Proficient Home Health Services, LLC

“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, to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, to develop and maintain an emergency preparedness communication plan, to develop and maintain an emergency preparedness training and testing program for staff, and to provide documentation for the required exercises. This deficient practice could affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients serviced by this Agency. Findings include: E0004 The Agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years. E0013 The Agency failed to ensure its Emergency Preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared. E0030 The Agency failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patients’ physicians and volunteers. E0036 The Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency’s emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster. E0039 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. The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the 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.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, it was determined the agency failed to provide evidence of its efforts to measure, track and analyze it’s quality indicators and show measurable improvement in patient care and services (See G 642); failed to develop Performance Improvement activities, as part of the agency’s Quality Assessment Performance Improvement program, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions (See G 654); failed to document any of the required annual quality improvement projects since 2023 through 8/1/25, including the reasoning for conducting these projects and the measurable progress achieved each year (See G 658); and failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety which evaluated its effectiveness (See G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care for all 16 patients who has received services from this Home Health Agency regarding the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to develop an infection control program that focused on infection prevention and control, including communicable diseases for the last 3 years (See G682); failed to ensure the infection control program was active and provided surveillance, identification, prevention, control and investigation of infectious and communicable diseases and was a part of the agency’s Quality Assessment and Performance Improvement program for the last 3 years (See G684); and failed to provide infection control education to all contracted staff for the last 3 years (See G686). The cumulative effects of these systemic problems resulted in the agency’s inability to ensure the provision of safe health care to the one patient currently receiving services for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the skilled nursing (SN) followed accepted standards of practice in assuming responsibility for the care of 1 (Patient/P-6) of 1 patient who required wound care management, from a total of 7 sampled patient records reviewed (See G 704); failed to ensure the registered nurse performed re-assessments of the patient’s health status and needs in 1 (P-6) of 1 patient record reviewed with diabetic non-compliance requiring wound care assessments, from a total of 7 sampled records reviewed (See G 706); and failed to ensure that skilled nursing provided assessments and interventions as ordered by the physician in 1 (P-6) of 1 patient record reviewed with required physician notification concerning diabetic and wound exacerbation (worsening), from a total of 7 sampled records reviewed (See G 710); and failed to ensure the physician was notified of the patient’s non-compliance with ordered medications and treatments in 1 (P-3) of 7 records reviewed (See G 718). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.75 Skilled Professional Services.”

“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 updated 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 in the event of a facility emergency or disaster. Findings include: On 7/30/25 at 10:00 am, review of the Agency’s Emergency Preparedness Plan failed to provide any evidence that a review or updates had been documented. This deficient practice was confirmed during an interview with the Administrator (Adm-1) at 11:30 am, on 7/30/25. Adm-1 stated, “We have not updated the Emergency Preparedness program since our last survey” The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed and updated at least every 2 years as required.”

“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 were reviewed and updated at least every 2 years, resulting in the potential for poor patient outcomes during a disaster if staff are ill-prepared. Findings include: On 7/30/25 at 10:00 am, review of the Agency’s Emergency Preparedness documents, it was noted that there was no documented evidence that the agency’s Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years. On 7/30/25 at 11:30 am, the Administrator (Adm-1) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, which had the potential to negatively affect the health and safety of all patients currently serviced by this agency as a result of lack of effective communication in the event of an actual emergency. Findings include: During a review of the agency’s emergency preparedness documents on 7/30/25 at 10:00 am, it was noted that there was no updated contact information for all current staff, patient’s physicians, or volunteers as appropriate. On 7/30/25 at 11:30 am, the Administrator (Adm-1) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“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, it was determined that the Agency failed to develop and maintain an emergency preparedness training and testing program for staff based on the agency’s emergency plan, resulting in agency personnel not being educated in actions to take in the event of an actual disaster. This deficient practice could affect all patients serviced by this Agency. Findings include: During review of the agency’s Emergency Preparedness documents and policies on 7/30/25 at 10:00 am, it was noted that the Agency did not have documented evidence that they had developed a training and testing program for staff that was based on the agency’s emergency plan. The above findings were reviewed with and confirmed by the Administrator (Adm-1) during an interview on 7/30/25 at 11:30 am, who stated, “Nothing has been updated since the last survey.””

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to provide initial and ongoing training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of trainings, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. Findings include: On 7/30/25 at 10:00 am, the Administrator (Adm-1) was asked to provide documented evidence of initial and ongoing training in Emergency Preparedness policies and procedures, for all staff employed by the agency, and all contracted staff, yet was unable to do so. There was no documented evidence of initial and ongoing training in Emergency Preparedness. The Agency failed to provide the required training in emergency preparedness policies and procedures for all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training. These findings were reviewed with and acknowledged by Adm-1 at the time of discovery.”

