Activ-Care Home Health Services, 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 develop an emergency preparedness plan that 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 (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach (E0006); failed to ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years (E0013); failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State and local laws that had been reviewed and updated at least every 2 years (E0029); facility failed to develop and maintain an emergency preparedness communication plan that included updated contact information for all current staff, entities providing services under contract and patient’s physicians (E0030); failed to develop and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section that had been reviewed and updated at least every 2 years (E0036); failed to provide documented evidence to ensure all new and existing staff, including contracted staff and volunteers as appropriate, received initial and ongoing training in emergency preparedness policies and procedures, and failed to maintain documentation of training’s (E0037); failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by this home health agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §484.102, Emergency Preparedness.”

“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 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 actively serviced by this Agency. Findings include: On 4/29/25 at 3:50 p.m., the Administrator (Adm #1) was asked for permission to review the agency’s Emergency Preparedness documentation. During the review, it was noted that the Emergency Plan was undated. Adm #1 could not remember the last time the plan had been updated. There was no documentation that showed the agency had developed an Emergency Preparedness plan that had been reviewed and updated at least every 2 years, as per this requirement. These findings were reviewed with the Office Manager and Adm #1 at the time of discovery and during a subsequent interview on 4/29/25 at 4:15 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 plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 4/29/25 at 3:50 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that a document titled, “Emergency Plan Analysis” was dated 3/12/20. The “Hazard Vulnerability Analysis/Community Based” document was dated 11/6/18. There was no documented evidence that the facility had developed an Emergency Preparedness plan that was based on a risk assessment utilizing an all-hazards approach. These findings were reviewed with and acknowledged by the Administrator and Office Manager at the time of discovery and during an interview on 4/29/25 at 4:15 p.m.”

“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 ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years, resulting in the potential for inappropriate responses in the event of an actual emergency. Findings include: On 4/29/25 at 3:50 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the Emergency Preparedness policy was undated. During an interview with the Administrator (Adm #1), who was present during the review, he acknowledged that he did not remember the last time the policy had been updated. The agency failed to ensure the Emergency Preparedness policy had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and confirmed by Adm #1 and the Office Manager 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 complies with Federal, State and local laws that had been reviewed and updated at least every 2 years, resulting in the potential for ineffective communication and unmet patient care needs in the event of an actual emergency. Findings include: On 4/29/25 at 3:50 p.m., the agency’s Emergency Preparedness documents were reviewed. During the review, it was noted that the Communication Plan had not been reviewed and updated at least every 2 years, as per this requirement. The Administrator (Adm #1), who was present during the review, acknowledged that he could not remember the last time the Communication Plan had been updated. The agency failed to maintain an effective Communication Plan that had been reviewed and updated at least every 2 years. These findings were reviewed with and confirmed by Office Manager during an interview on 4/30/25 at 1:20 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 updated contact information for all current staff, entities providing services under contract and patient’s physicians, resulting in the lack of effective communication in the event of an actual emergency and the potential for poor outcomes for all patients currently serviced by this agency. Findings include: On 4/30/25 at 12:55 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the Communication Plan’s contact list had not been updated. The list contained employees no longer associated with the agency and did not include all current employees. Further, the list of contract entities provided, were no longer used by this agency as confirmed by the Office Manager (OM #1) during the review. It was further noted that a patient list was dated for calendar year 2018 and there was no Physician contact information included. The agency failed to ensure the Communication Plan included updated contact information. These findings were reviewed with and acknowledged by OM #1 during an interview on 4/30/25 at 1:20 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 and maintain an emergency preparedness training and testing program for staff that is based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section that had been reviewed and updated at least every 2 years. Findings included: On 4/29/25 at 3:50 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that a document titled “Staff Emergency Preparedness Training’ was dated for calendar year 2021. There was no documented evidence that the agency’s Testing and Training program had not been reviewed and updated at least every 2 years. These findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 4/29/25 at 4:15 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 documented evidence to ensure all new and existing staff, including contracted staff and volunteers as appropriate, received initial and ongoing training in emergency preparedness policies and procedures, and failed to maintain documentation of training’s for the above, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 4/29/25 at 3:50 p.m., the agency’s Emergency Preparedness documents were reviewed. The Office Manager (OM #1) provided documents titled, “Emergency Preparedness Training Verification Form.” The documents indicated that the employees had completed either initial or annual training in Emergency Preparedness policies and procedures. All of the signed documents were dated 1/16/2020. there was no documented evidence that the agency’s employees, including contracted staff, received initial and ongoing training as per this requirement. These findings were reviewed with and acknowledged by the Administrator and OM #1 during an inter on 4/29/25 at 4:15 p.m. and again during the exit interview on 5/1/25.”

