential for being unprepared to respond effectively during an actual or simulated emergency. This deficient practice could negatively affect the health and safety of all 4 patients currently serviced by this Agency in the event of an emergency or disaster. Findings include: On 12/10/25 through 12/11/25, review of the agency’s Emergency Preparedness (EP) binder revealed no evidence of that the agency had assessed and updated its facility and community-based risk assessment within the last 3 years. Findings of collaborative efforts to participate with other healthcare entities at the community level to promote an integrated response were not evidenced. The agency failed to develop a risk assessment that was comprehensive, which identified the likeliness of emergencies that would endanger patient care within the agency and the community itself. The above findings were reviewed with and acknowledged by the agency’s administrator during an interview on 12/11/25 at 2:58 PM.”

“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 agency failed to develop and maintain an Emergency Preparedness communication plan that integrated specific roles, tasks and responsibilities of its staff in the event of an actual or simulated emergency, resulting in the agency’s inability to ensure the coordination of patient care during an emergency/disaster and the potential to negatively affect the health and safety of all 16 patients who have received services in the past 12 months. Findings include: On 12/10/25 through 12/11/25, review of the agency’s Emergency Preparedness (EP) documentation concerning its Communication Plan (CP) found no evidence that it had been updated and approved within the last 3 years. The CP failed to assign specific roles, tasks and responsibilities of its staff in the event of an emergency/disaster. Further, the CP contained no language or process of how any staff member would communicate and coordinate the support of patient care needs within the agency and other healthcare providers during an emergency/disaster. Additionally, no evidence was found that the CP had ever been tested within the last 3 years (drill or actual emergency) to ensure its effectiveness. These findings were reviewed and acknowledged by the agency’s administrator during an interview on 12/11/25 at 3:02 PM.”

“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 provide documentation that it had maintained an emergency preparedness (EP) training and testing program that utilized an all-hazard risk assessment, EP policies/procedures, or an EP communication plan, resulting in the potential for staff and all 4 active patients not to be properly prepared in the event of an actual emergency. Findings include: On 12/10/25 through 12/11/25, the agency’s Emergency Preparedness (EP) documentation was reviewed. During the review, it was noted that there was no documentation of staff training or participation in EP drills pertinent to the current staff and current location in Farmington Hills, Michigan. There was no documented evidence that the agency had developed a training and testing program to guide personnel actions during an emergent situation that was based on its EP plan within the last 3 years. Further, documentation of a community-based drill, an actual emergency event was not evidenced during review. The findings above were reviewed with and acknowledged by the agency’s administrator during an interview on 12/11/22 at 3:06 PM.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documentation that it had conducted exercises to test its emergency plan (EP) annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the full-scale exercise, resulting in the potential for staff and all 4 patients currently receiving services not to be properly prepared in the event of an actual emergency. Findings include: On 12/10/25 through 12/11/25, review of the agency’s EP binder found no evidence the agency had conducted the required full-scale community-based exercise within the last 3 years as required. No communication or effort was noted by the agency in reaching out to the local incident command center to participate in the community-based exercise within the last 3 years. In addition, documentation of an actual emergency/disaster event to take the place of testing/drills was not found during review. The above findings were reviewed with and acknowledged by the agency’s administrator during an interview on 12/11/25 at 3:10 PM.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 4 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: The agency’s Quality Assessment and Performance Improvement (QAPI) documentation was reviewed on 12/11/25. There was no documentation to support the agency’s performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and instructions for a QAPI program, but had no additional data added, thus unable to quantitively demonstrate improvements. The Administrator (Staff-A) was questioned regarding QAPI indicators and process to measure on 12/11/25 at 10:55 am and stated, “We have not done anything with QAPI since the last survey.” The agency failed to ensure their QAPI program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care, and identify opportunities for improvement by the quality assessment and performance improvement program, which had the potential to negatively affect all patients serviced by the agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: During an interview with the Administrator (Staff-A) on 12/11/25 at 10:55 am a request was submitted to review the QAPI (quality assessment performance improvement) documents for 2023, 2024 and 2025. There was no documentation to support the agency’s performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and instructions for a QAPI program, but had no additional data added, thus unable to quantitively demonstrate improvements.”