“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: During the review of the agency’s Emergency Preparedness documents on 7/30/25 at 10:00 am, it was noted that there was no evidence the agency had conducted any training or exercises to test the agency’s emergency plan. Further, there was no documentation of an actual event that would qualify as an emergency, no community based full-scale exercise, no second full-scale exercise or a table-top exercise that would satisfy this requirement. On 7/30/25 at 11:30 am, the Administrator (Adm-1) was asked if the agency had conducted the required risk assessment and reported, “We have not updated the Emergency preparedness program since our last survey.””

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a Quality Assessment and Performance Improvement (QAPI) program which provided documentation of its efforts to measure, track and analyze quality indicators that represented pre-established performance improvement projects (PIP’s) designed to optimize patient care services, resulting in the inability to determine the quality of services provided and the potential for unmet care needs for all 16 patients who have received services from this agency in the past 12 months. Findings include: On 7/30/25, the agency’s QAPI documentation was reviewed which revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body approved PIP’s. Review of the QAPI binder noted 6 QAPI meetings dated 1/1/23, 4/7/23, 1/17/24, 4/9/24, 1/17/25, and 3/10/25. During review of the above meeting minutes, the Administrator (Adm-1) and the Clinical Manager (CM-1) were queried concerning referenced components within the meeting minutes. Examples include: chart audits, improvement in national scores regarding bathing and ambulation of patients, and satisfaction surveys which generated a star rating. Adm-1 and CM-1 were asked how the above projects were chosen, the tools needed to collect data, and discussion of data analysis for the purpose of meeting pre-establish goals. Adm-1 and CM-1 were unable to provide evidence of any data collection or explain the methodology utilized to generate the noted improvements found within the meeting minutes. No evidence was found within the QAPI program that showed an effort was made by the agency to collect data to track and trend actions/interventions that would improve the delivery of patient care in measurable terms since 2023. During an interview on 8/1/25 at 9:45 AM., Adm-1 and CM-1 reviewed and acknowledged the above findings. The agency failed to adhere to its policy referenced below. Agency Policy: “QAPI/Performance Improvement” (undated) stated on page 1, “To analyze and aggregate data to make changes in policies, procedures and track trends. To help develop performance improvement activities for the agency to identify areas for improvement. To track undesirable trends and analyze to make improvements.””

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop performance improvement activities, as part of the agency’s Quality Assessment Performance Improvement (QAPI) program, that tracked and trended adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs for all 16 patients who have received services from this agency during the past 12 months. Findings include: On 7/30/25, during review of the agency’s QAPI documents since 2023, it was noted there was insufficient evidence that the agency had attempted to implement quality improvement measures or activities that would serve to track/trend adverse patient events, analyze causative factors and implement preventive interventions. The agency’s Governing Body meeting minutes concerning QAPI projects noted improvement activities regarding chart audits, improvement in national scores regarding bathing and ambulation of patients, and satisfaction surveys which generated a star rating. Adm-1 and CM-1 were asked how the above projects were chosen, the tools needed to collect data, and discussion of data analysis for the purpose of meeting pre-establish goals. Adm-1 and CM-1 were unable to provide evidence of any data collection or explain the methodology utilized to generate the noted improvements found within the meeting minutes. No evidence was found within the QAPI program that showed an effort was made by the agency to collect data to track and trend actions/interventions that would improve the delivery of patient care in measurable terms since 2023. The Administrator (Adm-1) and the Clinical Manager (CM-1) reviewed and acknowledged the findings above during an interview on 8/1/25 at 9:46 AM.”