“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 for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan, resulting in staff being ill-prepared in the event of an actual emergency. This deficient practice could negatively affect all patients currently serviced by this Agency. Findings include: On 4/29/25 at 3:50 p.m., the agency’s Emergency Preparedness documents were reviewed. The Office Manager (OM #1) provided a binder titled “Home Care Emergency Preparedness/Disaster Manual” which contained drills conducted by the agency. The agency conducted a Winter Storm with expected heavy snow fall drill on 1/8/25. Upon review, the only signed participant was the Administrator (Adm #1). A Snow Emergency Preparedness Activation drill was conducted on 1/16/25. Adm #1 was the only signed participant. There was no evidence of staff participation in the provided drills. The agency failed to provide evidence of the required drills that included staff participation to ensure all employees were prepared in case of a disaster. These findings were reviewed with and acknowledged by Adm #1 and OM #1 during an interview on 4/29/25 at 4:15 p.m. and again during the exit interview.”

“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 services were provided as ordered, and in accordance with the specified visit frequency for 4 (P-1, P-2, P-3, P-4) patients, from a total of 7 sampled records reviewed, resulting in the potential for poor grooming, decline in physiological functioning and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care (POC) ordered Skilled Nursing (SN) 1w6, Home Health Aide (HHa) 2w6, 1w3, and Physical Therapy (PT) services to be provided 1w1, 2w6. During the record review on 4/29/25 at 12:10 p.m., it was noted that the HHa missed 1 visit each week during the first 3 weeks of care and only made 2 of the 3 ordered visits during weeks 5 and 5. There were no documented missed visit notes, no evidence that the patient refused the visits, and no documented evidence that the Physician had been notified of the change in the visit frequencies. The agency failed to ensure services were provided in accordance with the specified visit frequency. These findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 5/1/25 at 10:40 a.m. P-2: The patient’s SOC was 3/13/25 with a diagnosis of Metabolic Encephalopathy. The POC ordered SN, PT, HHa 1w1, 3w4, 2w4 and Occupational Therapy (OT) services to be provided 1w1, 2w1, 1w1. During the record review on 4/30/25 at 10:55 a.m., it was noted that OT did not begin services until the 2nd week of care. There was no documented request to delay OT services. The HHa did not see the patient during the first week of care as ordered and there were no HHa visits made on 3/14/25, 4/22/25 and 4/24/25, which was against the ordered visit frequency. There were no documented HHa missed visit notes and no documented evidence that the Physician had been notified of the delay in OT services or the HHa missed visits. These findings were reviewed with and acknowledged by Adm #1 and OM #1 during an interview on 5/1/25 at 11:10 a.m. P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted the POC had Physical Therapy (PT) frequency of 2w8 (2 times per week for 8 week), 1w1. The visit scheduled for Tuesday, 4/22/25, Stated, “Missed Visit. Comments: Blank.” There was no attempt to complete the frequency as ordered. P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted the POC had Skilled Nursing (SN) recertified frequency of 1w4. The visit scheduled for Wednesday, 4/22/25, Stated, “Missed Visit. Comments: Son is caring for client at his house for the holiday Easter.” There was no attempt to complete the frequency as ordered. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:15 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 its quality improvement projects, the reasons for conducting these projects with measurable progress achieved for calendar years 2023 and 2024, 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 4/30/25 at 2:15 pm, during a review of the agency’s QAPI documents with Adm #1 (Administrator), it was noted that the QAPI program failed to document measurable progress for the projects. These findings were acknowledged at the time of interview and discovery.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to ensure the home health agency staff used standard precautions while providing care to the patients in 1 of 3 (P-7) records reviewed that included observation of home care staff providing services to patients resulting in the potential of spreading infections to the patient. Findings included: P-7: The Start of Care (SOC) was dated 3/31/2025. The Plan of Care (POC) for the certification period 3/31/25 to 5/29/25 identified diagnoses of Acute Kidney Failure (AKF), Osteoarthritis, Diabetes type 2 with hyperglycemia (DM2); Hypertension (HTN), Hypothyroidism, and Gastroenteritis and Colitis. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Home Health aide (HHa) services. During a joint survey home care observation visit with the registered nurse on 4/30/25 at 10:00 am., it was noted the nurse placed her nursing bag directly on the patient’s floor without using a barrier to guard the bag from contamination. In addition, it was observed that after the nurse took the patient’s blood pressure with her blood pressure cuff, she immediately placed the blood pressure cuff into the nursing bag without cleaning the cuff with a disinfectant, resulting in the possibility of spreading contamination to any future patient’s receiving services that day. Also, when the Nurse arrived at the patient’s home she failed to wash her hands before providing care to the patient resulting in the potential of spreading germs or infection to the patient. These findings were reviewed with and acknowledged by the Administrator (ADM) and Office Manager (OM) during an interview on 5/1/25 at 2:00 p.m.