“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 interview and record review, it was determined the Agency failed to develop a Quality Assessment Performance Improvement program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2023, 2024 and 2025 calendar years, 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 12/11/25 at 10:55 am during an interview, the Administrator (Staff-A) was queried about documentation of the Agency’s QAPI (Quality Assessment Performance Improvement) program and Performance Improvement Projects, reasons for conducting the projects along with measurable progress achieved. Staff-A was unable to provide the requested data and stated, “We do not have any improvement projects.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that 7 (Patient/P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 patients were appropriately informed of intended discipline visit frequencies, and failed to attain patient and staff signatures in 1 (P-7) of 7 completed home care admission consents reviewed, resulting in a lack of inclusion, authentication of consent, and opportunity to voice any potential visit frequency concerns in advance. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted that the referral dated 2/19/25 stated, “…The skilled home health services required are Skilled Nursing (SN)… Physical Therapy… Occupational Therapy… Medical Social Work (MSW)…” The consent signed by the patient on 2/21/25 and the comprehensive assessment completed by the SN on 2/21/25 were blank under the MSW section and there was no documentation of the patient refusing MSW. A review of the agency policy occurred on 12/12/25 titled “Patient Bill of Rights and Responsibilities” (Revised 8/2022). The policy states, “1. The patient has the right to participate in, be involved with all facets of care, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: e. The frequency of visits…” The Administrator (Staff-A) reviewed and acknowledged the finding listed above in an interview on 12/12/25 at 1:30 pm. On 12/11/25 at 2:10 PM, it was determined that the admission consents for home care were void of any information concerning the intended visit frequencies of all ordered disciplines in patient records P-5 and P-6. The above findings were reviewed with and acknowledged by the agency’s administrator (Staff-A) during an interview on 12/11/25 at 2:15 PM. Staff-A stated that she was unaware that patients had the right to know of the intended visits to be performed by each ordered disciplined. Patient #3 (P-3): This patient was admitted to this agency on 11/14/25 with the diagnoses of type 2 diabetes mellitus and chronic kidney disease. The record was reviewed on 12/10/25, and it was noted that “Patient Consent Form” used to obtain consent for treatment did not include the frequency of visits for the ordered skilled nursing and physical therapy services. Patient #4 (P-4): This patient was admitted to this agency on 3/29/25 with diagnoses of type 2 diabetes mellitus, right heel and midfoot ulcer, and chronic kidney disease. The record was reviewed on 12/11/25, and it was noted that “Patient Consent Form” used to obtain consent for treatment did not include the frequency of visits for the ordered skilled nursing services. The above findings were reviewed with and acknowledged by the agency’s administrator on 12/12/25 at 1430. Patient #1: (P-1) had a start of care date of 10/13/25 with the diagnoses of type 2 diabetes mellitus and chronic kidney disease. The record was reviewed on 12/10/25 and noted the patient’s admission consent failed to document what services were being provided and the frequency and duration of the clinician’s proposed visits. Patient #2: (P-2) had a start of care date of 3/5/25 with diagnoses of spinal fracture and hypertension. The record was reviewed on 12/11/25 and noted the patient’s admission consent was undated. The hospice failed to complete the patient’s consent to treat with a date that the patient signed it. A review of the agency’s policy on 12/12/25 titled “Patient Bill of Rights and Responsibilities” (Revised 8/2022). The policy states, “1. The patient has the right to participate in, be involved with all facets of care, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: e. The frequency of visits…” During an interview on 12/12/25 at 1:15 PM. the administrator (Staff-A) acknowledged the above findings.”