“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 Performance Improvement Project (PIP) within its Quality Assessment Performance Improvement (QAPI) program, resulting in the agency’s inability to effectively monitor proposed improvements in patient care, health outcomes, patient safety, quality of care and overall performance for all 16 patients who have received services from this agency during the past 12 months. Findings include: On 7/30/25, review of the agency’s QAPI binder since 2023, noted 6 QAPI meetings dated 1/1/23, 4/7/23, 1/17/24, 4/9/24, 1/17/25, and 3/10/25. During review of the above meeting minutes, the Administrator (Adm-1) and the Clinical Manager (CM-1) were queried concerning referenced QAPI components (PIPs) within the meeting minutes. PIP examples include: chart audits, improvement in national scores regarding bathing and ambulation of patients, and satisfaction surveys which generated a star rating. Adm-1 and CM-1 were asked how the above projects were chosen, the tools needed to collect data, and discussion of data analysis for the purpose of meeting pre-establish goals. Adm-1 and CM-1 were unable to provide evidence of any data collection or explain the methodology utilized to generate the noted improvements found within the meeting minutes or within the QAPI program itself. During an interview on 8/1/25 at 9:50 AM., Adm-1 and CM-1 reviewed and acknowledged the above findings. The agency failed to adhere to its policy referenced below. Agency Policy: “QAPI/Performance Improvement” (undated) stated on page 1, “Data collections helps identify specific areas (PIPs) that require further evaluation and study. These areas are determined by considering the information provided by the data about processes, risks, and sentinel events, as well as priorities set by the team leader. Performance measures are used to determine whether the changes result in desired outcomes.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care, maintained patient safety standards, and was evaluated for its effectiveness, resulting in the potential to adversely affect the quality of care to all 16 patients who have received services from this agency during the past 12 months. Findings include: On 7/30/25, the agency’s QAPI documentation was reviewed and revealed a failure to document efforts to systematically collect data, monitor, analyze and improve patient outcomes based off the Governing Body (GB) meeting minutes. The meeting minutes noted 6 QAPI meetings dated 1/1/23, 4/7/23, 1/17/24, 4/9/24, 1/17/25, and 3/10/25. During review of the above meeting minutes, the Administrator (Adm-1) and the Clinical Manager (CM-1) who represents the GB, were queried concerning referenced QAPI activities within the meeting minutes. Examples of the QAPI activities include: chart audits, improvement in national scores regarding bathing and ambulation of patients, and satisfaction surveys which generated a star rating. Adm-1 and CM-1 were asked how the above projects were chosen, the tools needed to collect data, and discussion of data analysis for the purpose of meeting pre-establish goals. Adm-1 and CM-1 were unable to provide evidence of any data collection or explain the methodology utilized to generate the noted improvements found within the meeting minutes or within the QAPI program itself. The agency’s GB failed to provide necessary documentation or knowledge that its QAPI program ensured that patient safety is defined, implemented, and maintained. The Administrator (Adm-1) and the Clinical Manager (CM-1) reviewed and acknowledged the findings above during an interview on 8/1/25 at 9:58 AM.”

“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 record review and interview, the agency failed to develop an infection control program which monitored staff’s performance to ensure infection control policies and accepted standard practices to prevent the transmission of infections and communicable diseases were followed in the last 3 years, resulting in a lack of oversight concerning infection control practices used during patient care by agency staff and the potential for poor clinical outcomes for the lone patient currently receiving services from this agency. Findings include: On 7/30/25, a request was submitted to the agency administration to review the agency’s infection control program for the last 3 years. Both the Administrator and the Clinical Manager stated that there was no documentation concerning infection control education, or in-services that had been provided to its staff (direct or contracted) for the last 3 years during an interview on 7/30/25 at 2:50 PM. The agency’s QAPI program noted there were no staff or patient acquired infections in the last 3 years. However, when Adm-1 and CM-1 were queried which infection control core measures were being monitored such as hand washing, use of PPE (personal protective equipment), or disinfecting medical equipment, both were unable to provide any evidence of collected data or audit tools. The agency failed to show that any of the 6-core infection control measures that represent “standard precautions” were being monitored and audited for quality improvement. The Administrator and the Clinical Manager reviewed and acknowledged the findings above during an interview on 8/1/25 at 9:58 AM. Both further acknowledged the agency’s policy referenced below was not being followed. Agency Policy: “QAPI/Performance Improvement” (undated) stated on page 1, “The agency collects data that measures the performance of each of the following-high risk processes... infection control, surveillance and reporting.