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions, prior to the provision of care in 2 (P-1, P-2) of 4 records in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for omission of care, the provision of unsafe care and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. During the record review on 4/29/25 at 12:10 p.m., it was noted that the Plan of Care (POC) ordered Home Health Aide (HHa) services to be provided. The POC indicated the following precautions, safety measures and functional limitations: slow position change, support during transfer and ambulation, fall precautions, bleeding precautions. These precautions had not been included in the Aide Care Plan. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Office Manager (OM #1) during an interview on 5/1/25 at 10:40 a.m. P-2: The patient’s SOC was 3/13/25 with diagnoses that included Metabolic Encephalopathy. During the record review on 4/30/25 at 10:55 a.m., it was noted that the POC ordered HHa services to be provided. The POC indicated the following: Leg bag, fall precautions, support during transfer and ambulation, slow position change. The Aide Care Plan was void of the aforementioned precautions. These findings were reviewed with Adm #1 and OM #1 during an interview on 5/1/25 at 11:10 a.m.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: During the entrance conference on 4/29/25, Adm #1 (Administrator) was asked what services were currently provided by the agency. The response was, “We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST) and Home Health aide (HHa) services.” When asked what service was provided directly by the agency, Adm #1 stated, “HHa.” The contracts were reviewed on 5/1/25 at 9:30 am and it was noted that a contract stated, “Home Care: Service… Home Health Aide.” The agency failed to ensure that at least one qualifying service was provided directly by agency employees.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure patient’s protected health information was appropriately stored and safeguarded, resulting in the potential for unauthorized use. Findings include: On 4/30/25, the Office Manager (OM #1) was asked to provide a tour of the agency and for permission to see where patient charts were stored. Om #1 entered a room and stated, they’re (files) kept in here. A file cabinet was observed with patient documents on top with visible health information. OM #1 stated, “I still have to file these.” A box of patient charts, care plans and other visible personal identifiable information was noted in 2 open boxes in the hallway on the floor. When questioned, OM #1 reported, “Those are files we have to dispose of.” The agency failed to ensure patient information was protected and safeguarded against inappropriate unauthorized use. These findings were reviewed with and acknowledged by OM #1 at the time of discovery and with the Administrator during an interview on 5/1/25 at 11:30 a.m.”

“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, interview and record review, the Agency failed to ensure that 2 (P-2, P-5) of 3 patients observed during a home visit and 1 (P-3) of 7 records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-2: The patient’s Start of Care was 3/13/25 with diagnoses that included Metabolic Encephalopathy. The Plan of Care ordered Skilled Nursing, Home Health Aide, Physical Therapy and Occupational Therapy services to be provided. On 4/30/25 at 3:15 p.m., a scheduled survey home visit was conducted with the Home Health Aide. During the visit, it was noted that the patient’s calendar of proposed visits was left blank. Upon completion of the visit, the patient’s wife was queried as to how they know when the ordered disciplines are coming to provide care and reported, “The PT said she can’t come Monday but can come tomorrow. I never know when any of them except the Aide, are coming. They don’t give you a heads up.” The agency failed to ensure the patient was included in the overall planning of his care. These findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 5/1/25 at 11:10 a.m. P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted that the referral stated, “Referral Comments: Can you accept this patient for RN (Registered Nurse), PT (Physical Therapy) and OT (Occupational Therapy)? The consent signed by the patient on 2/26/25 and the comprehensive assessment completed by the RN on 2/26/25 stated, “OT: Eval/Tx (Treat).” The OT failed to complete an evaluation. Additionally, the “Visit proposal notice” completed on 2/26/25 stated, “Home Health Aide 1w7 (1 visit a week for 7 weeks). The agency failed to complete any home health aide visits. P-5: The Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified diagnoses of Prostate cancer, Falls and Knee osteoarthritis. On 4/30/25 at 11:15 am, a survey home visit was conducted with the physical therapist. Review of the start of care folder, it was observed that the consent and individualized patient emergency plan were blank. The agency failed to ensure the patient was included in the overall planning of his care. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 11:50 am.”

“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 conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 3 (P-3, P-4, P-5) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted that the SOC comprehensive assessment dated 2/26/25, documented under “Primary Diagnosis and Other Diagnoses”, all 11 diagnoses had an exacerbation date of 2/25/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that the SOC comprehensive assessment dated 2/7/25, documented under “Primary Diagnosis and Other Diagnoses”, all 12 diagnoses had an exacerbation date of 2/4/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-5: The Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified diagnoses of Prostate cancer, Falls and Knee osteoarthritis. During record review on 4/30/25, it was noted that the SOC comprehensive assessment dated 1/30/25, documented under “Primary Diagnosis and Other Diagnoses”, all 9 diagnoses had an exacerbation date of 1/28/25. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 11:55 am.”