“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 4 (Patient P-1, P-3, P-4, P-7), and failed to date the Notice of Medicare Provider Non-Coverage for 1 patient (P-2) out of 7 total records reviewed, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted the “Notice of Medicare Non-Coverage” was signed on 2/21/25, the date of the admission. The areas were blank under “Patient Name” and “The effective date of coverage of your current services will end”. The agency failed to follow policy and notify the patient when their Medicare covered services are ending. A review of the agency policy occurred on 12/12/25 titled “Notice of Medicare Non-Coverage” (Revised 8/2017). The policy states, “1. Home health Agencies are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries when their Medicare covered service(s) are ending…” The Administrator (Staff-A) reviewed and acknowledged the finding listed above in an interview on 12/12/25 at 1:30 pm. Patient #3 (P-3): This patient was admitted to this agency on 11/14/25, with diagnoses of type 2 diabetes mellitus and chronic kidney disease. During the record review on 12/10/25, it revealed that the “Notice of Medicare Non-coverage” was signed by P-3 but lacked a date of authentication. Additionally, the section of the form stating, “The effective date of coverage of your current services will end.”, was left blank, omitting the required end date of services. The above findings indicate that the agency did not adhere to policy requirements for notifying the patient of the anticipated end of Medicare covered services. Patient #4 (P4): This patient was admitted to this agency on 3/29/25 with diagnoses of type 2 diabetes mellitus, right heel and midfoot ulcer, and chronic kidney disease. During the record review on 12/12/25, it revealed that the “Notice of Medicare Non-coverage” was signed by P-4 but lacked a date of authentication. Additionally, the section of the form stating, “The effective date of coverage of your current services will end.”, was left blank, omitting the required end date of services. The above findings indicate that the agency did not adhere to policy requirements for notifying the patient of the anticipated end of Medicare covered services. A review of the agency’s policy occurred on 12/12/25 titled “Notice of Medicare Non-Coverage” (last revised 8/2017). It states in the section “Under Reduction-Termination” that, “4. A minimum of two calendar days prior to discharge from Home Health services, the patient will be informed of the planned discharge and is to receive the appropriate ABN/HHCCN/NOMNC (Advance beneficiary notice, Home Health Change in Care, Notice of Medicare Non-coverage).” The above findings were reviewed with and acknowledged by the agency’s administrator on 12/12/25 at 1430. Patient #1’s (P-1) Start of Care (SOC) was dated 10/13/25. The Plan of Care (POC) identified diagnoses of Left leg fracture, congestive heart failure, and diabetes mellitus. During record review on 12/10/25, it was noted that no “Notice of Medicare Non-Coverage” (NOMNC) was documented in the record. During a surveyor home visit on 12/11/25 at 11:00 a.m., it was discovered that no NOMNC was located in the patient’s home care folder. The agency failed to follow their policy and notify the patient when their Medicare covered services were ending. Patient #2’s (P-2) SOC was dated 3/5/25. The POC identified diagnoses of spinal fracture and hypertension. During record review on 12/11/25, it was discovered that the NOMNC was signed by the patient but the “Effective date of coverage of your current services will end.”, was blank. The agency failed to follow their policy and notify the patient when their Medicare covered services were ending. A review of the agency policy occurred on 12/12/25 titled “Notice of Medicare Non-Coverage” (Revised 8/2017). The policy states, “1. Home health Agencies are required to provide a Notice of Medicare Non-Coverage to beneficiaries when their Medicare covered service(s) are ending…” The Administrator (Staff-A) reviewed and acknowledged the findings during an interview on 12/12/25 at 1:15 p.m.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on observation, record review, and interview, it was determined the Home Health Agency (HHA) failed to inform their patients of the names, addresses and phone numbers of the Federally funded and State funded entities, resulting in failure to maintain the patients’ informational rights and provide access to community resources and services for 4 of 4 active patients. Findings included: During review of the agency’s admission folder on 12/10/25, it was discovered that the agency failed to include the names, addresses and phone numbers of all five Federally and State funded entities, as stated in this regulation (Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization). The home health agency failed to provide patients with Federally and State funded entities in their living areas, that may be used to contact community services and resources. During an interview on 12/12/25 at 1:15 p.m., the administrator (Staff-A) acknowledged the above findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status for 3 (Patient P-1, P-5, P-6) of 3 records reviewed with congestive heart failure, out of a total sample of 7 records reviewed, resulting in missing clinical information that is essential towards monitoring baseline parameters to help meet the patient’s clinical needs and the potential for poor outcomes. Findings include: P-5: The patient was admitted to home care on 9/20/25, with diagnoses that included pressure ulcer-stage 3 to left buttock, congestive heart failure (CHF), and chronic kidney disease. On 12/10/25, review of the initial comprehensive assessment performed on 9/20/25 by skilled nursing (SN) noted