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency’s Quality Assessment Performance Improvement (QAPI program), resulting in the potential spread of infections between patient care staff and the agency’s 16 patients admitted in the past 12 months. Findings include: On 7/30/25, a request was submitted to the agency’s administration to review its infection control program for the last 3 years. During review, no evidence was found which indicated the agency had developed a method for identifying infectious and communicable disease problems. Further, plans which directed specific and appropriate actions intended for improvement and disease prevention were not found within the infection control program. The agency failed to provide evidence of an infection control methodology which identified infectious diseases, data collection (with analysis) and planning which would be utilized to monitor its effectiveness for meeting infection control goals. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 8/1/25 at 10:05 AM.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documented evidence of infection control education for 5 of 5 sampled staff members including those employed through an arranged contract which has the potential to negatively impact on the safety and well-being of all 15 patients serviced by the agency in the past 12 months. Findings include: On 7/31/25, 5 personnel files for varied skilled staff including those arranged through contracts were reviewed. During review, it was noted that no ongoing Infection Control (IC) education was found in the personnel files reviewed. A “Personnel File Checklist” was provided by the Administrator (Adm-1) and stated, “Section VII: In-service/Education…Annual Infection Control. A review of the agency policy on 7/30/25 titled “Personnel Records/Primary Source Verification” (undated). The policy states, “Policy: 1. The agency shall have personnel files on all staff, contractual and non-contractual…4. …For all contractual staff the following are required either from the other agency or the Agency will require the paperwork before the contractual employee can provide and services: J. In-service record (may attend Agency or outside & have documentation for hours) …P. Attend agency Mandatory in-services to keep current with agency standards…” The Adm-1 and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 12:40 pm.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure that skilled nursing (SN) followed accepted standards of practice in assuming responsibility for the care of 1 (Patient/P-6) of 1 patient who required wound care management with unmanaged diabetes, from a total of 7 sampled patient records reviewed, resulting in the potential of unmet care needs and a poor patient outcome. Findings include: P-6: The start of care (SOC) date to home care was 2/15/24, with diagnoses that poly-osteoarthritis, diabetes-2, open wound with necrosis (death of body tissues) of right BKA (below knee amputation), and chronic pain. On 7/31/25, a record review noted the physician referral for home care documented P-6’s CC (chief complaint) assessment was “Necrosis of amputation stump, right lower extremity, Depression, Fall Risk, Diabetes Mellitus-type 2.” The referral further documented, “Patient reports not monitoring blood glucose previously... The patient needs Skilled Nursing to: Monitor Vitals; Diabetic Teaching; Diet/Nutrition Management; Monitor Blood Sugar; Manage Medications... Patient reports prosthesis should arrive approximately 1 week.” Additional record review revealed the SOC assessment performed by SN, documented only the lone visit with no follow-up concerning the potential for the necrotic R leg stump to get infected due to the complications associated with unmanaged diabetes and wound healing. Subsequently, the plan of care (POC) reflected just the SOC SN visit. Further review of the clinical record found no evidence that physical therapy (PT) acknowledged this significant aspect of clinical needs for P-6. No documentation was found the medical record that any blood sugar values or wound care assessments with treatment/interventions were ever performed while P-6 was under the agency’s care. Further, no documentation was found in the medical record that indicated SN or PT services were aware and acknowledged if the new prothesis had arrived. No documentation was found that ensured the fit of the prosthesis was appropriate and was not going to exacerbate (worsen) the current necrotic wound. No education with return demonstration (verbal or physical) concerning wound care, diabetic management, diet/nutrition, prosthesis application, and management of depression was evidenced in the medical record from admission through discharge on 9/12/24. The findings above were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:28 AM. Both noted the findings above did not meet agency expectations and represented poor coordination of care.”

“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: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 7/31/25, review of CMS (Centers for Medicare & Medicaid) form 1572 noted under “Services Provided” that all services furnished by the Agency were under contract or “Under Arrangement” to some degree. Further review of the agency’s staff roster under “W2/Contract” confirmed this finding. In addition, the staff roster above documented Assured Health, a contracted staffing agency, had an agreement to provide 6 of 6 of the following services: PT-physical therapy, OT-occupational therapy, RN-registered nurse, SLP-speech language pathology, MSW-medical social worker, and HHA-home health aide. These findings were discussed with and acknowledged by the agency’s Administrator during an interview on 8/1/25 at 9:50 AM. The agency failed to provide at least one of the services directly as required.”