“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 observation, interview and record review, the agency failed to ensure the patient’s medical needs were adequately met in the patient’s home for 1 (P-2) patient who required Speech Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for worsening of health conditions. Findings include: P-2: The patient’s Start of Care was 3/13/25 with diagnoses that included Metabolic Encephalopathy. The Plan of Care ordered Skilled Nursing, Home Health Aide, Physical Therapy and Occupational Therapy services to be provided. On 4/30/25 at 3:15 p.m., a scheduled survey home visit was conducted with the Home Health Aide. During the visit, the patient’s wife (F1) showed this writer 2 prescriptions/orders (Rx) for Speech Therapy services with swallow evaluation. One of the Rx was dated 4/4/25 and the other was dated 4/15/25. F1 then stated, “I called the agency and told them my husband needed Speech Therapy, but the doctor (Administrator/Adm #1) told me they didn’t have Speech Therapy services. When asked if the agency was made aware of the initial Rx dated 4/4/25, F1 said, “No. I didn’t inform them.” When asked if the agency had been made aware of the Rx dated 4/15/25, F1 reported, “That’s when I called him (Adm #1) and he told me they didn’t offer Speech Therapy. I never sent the actual order because he said they didn’t have the service.” During the visit, the patient was noted to have difficulty speaking and difficulty swallowing the water provided by his daughter. F1 reported, “We’ve been adding powder to his liquids to thicken them so he can swallow better. He really needs the help.” These findings were discussed with the Administrator (Adm #1) during an interview on 5/1/25 at 11:10 a.m. When asked if he had a conversation with F1 regarding the need for Speech Therapy services, Adm #1 responded, “We talk all the time. She calls me all the time. I just got the faxed order today.” Based on this information, it was determined that the agency failed to ensure the patient’s needs were adequately met in the patient’s home.”

“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 Initial Assessment included a comprehensive drug review to ascertain any adverse reactions for 5 (P-1, P-3, P-4, P-5, P-7) patients, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects. Findings include: **Agency Policy: “Medication Profile:” The policy states, “The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that 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, duplicative drug therapy and noncompliance with drug therapy.” P-7: The Start of Care (SOC) was dated 3/31/2025. The Plan of Care (POC) for the certification period 3/31/25 to 5/29/25 identified diagnoses of Acute Kidney Failure (AKF), Osteoarthritis, Diabetes type 2 with hyperglycemia (DM2); Hypertension (HTN), Hypothyroidism, and Gastroenteritis and Colitis. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Home Health aide (HHa) services. During a Joint Survey Home Visit on 4/30/2025 at 10:00 am with the Registered Nurse (RN#1), it was observed a medication placed on the patient’s counter-top (trimamcinolone acetonide 1% ointment) prescribed on 3/13/25 by the physician which was not included on the patient’s medication profile dated 4/9/25. These findings were reviewed with and acknowledged by the Administrator (ADM) and Office Manager (OM) during an interview on 5/1/25 at 2:00 p.m. P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, a medication interaction report was completed in the EMR (Electronic Medical Record) and noted 2 duplicate therapy medications: Losartan Potassium and Furosemide. There was no documented evidence, during the 2/26/25 clinical record review, that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that the medication profile was blank for the “Yes/No” questions under the “Drug Regimen Review” section for A, C, D and E. A: The patient reports experiencing 1 or more significant side effects to current drug regimen. C: Does the patient demonstrate noncompliance with medication use, as prescribed by physician? D: Does patient and/or caregiver have any questions related to current medications, including purpose, dosage, or administration? E: Have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified? The agency failed to accurately complete the medication profile. P-5: The Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified diagnoses of Prostate cancer, Falls and Knee osteoarthritis. During record review on 4/30/25, it was noted that the Physical Therapist completed the comprehensive assessment on 1/30/25 and documented “No” under “(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?” A medication interaction report was generated by OM #1 (Office Manager) on 4/30/25. The interaction report indicates duplicate drug therapy consisting of: Metoprolol Tartrate, Lisinopril and Furosemide. Additionally, a drug-drug “Review Suggested” was noted between Potassium Chloride ER and Meclizine and between Lisinopril and Potassium Chloride ER. During the entrance interview with Adm #1 on 4/29/25 at 10:40 am, when questioned on the medication drug review stated, “The medications with review suggested are reported to the physician.” The EMR failed to contain all interactions and there was no documentation to indicate the physician was notified of the interactions. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:00 pm. P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fracture of Orbital Floor. During the clinical record review on 4/29/25 at 12:10 p.m., it was noted that section M2001 (Drug Review) of the Initial Comprehensive Assessment documented, “No issues found during review.” There was no drug interaction report available for review to support this finding. On 4/29/25 at 1:05 p.m., the Office (OM #1) was asked to run a drug review utilizing the agency’s Electronic Medical Record (EMR) system. The report revealed duplicate drug therapy and review suggested for drug-to-drug interactions. Based on these findings, there was no documented evidence that agency personnel conducted a comprehensive drug review at the start of care to ascertain any untoward interactions. These findings were reviewed with and acknowledged by the Administrator and OM #1 during an interview on 5/1/25 at 10:40 a.m.”

