Atlantic Home Health Care, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every 2 years (E0004); failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach (E0006); failed to ensure their emergency preparedness policies and procedures were reviewed and updated at least every 2 years (E0013); failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment (E0017); failed to develop an Emergency Preparedness Policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs (E0024); failed to develop and maintain a communication plan for emergency preparedness that included methods of communication and strategies that had been updated at least every 2 years (E0029); failed to develop and maintain an emergency preparedness communication plan that had been reviewed/updated at least every 2 years and included contact information for all current staff, patient’s physicians, and volunteers, as appropriate (E0030); 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 (E0037); and, failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by 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: The Condition of Participation has not been met. Based on interview and document review, the Agency failed to develop a Quality Assessment and Performance Improvement Program that measures, tracks, and analyzes quality indicators to assess quality, processes of care, and services for the agency. Findings included: Based on record review and interview, the agency failed to develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. On 8/1/2025, the Administrator was asked to provide documentation of the agency’s Quality Assessment and Performance Improvement Program (QAPI). The Administrator provided a document titled “Home Care QAPI Annual Evaluation Tool” with a grading process of met or not met. This document did not have the year of the QAPI evaluation tool. Page 5 was completely blank of information including the date the review was completed, the signature of the QAPI Coordinator, the Governing Board member’s signature, and the date of the review were also blank of information. The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency due to the agency had not analyzed the services provided by the agency regarding Quality Assessments and Performance Improvement for the Condition of Participation at 42 CFR §484.65, Quality Assessment and Performance Improvement.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan that had been reviewed and updated at least every 2 years resulting in lack of direction for agency personnel in the event of an actual emergency or disaster. Findings include: On 7/30/25 at 12:30 p.m., the agency’s Emergency Preparedness documentation was reviewed. During the review, it was noted that the agency’s plan had not been updated since 4/2022. There was no documented evidence that showed the agency had developed an Emergency Preparedness plan that had been reviewed/updated in accordance with the requirements of this section. The Administrator reviewed and confirmed these findings during an interview on 8/1/25 at 1:05 p.m.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 7/30/25 at 12:30 p.m., the agency’s Emergency Preparedness documents were reviewed. The Risk Assessment document was noted to be blank. During the review, Adm #1 s stated, “Nothing has been done.” The Administrator reviewed and confirmed the above findings at the time of discovery during the review.”

“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 their emergency preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the agency’s inability to ensure staff actions during an emergency aligned with current practices and guidelines. These practices could negatively affect the health and safety of the agency’s 11 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency’s Emergency Preparedness documents were reviewed on 7/30/25 at 12:30 p.m. During the review, the Emergency Preparedness policy was requested. Upon receipt, it was noted that the presented document titled, “Home Health Chapter V-Emergency Preparedness Plan” was noted to have been revised 11/2017. The agency failed to ensure its Emergency Preparedness Plan had been updated at least every 2 years as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 1:05 p.m.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review, and interview, the agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 2 (P-4, P-5) records of patients who required individualized assessments in Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for overlooked patient needs in the event of an actual emergency for all patients services by this agency. Findings include: Patient #4 (P-4)’s start of care (SOC) was 12/14/24 with diagnoses that included Congestive Heart Failure and Osteoarthritis Bilateral Knees. During the record review on 7/30/25 at 1:50 p.m., there was no completed individualized patient Emergency Preparedness Assessment that would aid staff in assisting the patient in the event of an emergency. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 8/1/25 at 12:05 p.m. P-5’s SOC was 7/18/25 with diagnoses that included Osteoarthritis Bilateral Knees, Hypertension and Cervicalgia. During the record review on 7/30/25 at 4:00 p.m., it was noted that the patient’s Emergency Preparedness Assessment was incomplete. The section that addressed the category of patient needs in the event of an emergency was left blank. Adm #1 reviewed and acknowledged these findings during an interview on 8/1/25 at 12:20 p.m.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an Emergency Preparedness Policy/Plan, that included the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs, resulting in the potential for the interruption in needed care and services for staff and all 11 patients currently serviced by this agency. Findings included: A review the agency’s Emergency Preparedness documents was conducted on 7/30/25 at 12:30 p.m. During the review, it was noted that there was no specific language that included a process for the integration or use of volunteers, as appropriate, or other staffing strategies with local, regional, State, and Federal officials to address surge needs during an emergency. The Administrator reviewed and acknowledged these findings during an interview on 8/1/25 at 1:05 p.m.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain a communication plan for emergency preparedness that included methods of communication and strategies that had been updated at least every 2 years, resulting in the inability to communicate with staff and officials in the event of an actual disaster, and the potential for uncoordinated care for all 11 patients currently serviced by this agency in the event of a facility emergency or disaster. Findings include: On 7/30/25 at 12:30 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the agency’s communication Plan had not been updated since 4/2022. There were no updated methods identified in which staff and patients would communicate in the event of a disaster. The Administrator reviewed and acknowledged these findings during an interview on 8/1/25 at 1:05 p.m.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that had been reviewed/updated at least every 2 years and included contact information for all current staff, patient’s physicians, and volunteers, as appropriate, resulting in the 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 12:30 p.m., it was noted that there was no contact information for all current staff, contracted agencies, patient’s physicians, or volunteers as appropriate. The Administrator reviewed and confirmed these findings during an interview on 8/1/25 at 1:05 p.m.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, 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 12:30 p.m., The agency’s Administrator was asked to provide evidence of initial and ongoing training for all staff employed by the agency, including contracted staff, yet was unable to do so. Adm #1 reported, “Nothing has been done.” The Administrator acknowledged the findings during the above request.”