“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 record review and interview, the agency failed to ensure that 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided, and the duration with visit frequency of those services, resulting in a lack of inclusion in planning, lack of informed consent and unmet care needs. Findings include: P-4: The start of care (SOC) to home care was 5/16/25, with diagnoses which included chronic pain, hypertension and seizure disorder. On 7/30/25, a record review of the P-4’s admission packet documentation noted the patient’s consent for home care was void of all information except for P-4’s signature. For example, the consent for treatment was blank concerning the types of services (Skilled Nursing/SN and Physical Therapy/PT) to be provided along with their intended visit frequencies and the section for intended charges was also blank. The findings above were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:12 AM. P-5: The SOC to home care was 11/25/24, with diagnoses which included depression, hypertension, diabetes-type 2, and MS (Multiple Sclerosis). On 7/30/25, a record review of the P-5’s admission packet documentation noted the patient’s consent for home care was void of all information except for P-5’s signature and a circle around “PT”. The consent for treatment indicated only PT services would be provided, but the intended duration and visit frequency was blank and the section with the intended charges was also left blank. The findings above were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:13 AM. P-6: The start of care (SOC) date to home care was 8/1/24, with diagnoses that included diabetes-type 2, COPD (chronic obstructive pulmonary disease), and hypertension. On 7/31/25, a record review of the P-6’s admission packet documentation noted the patient’s consent for home care was void of all information except for P-6’s signature and a circle around “SN” and “PT”. The consent for treatment indicated both SN and PT services would be provided, but their intended duration and visit frequency was blank and the section with the intended charges was also left blank. The findings above were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:15 AM. P-7: The SOC date to home care was 1/3/25, with diagnoses that included diabetes-type 2, epilepsy, chronic respiratory failure with supplemental oxygen, and hypertension. On 7/31/25, a record review of the P-7’s admission packet documentation noted the patient’s consent for home care was void of all information except for P-7’s signature and a circle around “SN” and “PT”. The consent for treatment indicated both SN and PT services would be provided, but their intended duration and visit frequency was blank and the section with the intended charges was also left blank. The findings above were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:16 AM. Both further acknowledged this did not meet agency expectations nor did its policy referenced below. Agency Policy: “Patient Bill of Rights” (undated) pg. 1 stated, “To be informed verbally & in writing of the services (agency providing), frequency of the services, be informed of changes in the visit schedule and/or any charges for items not covered by insurance prior to services being started.” Patient #1’s (P-1) Start of Care (SOC) was dated 7/29/25. The Plan of Care (POC) identified diagnoses of Hypertension, Prostate Cancer and Weakness. During record review on 7/30/25, it was noted that the referral stated, “Circle Disciplines Ordered: RN (Registered Nurse), PT (Physical Therapy), HHA (Home Health Aide)”. The consent signed by the patient on 7/29/25 was blank. The comprehensive assessment completed by the RN on 7/29/24 was blank under the HHA section and there was no documentation of the patient refusing HHA. The agency failed to provide HHA services as ordered and complete the consent form. Patient #2’s (P-2) Start of Care (SOC) was dated 1/27/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 Spondylosis and Bilateral Knee Osteoarthritis. During record review on 7/30/25, it was noted that the referral stated, “Start of Care Order. Start Home Health Services. Services to include: RN, PT.” The consent signed by the patient on 1/27/25 was blank. The agency failed to complete the consent form. Patient #3’s (P-3) Start of Care (SOC) was dated 5/16/25. The Plan of Care (POC) identified diagnoses of Polyosteoarthritis, Muscle Weakness, Hypertension and Diabetes Type 2. During record review on 7/31/25, it was noted that the referral stated, “Services Requested: SN (Skilled Nurse), PT, OT (Occupational Therapist), ST (Speech Therapist).” The consent signed by the patient on 4/17/25 was blank. The comprehensive assessment completed by the RN on 4/17/25 was blank under the OT and ST section and there was no documentation of the patient refusing OT and ST. The agency failed to provide OT and ST services as ordered and complete the consent form. The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 12:40 pm.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of the home care referral to determine the immediate care needs of the patient for 3 (P-1, P-2, P-4) of 5 records reviewed with skilled nursing services; and 1 (P-5) of 2 therapy only cases, from a total sample of 7 records reviewed, resulting in delay in needed care and services and the potential for unmet care needs. Findings include: P-4: During record review on 7/29/25, it was noted the home care referral for skilled nursing (SN) and physical therapy (PT) services was dated 5/8/25. However, the initial start of care (SOC) assessment performed by the agency’s SN was dated 5/16/25 (8 days after the referral). There was no documentation in the medical record to indicate why the SOC was delayed and no physician order was obtained to authorize a delay in the SOC. P-5: During record review on 7/29/25, it was noted the home care referral for a PT only case was dated 11/5/24. The initial SOC assessment performed by the agency’s PT was dated 11/25/24 (20 days after the referral). There was no documentation in the medical record to indicate why the SOC was delayed and no physician order was obtained to authorize a delay in the SOC. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 8/1/25 at 10:10 AM. Patient #1’s (P-1) Start of Care (SOC) was dated 7/29/25. The Plan of Care (POC) identified diagnoses of Hypertension, Prostate Cancer and Weakness. During record review on 7/30/25, it was noted that the initial assessment of the patient was dated 7/29/25, it was noted that the referral for home care services was dated and signed by the physician on 7/23/25. The start of care assessment was completed 6 days after the date of the referral. There was no documented evidence that the patient had requested delay services. Patient #2’s (P-2) Start of Care (SOC) was dated 1/27/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 Spondylosis and Bilateral Knee Osteoarthritis. During record review on 7/30/25, it was noted that the initial assessment of the patient was dated 1/27/25, it was noted that the referral for home care services was dated and signed by the physician on 1/10/25. The start of care assessment was completed 17 days after the date of the referral. There was no documented evidence that the patient had requested delay services. The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 12:45 pm.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record documented all medications with a completed reconciliation and failed to provide documented evidence that the physician was notified of identified drug interactions in for 3 (P-1, P-2, P-3) of 7 records reviewed. This deficient practice results in the potential for unrecognized medication side effects and drug interactions that could affect all patients serviced by the agency. Findings included: Patient #1’s (P-1) Start of Care (SOC) was dated 7/29/25. The Plan of Care (POC) identified diagnoses of Hypertension, Prostate Cancer and Weakness. During record review on 7/30/25, it was noted that the Skilled Nurse (SN) completed a comprehensive assessment on 7/29/25 and stated, “Medication Status: Medications reconciled. Medications issues identified: Faxed MD (physician) 7/30/25 all RX (prescription) interactions, high risk RX, duplicate RX: Amlodipine, Lisinopril & Clonidine, Ventolin & Albuterol. The Electronic Medical Record (EMR) and paper chart had no evidence that the physician was faxed and made aware of medication issues per policy. Additionally, EMR documented discrepancies from the Face to Face (F2F) and medication profile. The missing medications from the F2F were Fluticasone-Salmeterol, Omeprazole, Seroquel. Furthermore, the medication profile contained Clonidine, Lisinopril and Ventolin HFA, which was not on the F2F. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. Patient #2’s (P-2) Start of Care (SOC) was dated 1/27/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 Spondylosis and Bilateral Knee Osteoarthritis. During record review on 7/30/25, it was noted that the SN completed a comprehensive assessment on 1/27/25 and stated, “Medication Status: Medications reconciled. Medications issues identified: Faxed MD 1/28/25 all RX interactions, high risk RX, duplicate RX: Metformin, Glyburide & Pioglitazone. The Electronic Medical Record (EMR) and paper chart had no evidence that the physician was faxed and made aware of medication issues per policy. Patient #3’s (P-3) Start of Care (SOC) was dated 5/16/25. The Plan of Care (POC) identified diagnoses of Polyosteoarthritis, Muscle Weakness, Hypertension and Diabetes Type 2. During record review on 7/31/25, it was noted that the EMR documented discrepancies from the Face to Face (F2F) and medication profile. The missing medications from the F2F were Lasix, Loratadine, Gabapentin, Montelukast Sodium, Prednisone, Sertraline HCl, Clopidogrel Bisulfate and Albuterol Sulfate. Furthermore, the medication profile contained Omeprazole, Potassium Chloride and Robaxin, which was not on the F2F. There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen. A review of the agency policy on 7/31/25 titled “Medication Profile & Reconciliation” (undated). The policy states, “Purpose: 1. It is the commitment of the Agency to assure the appropriateness and accuracy of documentation of clinical services provided to all patients… 2 The standard is that the agency staff check all medications a patient may be taking to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, contraindicated, and duplicated medications/s, and promptly report to physician/s. 3. The agency commits to reconciling medication lists and profiles upon admission to the agency… Medication Reconciliation: 1. The agency will fax a current medication list to the referring physician and any other physician’s patient makes agency aware of on admission…” The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 1:15 pm.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure the Plan of Care (POC) included appropriate and measurable skilled nursing goals in 4 (P-1, P-2, P-5, P-6) of 7 total sampled records and failed have an appropriate number of SN visits to meet the clinical needs of the patient in 1 (Patient/P-6) 1 record reviewed with wound care, out of a total sample of 7 records reviewed, resulting in the potential for unidentified goals, unmet patient goals and negative patient outcomes. Findings include: P-5: The start of care (SOC) to home care was 11/25/24, with diagnoses which included hypertension, diabetes-type 2, and MS (Multiple Sclerosis). On 7/30/25, a record review of the P-5’s POC noted 8 of 8 listed skilled nursing (SN) goals were not written in measurable terms. Examples include: “Patient/Caregiver demonstrate ability to effectively manage medication regimen by the end of the episode; Patient will attain optimal effectiveness of pain management by the end of the episode.” In addition, none of the 8 SN goals addressed any of the 7 listed active diagnoses, notably diabetes. The physician referral documented P-5’s blood sugar was uncontrolled with an A1c (value indicating effectiveness of diabetes management) of 8.5% (below 5.7% is healthy) and noted “The patient admits that he is not checking his blood glucose values... administers insulin on how he feels.” Further, the physician referral for home care documented P-5 has a “history of depression and anxiety...” and is currently prescribed 3 medications to treat. The POC failed to instruct SN to obtain verification that P-5 has the ability to effectively manage his diabetes, failed to instruct