“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 covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 5 (P-1, P-2, P-3, P-4, P-6) 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-1: The patient’s start of care (SOC) was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care (POC) ordered Skilled Nursing (SN) 1x/wk. x 6 wks., Physical Therapy (PT) 1x/wk. x 1 wk. 2x/wk. x 6 wks. During the record review on 4/29/25 at 12:10 p.m. it was noted that the POC listed all the patient’s diagnoses with an exacerbation date of 11/12/24. There were no interventions to address the exacerbated conditions. There were no reportable parameters or measurable pain goals. One of the patient goals stated, “Patient will be free from signs/symptoms of hypo/hyperglycemia during the episode”, however, the patient did not have the diagnosis of Diabetes Mellitus added to the POC. The POC was not individualized to address the identified needs of the patient. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Office Manager (OM #1) during an interview on 5/1/25 at 10:40 a.m. P-2: The patient’s SOC was 3/13/25 with a diagnosis that included Metabolic Encephalopathy. The POC ordered SN, Home Health Aide (HHa), PT and Occupational Therapy (OT) services to be provided. During the record review on 4/30/25 at 10:55 a.m., it was noted that the POC listed all the patient’s diagnoses as having exacerbated on the date of admission (3/13/25). Additionally, there were no reportable pain parameters or interventions to address the identified diagnoses. These findings were reviewed with and acknowledged by Adm #1 and OM #1 during an interview on 5/1/25 at 11:10 a.m. P-6: The Start of Care (SOC) was dated 1/14/2025. The Plan of Care (POC) for the certification period 1/14/25 to 3/14/25 identified diagnoses of Hypertensive Heart Disease with Heart Failure (HF), Chronic Systolic Congestive Heart Failure (CHF), Parkinson’s disease without dyskinesia (PD), Diabetes type 2 (DM2), Hyperlipidemia, Atrial Fibrillation (A-fib), and Chronic Obstructive Pulmonary Disease (COPD). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the POC, it was noted there were no orders for reportable weight parameters or lower extremity measurements to address the patient’s diagnosis of Congestive Heart Failure. These findings were reviewed with and acknowledged by the Administrator (ADM) and Office Manager (OM) during an interview on 5/1/25 at 2:00 p.m. P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will be free from signs and symptoms of respiratory distress during the episode.” Additionally, another goal stated, “Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode.” Additionally, another goal stated, “Patient will be free from signs and symptoms of respiratory distress during the episode.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Additionally, the referral dated 2/4/25 documented the following allergy: Tape. The POC dated 4/27/24 failed to document the allergy to Tape. The agency failed to document and accurately assess the patient’s allergy. Furthermore, it was documented that the patient was a diabetic and there were no diabetic parameters to notify the physician of blood sugar irregularities. The POC failed to contain the blood sugar parameters to notify the physician. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:25 pm.”

“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 1 (P-1) patient who was discharged prior to completion of services and 1 (P-4) patient who received services without an order, from a total of 7 sampled records reviewed. Findings include: P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care ordered Skilled Nursing (SN) 1x/wk. x 6 wks., Physical Therapy (PT) 1x/wk. x 1 wk. 2x/wk. x 6 wks. During the record review on 4/29/25 at 12:10 p.m., it was noted that PT only provided services for 4 weeks and SN only provided services for 5 weeks. Upon further review, there was no documented evidence that the Physician had been notified prior to discharge or approved the discharges. Additionally, there was no documented evidence that the patient requested an early discharge. These findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 5/1/25 at 10:40 a.m. **Agency Policy: “Plan of Care – CMS #485 and Physician Orders” (Revised March 2018). The policy states, “20. Care and services provided will be provided according to physician orders. Orders are current and updated.” P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that Skilled Nursing completed a resumption of care on 2/23/25 with an ordered frequency of 1w6 (1 time a week for 6 weeks) and Home Health Aide (HHA) at a frequency of 1w1, 2w3. The HHA completed a total of 11 visits, 4 more than what was ordered. The agency failed to obtain physician orders for the additional HHA visits. This finding was reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:00 pm.