the following under P-5’s “Cardiovascular” section. A failure to acknowledge any CHF history, or previous hospitalizations (or lack of) for fluid overload. In addition, under “Interventions” SN left the weight monitoring section for potential fluid overload blank, with no weight or circumference measurements to be obtained. No other means to monitor CHF exacerbation (worsening) were found in the clinical record. Further, SN failed to obtain an actual weight during the assessment to ensure P-5 was within a safe baseline. P-6: The patient was admitted to home care on 8/8/24, with diagnoses that included combined systolic and diastolic CHF (primary), diabetes-type 2, dementia, and seizures. On 12/11/25, review of the initial comprehensive assessment performed on 8/8/24 by SN, noted the following under P-5’s “Cardiovascular-Interventions” section. “SN to instruct patient on daily weight self-monitoring... SN to assess patient’s weight log every visit... SN to instruct the Patient/Caregiver on measures to recognize cardiac dysfunction and relieve complications.” The “Goals” section documented “Patient weight will be maintained between 167 and 171 lbs. during the episode.” Evidence that SN obtained an actual weight to confirm P-6 was within the specified weight range or that CHF education/instruction was provided to P-6 was not found in the medical record. The findings above were reviewed and acknowledged by the agency’s administrator (Staff-A) during an interview on 12/11/25 at 3:24 PM. (Staff-A) further acknowledged that in both cases, an actual weight should have been obtained by SN. Patient #1: (P-1) had a start of care date of 10/13/25 with the diagnoses of type 2 diabetes mellitus, congestive heart failure, and chronic kidney disease. The record was reviewed on 12/10/25 and noted the patient’s comprehensive assessment dated 10/13/25, under the Vital Signs section documented a stated weight instead of an actual weight. A stated weight does not give an accurate baseline to monitor P-1’s congestive heart failure. An actual weight should be documented. The plan of care (POC) dated 10/13/25, under the Orders and Treatments section, documented to “Notify physician of weight greater than 5 pounds or less than 5 pounds. During review of the 10 skilled Nursing visit notes in P-1’s record, it was found that no weights or measurements were documented for any of the visits. During an interview on 12/12/25 at 1:15 p.m., the administrator (Staff-A) acknowledged the findings.”

“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 the patient’s clinical record documented all medications with a completed reconciliation for 1 (Patient/P-7) of 7 records reviewed. This deficient practice resulted in the potential for unrecognized medication side effects and complications that could affect all patients serviced by the agency. Findings included: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted that the Electronic Medical Record (EMR) documented discrepancies from the hospital discharge instructions dated 2/19/25 and the medication profile. The missing medications from the hospital discharge instructions were Erythromycin ophthalmic ointment and Melatonin. Furthermore, the medication profile contained Docusate Sodium, Sennosides and Sildenafil, which were listed on the hospital discharge instructions under “Stop taking these medications”. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. A review of the agency policy occurred on 12/12/25 titled “Medication, Regimen Review Comprehensive” (Revised 8/2017). The policy states, “Procedure: 2. All required comprehensive assessments will include a review of all medications the patient is currently using 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. 3. At the time of admission an accurate, current and complete list of all prescription and over the counter (OTC) medications, as well as herbal medications, taken by the patient will be maintained on the medication profile.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 12/12/25 at 1:30 pm.”

“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 record review and interview, the agency failed to ensure the Plan of Care (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient in 1 (Patient/P-5) of 7 records reviewed, out of a total sample records of 7 reviewed, resulting in the potential for all 4 patients currently receiving home care services not to receive clinical care based on their individual needs and the potential for poor patient outcomes. Findings include: Patient #5 (P-5): The patient was admitted to home care on 9/20/25, with diagnoses that included pressure ulcer-stage 3 to left buttock, congestive heart failure (CHF), chronic kidney disease, and diabetes-type 2. On 12/10/25, review of P-5’s POC noted a failure to specify what weight parameters would be needed to notify the physician. For example, the POC documented, “Weight greater than 5 lbs. or less than 5 lbs.” The POC had no documented reference point of weight in which to compare the 5 lbs. to and had no assigned timeframe to assess for potential weight gain or losses. (1 day vs. 1 month). In addition, review of the POC goals found 22 of 23 listed goals were not written in objective, measurable terms to ascertain progress made (or lack of) throughout the provision of home care services. Examples include: “Wounds will heal without complication; Patient will remain free from increased confusion during episode. The findings above were reviewed and acknowledged by the agency’s administrator during an interview on 12/11/25 at 3:32 PM.