SN to obtain blood sugar values directly or through patient log entries to ensure blood sugar safety parameters are acceptable, and failed to incorporate a depression screening assessment. The findings above were reviewed and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:18 AM. P-6: The SOC date to home care was 2/15/24, with diagnoses that poly-osteoarthritis, diabetes-2, open wound with necrosis (death of body tissues) of right BKA (below knee amputation), and chronic pain. On 7/31/25, a record review of P-6’s POC noted 7 of 7 listed SN goals were not written in measurable terms. Examples include: Patient will receive safe and effective personal care during this episode; Patient will be able to verbalize diabetic precautions...” In addition, the physician referral for home care documented P-6’s CC (chief complaint) was “Diabetes-type 2, Falls, Right leg stub wound, and Depression.” None of the above diagnoses listed on the POC for home care or physician referral (except diabetes) were acknowledged. Further, P-6’s POC only ordered SN to perform the SOC visit with no follow-up concerning the potential for the necrotic R leg stump to get infected due to the complications associated with diabetes and wound healing. Review of the clinical record found no evidence that physical therapy acknowledged this significant aspect of clinical needs for P-6. Subsequently, no documentation was found the medical record that any blood sugar values or wound care were ever performed while P-6 was under the home health agency’s care. The findings above were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:22 AM. Patient #1’s (P-1) Start of Care (SOC) was dated 7/29/25. The Plan of Care (POC) identified diagnoses of Hypertension, Prostate Cancer and Weakness. During record review on 7/30/25, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, “Patient/caregiver will demonstrate competence with self-management of COPD (Chronic Obstructive Pulmonary Disease) as evidenced by adherence to medication regimen, ability to identify s/s (signs and symptoms) necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management by/within time period.” Additionally, another goal stated, “Patient will attain optimal effectiveness of pain management regimen by the end of the episode.” There was no evidence of how these goals could be quantitatively measured. Patient #2’s (P-2) Start of Care (SOC) was dated 1/27/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 Spondylosis and Bilateral Knee Osteoarthritis. During record review on 7/30/25, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, “Patient/caregiver demonstrate ability to effectively manage medication regimen by/within time period.” Additionally, another goal stated, “Patient will attain optimal effectiveness of pain management regimen by/within time period.” There was no evidence of how these goals could be quantitatively measured. A review of the agency policy on date titled “Care Plans” (undated). The policy states, “3. The Care Plan shall include but not be limited to: … c. Patient specific interventions and education, measurable outcomes and goals that are identified by the patient representative, (if applicable) and agency staff.” The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 12:55 pm.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that skilled nursing (SN) and physical therapy (PT) coordinated patient care needs in 1 (Patient/P-6) of 1 patient record reviewed with diabetic wound care, out of a total sample of 7 records, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: P-6: The start of care (SOC) date to home care was 2/15/24, with diagnoses that poly-osteoarthritis, diabetes-2, open wound with necrosis (death of body tissues) of right BKA (below knee amputation), and chronic pain. On 7/31/25, a record review noted the physician referral for home care documented P-6’s CC (chief complaint) assessment was “Necrosis of amputation stump, right lower extremity, Depression, Fall Risk, Diabetes Mellitus-type 2.” The referral further documented, “Patient reports not monitoring blood glucose previously... The patient needs Skilled Nursing to: Monitor Vitals; Diabetic Teaching; Diet/Nutrition Management; Monitor Blood Sugar; Manage Medications... Patient reports prosthesis should arrive approximately 1 week.” Additional record review revealed the SOC assessment performed by SN, documented only the lone visit with no follow-up concerning the potential for the necrotic R leg stump to get infected due to the complications associated with diabetes and wound healing. Subsequently, the plan of care (POC) reflected just the SOC SN visit. However, SN documented under “Care Coordination” that SN had coordinated care needs with PT services. Additional record review was performed to ascertain the extent of P-6’s clinical care needs were picked up by PT in the absence of SN services. The review of the clinical record found no evidence that PT services had acknowledged any of the following medical needs for P-6. No documentation was found the medical record that any blood sugar values or wound care assessments with treatment/interventions were ever performed while P-6 was under the agency’s care. Further, no documentation was found in the medical record that indicated SN or PT services were aware and acknowledged if the new prothesis had arrived. No documentation was found that ensured the fit of the prosthesis was appropriate and was not going to exacerbate (worsen) the current necrotic wound. No education with return demonstration (verbal or physical) concerning wound care, diabetic management, diet/nutrition, prosthesis application, and management of depression was evidenced in the medical record from admission through discharge on 9/12/24. The findings above were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 8/1/25 at 10:28 AM. Both noted the findings above did not meet agency expectations and represented poor coordination of care.