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency had failed to promptly notify the Physician concerning vital signs outside of the specified reportable parameters for 2 (P-1, P-3) of 7 records reviewed, resulting in a potential poor clinical outcome. Findings include: P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care ordered Skilled Nursing (SN) 1x/wk. x 6 wks., Physical Therapy (PT) 1x/wk. x 1 wk. 2x/wk. x 6 wks. During the record review on 4/29/25 at 12:10 p.m. it was noted that the Plan of Care instructed the physician be notified of systolic blood pressure greater than 160. A SN visit note dated 1/8/25 documented a blood pressure of 168/87. There was no documented evidence that the SN promptly notified the Physician as instructed. these findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 5/1/25 at 10:40 a.m. **Agency Policy: “Coordination of Patient Care” (Revised March 2018). The policy states, “Policy: Agency staff members regularly communicate to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care. Procedure: 1. The Agency must: Assure communication with all physicians/practitioners involved in the plan of care...6. Staff provides the physician/practitioner with patient information on an ongoing basis regarding: Current condition and changes in condition…” P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted that the POC noted a reportable parameter stating, “Heart Rate: greater than (>) 120 bpm (beats per minute) less than ( The was no documented evidence of the SN reporting the low HR. The SN failed to notify the physician as per policy. This finding was reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:00 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 ensure its skilled disciplines coordinated services for 1 (P-1) patient who continued to receive services after discharge from the agency, from a total of 7 sampled records reviewed, resulting lack of coordinated care and the potential for substandard care. Findings include: P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care ordered Skilled Nursing (SN) 1x/wk. x 6 wks., Physical Therapy (PT) 1x/wk. x 1 wk. 2x/wk. x 6 wks. During the record review on 4/29/25 at 12:10 p.m. it was noted that the Physical Therapist discharged the patient from the agency’s services and completed the required discharge Oasis (Comprehensive Assessment) on 1/17/25. Upon further review, it was noted that the SN continued to see the patient after she was discharged from the agency. There was no documented evidence that the PT coordinated services with the SN prior to discharge. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 5/1/25 at 10:40 a.m.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the Home Health Aide failed to provide care and services as ordered in the Aide Care Plan for 1 (P-1) patient, from a total of 7 sampled records reviewed, resulting in the potential for unidentified health concerns and unmet care needs. Findings include: P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care ordered Home Health Aide services to be provided. During a review of the Aide Care Plan on 4/29/25 at 12:10 p.m., it was noted that the HHa was ordered to check the patient’s vital signs (blood pressure, pulse, respirations, temperature) every visit. The Aide visit notes dated 12/20/24, 12/28/24, 1/2/25, 1/10/25, 1/11/25, 1/15/25 and 1/17/25 had no documented vital signs. The HHa failed to check the patient’s vital signs as ordered. These findings were reviewed with and acknowledged by the Administrator and Office Manager during an interview on 5/1/25 at 10:40 a.m.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure they adequately documented on-site supervisory visit to the patient’s home to supervise the services that were provided by the home health aide for 1 (P-4) of 4 records reviewed in which aide services had been provide, from a total sample of 7 records reviewed, resulting in a lack of oversight of aide care and services. Findings include: **Agency Policy: “Home Health Aide Supervision” (Revised March 2018). The policy states, “All home health aide supervisory visits will be made at least every 14 days.” P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that the Skilled Nurse (SN) completed a comprehensive assessment on 2/7/25 with an ordered frequency of 1w6 (1 time a week for 6 weeks) and Home Health Aide (HHA) with a frequency of 1w4. The Patient had a resumption of care order on 3/23/25 with a frequency of SN: 1w6 and HHA: 1w1, 2w3. The patient was then recertified on 4/5/25 with a frequency of SN: 1w4 and HHA: 2w4. The HHA completed a total of 16 visits, of which 15 were over 8 consecutive weeks without supervisory visits. The agency failed to follow policy and complete onsite supervisory visits. This finding was reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:00 pm.”