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care to meet the needs of the patient in 1 (Patient/P-6) of 2 records reviewed with congestive heart failure, out of a total sample of 7 records reviewed, resulting in the potential for poor clinical outcomes. Findings include: Patient #6 (P-6): The patient was admitted to home care on 8/8/24, with diagnoses that included combined systolic and diastolic CHF (primary), diabetes-type 2, dementia, and seizures. On 12/11/25, review of the initial comprehensive assessment performed on 8/8/24 by skilled nursing (SN) noted the following under P-6’s “Cardiovascular-Interventions” section. “SN to instruct patient on daily weight self-monitoring... SN to assess patient’s weight log every visit... SN to instruct the Patient/Caregiver on measures to recognize cardiac dysfunction and relieve complications.” The “Goals” section documented “Patient weight will be maintained between 167 and 171 lbs. during the episode.” SN was discontinued on 8/15/24 after 3 visits, and Physical Therapy (PT) services provided a total of 14 visits from 8/8/24 through 9/24/24 (agency discharge). No evidence was found that an actual weight was obtained during any of the 3 SN visits or in 12 of 12 PT visits that followed after SN was discontinued. The agency failed to coordinate care to mitigate fluid overload complications and the potential for subsequent hospitalization. The findings above were reviewed and acknowledged by the agency’s administrator (Staff-A) during an interview on 12/11/25 at 3:24 PM. Staff-A further acknowledged that SN should have obtained an actual weight during admission and that the CHF monitoring needs for P-6 do not go away just because SN stopped services, and that PT should have assessed P-6’s actual weight to ensure and optimize patient safety.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to document blood glucose levels as ordered for 1 (Patient/P-3) of 4 records reviewed with diabetes, out of a total sample of 7 records reviewed, resulting in the potential for physical decline and unmet care needs in all 2 active patients with diabetes. Patient #3 (P-3) was admitted to this agency on 11/14/25 with the diagnoses of type 2 diabetes mellitus and chronic kidney disease. The record was reviewed on 12/10/25 and noted the plan of care (POC) (effective 11/14/25), ordered “SN (skilled nursing) to perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypo/hyperglycemia.” Additional orders outlined parameters for blood glucose levels: Fasting blood sugar will remain between 70mg/dl-200mg/dl (milligrams per deciliter) and the random blood sugar will remain 70mg/dl-250mg/dl. Additional review noted the patient does not independently monitor glucose at home per physician referral dated 11/13/25. The referral documented under the “History of Present Illness”, in bold font “Not monitoring home glucose.” Review of the initial comprehensive assessment under “Endocrine” noted the following question: “Is patient independent with glucometer use?” The documented response was “No.” Review of 4 of 4 SN visits to P-3 (11/14/25 through 12/2/25) noted all visits performed failed to have a documented blood sugar by SN as ordered in the POC. Due to the above finding of P-3 not performing blood sugar checks, SN failed to follow the POC order to obtain blood sugar during each visit. The above findings were reviewed with and acknowledged by the agency’s administrator on 12/12/25 at 1430.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and caregiver were provided with medication administration and wound care teaching and instructions for 1 (Patient/P-7) of 7 records reviewed, for a potential of missed medication and improper wound care resulting in the potential of unmet care needs. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 2/21/25 and ordered RN visits at a frequency of 1w3 (1 visit a week for 3 weeks). The POC stated orders, “SN (Skilled Nurse) to perform wound care to R (Right) and L (Left) buttocks as follows: cleanse site with wound cleanser, pat dry, apply foam dressing with gentle border 3 x week, or as needed for loose/soiled dressing, may discontinue when healed. SN to I (Instruct)/T (Teach) paid cg (care giver) on wound care. Once healed, SN to I/T application of barrier cream to area to prevent skin breakdown.” On 2/21/25, the RN SOC stated, “…SN cleansed with wound cleanser, patted dry, applied Duoderm dressing covering each side. Pt (Patient) tolerated well…” The following SN visit was completed 4 days later on 2/25/25 and stated, “…SN I/T paid cg on care to site and left dressings with her…” The SN discharged from nursing services on 3/5/25, 9 days after the last visit and stated, “…paid cg not present today…SN performed wound care only to R side. SN did apply Calmoseptine to L side. SN left note for cg, letting her know to continue with dressing until redness has resolved and then to use Calmoseptine…” The SN failed to document observed evidence that the caregiver was capable of the wound care dressing change and compliant with infection control during dressing changes. Additionally, on 2/21/25, the RN SOC stated, “…Pt attempted to put the drops in by himself, but is unable to do it. SN instilled drops into L eye as ordered on the labels…” The SN failed to document education of eye drop administration to the patient or care giver. A review of the agency policy occurred on 12/12/25 titled “Education – Patient/Family” (Revised 8/2017). The policy states, “Procedure: 1. Education is coordinated among the disciplines providing care, treatment, and services. 2. The Interdisciplinary team will: a. Provide patient/family education and instruction as an integral part of the provision of patient care. b. Evaluate the patient/family current knowledge level and ability to learn… e. Educate of patient/family may include, but is not limited to medications, safety, infection control, treatments and procedures and discharge planning.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 12/12/25 at 1:30 pm.”