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-2, P-6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: P-6: The start of care (SOC) date to home care was 2/15/24, with diagnoses that poly-osteoarthritis, diabetes-2, open wound with necrosis (death of body tissues) of right BKA (below knee amputation), and chronic pain. On 7/31/25, a record review noted the physician referral for home care documented P-6’s CC (chief complaint) assessment was “Necrosis of amputation stump, right lower extremity, Depression, Fall Risk, Diabetes Mellitus-type 2.” The referral further documented, “Patient reports not monitoring blood glucose previously... The patient needs Skilled Nursing to: Monitor Vitals; Diabetic Teaching; Diet/Nutrition Management; Monitor Blood Sugar; Manage Medications... Patient reports prosthesis should arrive approximately 1 week.” The home care’s POC for P-6 noted the following orders: “SN to assess other co-morbidities including Wound assess, DM (diabetes mellitus) and other conditions that present themselves during this episode of care. (sic) SN to recognize and intervene to minimize complications... Notify Physician of... Blood Sugar, Fasting: Greater Than (>) 200 Less Than () 350 Less Than (Patient #2’s (P-2) Start of Care (SOC) was dated 1/27/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 Spondylosis and Bilateral Knee Osteoarthritis. During record review on 7/30/25, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w4 (1 visit a week for 4 weeks). The SN completed the comprehensive assessment on 1/27/25 and no further visits were completed to meet the ordered frequency. The SN failed to provide the services and frequency as ordered by the physician. The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 12:50 pm.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of the patient’s non-compliance with ordered medications and treatments in 1 (P-3) of 7 records reviewed, which resulted in the potential of uncontrolled blood sugars. Findings include: Patient #3’s (P-3) Start of Care (SOC) was dated 5/16/25. The Plan of Care (POC) identified diagnoses of Polyosteoarthritis, Muscle Weakness, Hypertension and Diabetes Type 2. During record review on 7/31/25, it was noted that the Skilled Nurse (SN) completed a comprehensive assessment on 4/17/25 and stated, “Endocrine: Diabetes: Patient’s Blood Sugar Status Unknown (no glucometer paper logs, visit reports, nor patient ability to report). Blood Sugars Status Unknown Reason: Patient does not check blood glucose. Comments: Blank… Admission Summary/F2F (Face to Face) Addendum: …Patient reports not checking bs (blood sugar) regularly or taking insulin. Patient educated on monitoring feet daily and the importance of checking blood glucose… Care Coordination: Coordinated care with: … Physician, primary care… Regarding: POC…” The SN failed to notify the physician of not checking blood sugars and not taking insulin. A review of the agency policy on 7/31/25 titled “Case management/Coordination of care” (undated). The policy states, “1. The coordination of services occurs at start of care, at least every 30 days, at 60 days if recertification occurs and more frequently if the patient’s condition warrants. 2. All home care staff furnishing services will maintain liaison from admission to discharge to ensure that the patient receives care necessary for meeting specific outcomes.” The Administrator (Adm-1) and Clinical Manager (CM-1) reviewed and acknowledged the findings listed above in an interview on 8/1/25 at 1:05 pm.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summary was complete, provided the patient’s current health status at the time of discharge, progress toward goals, and included all ordered disciplines that provided care in 2 (Patient/P-6, Patient/P-7) of 6 closed records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-6: The start of care (SOC) date to home care was 8/1/24, with diagnoses that included diabetes-type 2, COPD (chronic obstructive pulmonary disease), and hypertension. On 7/31/25, record review noted P-6 had skilled nursing (SN) ordered 1W4 (once weekly times 4 weeks) and physical therapy (PT) with a visit frequency of 1W1, 2W5, 1W1. P-6 was discharged on 9/12/24 and review of the discharge (DC) summary revealed the following concerns. There was no documentation evidenced within the DC summary that acknowledged SN services were provided and how P-6 responded towards goal attainment concerning treatments/interventions and education that SN provided. Further, no information was found in the DC summary that detailed the status regarding P-6’s diabetes, COPD, and hypertension. P-7: The SOC date to home care was 1/3/25, with diagnoses that included diabetes-type 2, epilepsy, chronic respiratory failure with supplemental oxygen, and hypertension. On 7/31/25, record review noted P-7 had skilled nursing (SN) ordered 1W5 (once weekly times 5 weeks) and physical therapy (PT) with a visit frequency of 1W1, 2W6. P-7 was discharged on 2/17/25 and review of the discharge (DC) summary revealed the following concerns. There was no documentation evidenced within the DC summary that acknowledged SN services were provided and how P-7 responded towards goal attainment concerning treatments/interventions and education that SN provided. Further, no information was found in the DC summary that detailed the status, treatments/interventions provided (or lack of) regarding any of P-7’ medical diagnoses noted above. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 8/1/25 at 10:20 AM. The agency failed to provide the physician with a complete and comprehensive DC summary concerning the care provided and outcomes achieved and failed to adhere to its policy referenced below. Agency Policy: “Discharge Policy and Summary” (undated) pg. 1 stated, “To record a summary of care received by the client from the start of care through discharge. The discharge summary shall include, but not limited to: Services provided; Status upon admission; Status at time of discharge; Patient response to treatment ...””