“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 that the Administrator failed to ensure the Clinical Manager was available at all times during operating hours, resulting in the lack of clinical supervision and oversight and the potential for unmet care needs for all patients currently serviced by this agency. Findings include: On 4/29/25 during the Entrance Conference, the Administrator (Adm #1) was asked if the Clinical Manager (CM #1) would be joining the survey to which he responded, “The Clinical Manager is unavailable because he is out seeing patients.” When asked if he was seeing the agency’s patients, Adm #1 reported that CM #1 works for another agency as well. On 4/30/25, CM #1 was not available during the survey. On 5/1/25 at 11:30 a.m., during an interview with Adm #1 and the Office Manager, Adm #1 was queried about CM #1’s whereabouts and said, “I thought he (CM #1) said he may be in today.” The Clinical Manager was not available during all hours of operation as per this requirement. These findings were reviewed with Adm #1 and OM #1 during the above interview.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on observation, interview and record review, it was determined that the Clinical Manager failed to ensure the patient’s needs were continually assessed for 1 (P-2) patient observed during a home visit, who required Speech Therapy services and ongoing assessments, from a total 7 sampled records reviewed, resulting in lack of assurance that assessments are performed in accordance with the patient’s needs and the potential for physical decline. Findings include: P-2: The patient’s Start of Care was 3/13/25 with diagnoses that included Metabolic Encephalopathy. During the clinical record review on 4/30/25 at 10:55 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The Initial Comprehensive Assessment dated 3/13/25 documented, “Nutritional Approaches: Mechanically altered diet - require change in texture of foods or liquids (e.g. pureed food, thickened liquids..., Therapeutic diet..., Has an illness or condition that made pt (patient) change the type and/or amount of food eaten..., Able to feed self independently but requires (a) meal set-up (b) intermittent assistance or supervision from another person; or (c) a liquid, pureed or ground meat diet.” Further review of the SN visit notes revealed no documented evidence that the patient’s swallowing/nutritional needs had been assessed. Additionally, there was no documented evidence that the Clinical Manager (CM #1) ensured the patient’s needs, specifically nutritional/swallowing needs, were adequately and continually assessed. On 4/30/25 at 3:15 p.m., a scheduled survey home visit was conducted with the Home Health Aide (HHa #1). During the visit, the patient’s wife (F1) showed this writer 2 prescriptions/orders (Rx) for Speech Therapy services with swallow evaluation. One of the Rx was dated 4/4/25 and the other was dated 4/15/25. F1 then stated, “I called the agency and told them my husband needed Speech Therapy, but the doctor (Administrator/Adm #1) told me they didn’t have Speech Therapy services. When asked if the agency was made aware of the initial Rx dated 4/4/25, F1 said, “No. I didn’t inform them.” When asked if the agency had been made aware of the Rx dated 4/15/25, F1 reported, “Yes. That’s when I called him (Adm #1) and he told me they didn’t offer Speech Therapy. I never sent the actual order because he said they didn’t have the service.” During the visit, the patient was noted to have difficulty speaking and difficulty swallowing the water that had been provided by his daughter. F1 reported, “We’ve been adding powder to his liquids to thicken them so he can swallow better. He really needs the help.” These findings were discussed with the Administrator (Adm #1) and Office Manager (OM #1) during an interview on 5/1/25 at 11:10 a.m. When asked if he had a conversation with F1 regarding the need for Speech Therapy services, Adm #1 responded, “We talk all the time. She calls me all the time. I just got the faxed order today.” When asked of the Clinical Manager’s whereabouts and involvement in patient care, Adm #1 asked OM #1, “He (CM #1) said he might be coming in today, didn’t he?” Based on this information, it was determined that the agency failed to ensure the Clinical Manager continually assessed the needs of the patient.”

“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 3 (P-3, P-4, P-5) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: **Agency Policy: “Timely Submission of Patient Documentation,” (Revised October 2017). The policy states, “Procedure: Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding seven (7) business days. All patient visit reports from contract personnel must be submitted within seven (7) business days from the date of the visit, e.g., PT (Physical Therapy), SLP (Speech-Language Pathologist), etc.” **Agency Policy: “Medical Record Content,” (Revised March 2018). The policy states, “Procedure: 1. The Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations. The Agency will use a standardized format for medical records…” P-3: The Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart Disease with Heart Failure, Diabetes Type 2 and Atrial Fibrillation. During record review on 4/29/25, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w1 (1 time a week for 1 week), 2w1, 1w7. The comprehensive assessment dated 2/26/25 documented a weight of 223. The following 5 SN visits contained no weight recordings: 3/3/25, 3/10/25, 3/20/25, 3/26/25 and 4/9/25. The administrator (Adm #1) was questioned during the entrance interview on 4/29/25 at 10:40 am regarding patient’s weight documentation with Congestive Heart Failure and stated, “Every visit the patient will be weighed and documented.” The agency failed to ensure that the medical record was complete and accurate. P-4: The Start of Care (SOC) was dated 2/7/25. The Plan of Care (POC) identified diagnoses of Pulmonary Embolism, Muscle Weakness and Diabetes Type 2. During record review on 4/30/25, it was noted that the POC ordered Skilled SN at a frequency of 1w6, resumption of care at a frequency of 1w6 and recertification at a frequency of 1w4. The comprehensive assessment dated 2/7/25 documented a blood sugar reading of 174. The POC contained an order stating, “SN 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. The following 4 SN visits contained no blood sugar readings: 2/14/25, 3/13/25, 3/19/25, 3/26/25, 4/9/25 and 4/26/25. The agency failed to ensure that the medical record was complete and accurate. P-5: The Start of Care (SOC) was dated 1/30/25. The Plan of Care (POC) identified diagnoses of Prostate cancer, Falls and Knee osteoarthritis. During record review on 4/30/25, it was noted that Physical Therapy (PT) completed a recertification visit on 3/28/25 with an ordered frequency of 1w8. There is no documented evidence that the PT has completed a visit since 3/28/25. P-5 was queried during a joint home care observation visit with the PT on 4/20/25 at 11:20 and stated, “The PT has been here weekly.” Adm #1 was questioned during the entrance interview on 4/29/25 at 10:40 am regarding timeframe of completing visit documentation and stated, “Visit notes are expected to be completed within 7 days of the visit.” The agency failed to document visits timely. These findings were reviewed with and acknowledged by Adm #1 (Administrator) during an interview on 5/1/25 at 12:30 pm.”