“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 observation, record review and interview, the agency failed to ensure clinical notes were accurate for 1 (P-7) patient, and that clinical notes were submitted for 1 (P-1) patient of 7 total records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted that Physical Therapy (PT) was ordered at a frequency of 1w1 (1 times a week for 1 week), 2w6, 1w1. On 2/27/25, the PT documented a “Subjective Information Collected During Visit” and stated, “Ongoing issue of patient forgetting/ not wanting to shower, encouraged patient w (with) cg (caregiver) present emphasizing importance of showering and follow through w rec (recommend) safety measures, use of necessary equipment and acceptance of assistance to maximize safety. Importance of cgs shown today 2/27/25, after cg delayed and patient did not take am meds, glasses on the floor, couldn’t find his cell phone which was in his coat pocket and did not eat breakfast yet. Trying to ambulate w/o (without) AD (Assistive Device), not knowing where it was left, wearing shoes not recommended. With memory issues patient had forgotten he was told of cg delay in arriving and was flustered. Patient is fully aware of functional limitations r/t (related to) deficits exacerbated over the years, NPH (Normal Pressure Hydrocephalus), Parkinsons dx (diagnosis), and now w (with) repeated falls, past fx (fracture) to the R (Right) clavicle w aggravation upon repeated falls, and now some improvement w VP shunt placement completed on 6/6/24 motivated to pursue skilled PT services with good support of family, optimistic with PT he can make further functional improvements as he did in the past and meet established goals, staying in his home with private duty caregivers. Patient realizes the importance of adhering to recs (recommendations) for improved safety in home where he wants to stay.” This same exact documentation listed above by the PT was documented for the visits: 3/4/25, 3/6/25, 3/12/25, 3/14/25, 3/18/25, 3/20/25, 3/27/25, 4/2/25, and 4/3/25. For each additional visit, the PT would add 3-4 new sentences under the section “Subjective Information Collected During Visit” and that would get copied to the following visits and so on. The Physical Therapist failed to document complete and accurate visit notes for the date of service. A review of the agency policy occurred on 12/12/25 titled “Contents of Clinical Records” (Revised 8/2017). The policy states, “1. The patient’s Clinical record shall include: …Signed, dated, and timed clinical notes for each home visit, including responses to medications, symptom management, treatments, and services, any change in the patient’s condition, and any patient/patient’s family instructions given. These notes are written the day of service and are incorporated into the clinical record.” The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 12/12/25 at 1:30 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 send the discharge summary of care provided by skilled nursing (SN) within 5 days of discharge as required in 4 (Patient P-2, P-4, P-6, P-7) of 7 records reviewed, out of a total sample of 7 records reviewed, resulting in the physician not having timely clinical information concerning the outcomes of home care services provided and the potential for unmet patient needs for all 4 patients discharged from home care services. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/21/25. The Plan of Care (POC) identified diagnoses of Sepsis, Acute Respiratory Failure, Stage 2 Pressure Ulcer Right and Left Buttock. During record review on 12/11/25, it was noted that the agency failed to verify that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. The Administrator (Staff-A) reviewed and acknowledged the findings listed above in an interview on 12/12/25 at 1:30 pm. Patient #6 (P-6): The patient was admitted to home care on 8/8/24, with diagnoses that included combined systolic and diastolic CHF (primary), diabetes-type 2, dementia, and seizures. On 12/11/25, record review noted P-6 was discharged from SN services 8/15/24 and interview with the agency’s administrator on 12/11/25 at 2:56 PM confirmed the SN discharge summary was sent to the physician on 9/11/24. This was 27 days after discharge and 22 days beyond the required timeframe. Patient #4 (P4): This patient was admitted to this agency on 3/29/25 with diagnoses of type 2 diabetes mellitus, right heel and midfoot ulcer, and chronic kidney disease. On 12/11/25, record review noted P-4 was discharged from SN (skilled nursing) services on 8/6/25. The agency failed to verify that the discharge summary was sent to the physician within 5 days of the patient’s discharge. During the interview with the agency’s Administrator (Staff-A) on 12/11/25 at 3:00 PM it was confirmed that the discharge summary was not sent to the physician (137 days after discharge). Patient #2’s (P-2) start of care (SOC) was dated 3/5/25. The Plan of Care (POC) identified diagnoses of spinal fracture and hypertension. During record review on 12/11/25, it was discovered that there was no documented evidence in the record that P-2’s discharge summary was sent to the physician within 5 business days of the patient’s discharge. During an interview on 12/12/25 at 1:15 p.m., the administrator (Staff-A) acknowledged the above findings.”