“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, policy review, and interview, the agency failed to include measurable goals in the plan of care in 2 of 7 records (P-6, P-7) to determine the patient’s progress towards obtaining the goals. Findings included: **Agency Policy: Plan of Care-CMS#485 and Physician Orders”. The policy states, “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...” P-6: The Start of Care (SOC) was dated 1/14/2025. The Plan of Care (POC) for the certification period 1/14/25 to 3/14/25 identified diagnoses of Hypertensive Heart Disease with Heart Failure (HF), Chronic Systolic Congestive Heart Failure (CHF), Parkinson’s disease without dyskinesia (PD), Diabetes type 2 (DM2), Hyperlipidemia, Atrial Fibrillation (A-fib), and Chronic Obstructive Pulmonary Disease (COPD). The patient was receiving Skilled Nursing (SN) and Physical Therapy (PT) services. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “The patient/caregiver will verbalize an understanding of skin conditions that must be reported to SN or physician immediately; Home exercise program will be established by the physical therapist; Patient will demonstrate proper pain management measures during this episode; Patient will maintain heart healthy NCS diet compliance during the episode.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals.” P-7: The Start of Care (SOC) was dated 3/31/2025. The Plan of Care (POC) for the certification period 3/31/25 to 5/29/25 identified diagnoses of Acute Kidney Failure (AKF), Osteoarthritis, Diabetes type 2 with hyperglycemia (DM2); Hypertension (HTN), Hypothyroidism, and Gastroenteritis and Colitis. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Home Health aide (HHa) services. Upon review of the record, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “The Patient/Caregiver will verbalize understanding of individualized emergency plan by 4/9/25; The patient/caregiver will verbalize an understanding of skin conditions that must be reported to SN or physician immediately; Home exercise program will be established by physical therapist.” These goals are not measurable or specific to the patient’s identified needs. These findings were reviewed with and acknowledged by the Administrator (ADM) and Office Manager (OM) during an interview on 5/1/25 at 2:00 p.m.”

“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, policy review, and interview, the agency failed to document a discharge summary with all required information, and failed to provide the primary care professional responsible for providing care and services to the patient with a copy of the discharge summary within 5 business days of the discharge in 2 of 2 discharge (P-1, P-7) records reviewed. Findings included: **Agency Policy:” Discharge Summary (revised March 2018). The policy states, “A discharge summary will be completed for all patients discharged from the agency. The Discharge Summary will include Discharge date, Reason for discharge, Laboratory data, Patient’s discharge condition, Types of services provided and frequency of services, Patient’s outcome in meeting goals in the plan of care, Patient/family post-discharge instructions, medications at time of discharge. A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. The original Discharge Summary form from each service will be filed in the medical record.” P-7: The Start of Care (SOC) was dated 3/31/2025. The Plan of Care (POC) for the certification period 3/31/25 to 5/29/25 identified diagnoses of Acute Kidney Failure (AKF), Osteoarthritis, Diabetes type 2 with hyperglycemia (DM2); Hypertension (HTN), Hypothyroidism, and Gastroenteritis and Colitis. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Home Health aide (HHa) services. The patient was discharged from the agency on 4/30/2025. Upon review of the Discharge Summary it was noted that required information had not been documented in the discharge summary as follows: There was no discharge instructions; no final pain assessment documented on the discharge summary; no reason documented for the discharge such as goals met or not met; no documentation of any discharge instructions provided or medically necessary /appropriate follow-up advised. Also there was no documentation that the Discharge Summary had been sent to the physician as required. The agency documented “Physician notified of Discharge Summary availability”, but there was no documented proof that the Discharge Summary had been sent to the physician within 5 days of discharge as required. These findings were reviewed with and acknowledged by the Administrator (ADM) and Office Manager (OM) during an interview on 5/1/25 at 2:00 p.m. P-1: The patient’s start of care was 12/18/24 with diagnoses that included Fractured Nasal Bone and Fractured Orbital Floor. The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical Therapy (PT) services to be provided. On 4/29/25 at 12:10 p.m., it was noted that the patient was discharged from PT services on 1/17/25. There was no documented evidence that the PT Discharge Summary had been forwarded to the Physician within 5 days of the date of discharge. Additionally, the patient was discharged from SN services on 1/18/25. The SN Discharge Summary dated 1/18/25 was void of a summary which detailed the course of care provided with responses and the patient’s overall health status at the time of discharge. The section titled “Care Summary” was left blank. The section titled “Care Coordination” documented “Discharge from home health services.” Further, there was no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator and the Office Manager during an interview on 5/1/25 at 10:40 a.m.”