“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. Findings include: During a review of the agency’s Emergency Preparedness documents on 7/30/25 at 12:30 p.m., it was noted that there was no evidence the agency had conducted any training or exercises to test the agencies 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. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 1:05 p.m.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its skilled discipline honored the ordered visit frequency for 1 (P-4) of 7 sampled records reviewed, resulting in the patient not receiving care according to their identified needs and the potential for unmet care needs. Findings include: Patient #4 (P-4)’s start of care was 12/14/24 with diagnoses that included Congestive Heart Failure and Osteoarthritis Bilateral Knees. The Plan of Care ordered Physical Therapy (PT) services at a frequency of 1w1, 2w1, 1w4. During the record review on 7/30/25 at 1:50 p.m., it was noted that the patient requested a start date of 12/18/24. Upon further review, PT did not begin services until 12/27/24. There was no documented rationale for the additional delay in needed services. There was no evidence that the patient requested to further delay PT services, or that the Physician had been notified. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:05 p.m.”

“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 document review and interview, the agency failed to collect data to monitor and measure indicators to use in it’s QAPI program based on agency processes and negative patient outcomes. Based on record review, document review and interview, the agency failed to measure, track, and analyze quality indicators in order to assess processes of care and services, resulting in the inability to determine the scope of services provided. During a review of the QAPI documents provided by the agency on 7/29/2025, it was noted there was no collection of data used to monitor and measure indicators the agency deemed needing improvement included in the agency’s QAPI program. These findings were reviewed and confirmed at 3:30 p.m. on August 1, 2025 with the Administrator.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to include program data in the agency QAPI Program. Findings included: During a review of the QAPI meeting minutes dated 7/20/2022, it was noted the minutes had instructions on the use of a Quality Assessment/Program Improvement program, but no collected data was included for evaluation. During a review of the QAPI meeting minutes dated 7/20/2022, it was noted the minutes had instructions on the use of a Quality Assessment/Program Improvement program, but no collected data was included for evaluation.These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review and interview the agency failed to focus on high risk, high volume, or problem-prone areas, failed to consider incidence, prevalence, and severity of problems in those areas that lead to immediate correction of any identified problems that directly or potentially threaten the health and safety of patients. On August 1, 2025, the agency Quality Assessment and Performance Program was reviewed. Upon review, it was noted that the QAPI program lacked any data relating to high risk, high volume or problem areas. The data consisted of instructions on how to perform QAPI. There were 10 records audited, 6 active and 4 discharged or closed records between the dates of 1/1/2022 and 6/30/22. The QAPI Program documentation consisted of the statement “the agency was below national average for bathing, upper and lower body dressing, bed transfers, ambulation, management of oral meds, dyspnea, toilet transfer, bowel incontinence, and confusion frequency. There was no data provided to confirm this information. These findings were reviewed and confirmed at 3:30 p.m. on August 1, 2025 with the Administrator.”

“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 track adverse patient events, analyze their causes, and implement actions. There was no data documented of incidents that included negative and unexpected events that had the potential to cause decline in a patient’s condition in the agency QAPI program; nor was there a statement that indicated that no adverse patient events had occurred. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”

“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, the agency failed to ensure at least one performance improvement project was in development, on-going, or completed. During an interview with the Administrator on 7/31/2025, the Administrator was queried regarding the agency’s current performance improvement project. The administrator stated that currently they were performing chart reviews. There was no further information provided regarding a performance improvement project in development, on-going, or completed. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”

“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, the governing body failed to assume overall responsibility for ensuring that the QAPI Program reflects the complexity of the Home Health Agency and its services, involves all services, focuses on indicators related to improved outcomes, and takes actions that address the HHA’s performance across the spectrum of care. On 7/31/2025 the Governing Board Meeting Minutes were reviewed. The Meeting Minutes were dated 1/29/2019. The Administrator was asked if there were any further documented Governing Board Meeting minutes available to review. The administrator stated “yes” and provided the Governing Board Meeting Minutes dated 6/20/2018. The Administrator was asked to provide all Governing Board Meeting minutes for 2017 through 2025. Upon review of the meeting minutes, it was noted there was no approvals for any of the QAPI programs during the years 2017 through 2025. These findings were reviewed and confirmed at 3:30 p.m. on August 1, 2025 with the Administrator. .”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its skilled discipline utilized Infection Control standards of practice during the provision of care and services for 1 (P-5) of 3 patients observed during a home visit from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: Patient #5 (P-5)’s start of care was 7/18/25 with diagnoses that included Left Hip Replacement. On 7/31/25 at 10:00 a.m., a scheduled joint survey home visit was conducted with the Licensed Practical Nurse (LPN #1). During the visit, LPN #1 assessed the patient’s vital signs (blood pressure, temperature, oxygen saturation), lung sounds and bowel sounds. After assessing the patient, LPN #1 placed her equipment (blood pressure cuff, thermometer, pulse oximeter unit) on the patient’s table. Upon completion of the visit, LPN #1 placed her equipment in her work bag. LPN #1 did not clean her equipment prior to placing the items in her work bag. LPN #1 then exited the patient’s home and went to sit in her car. When queried as to why she (LPN #1) did not clean her equipment prior to placing the items in her work bag, LPN #1 stated, “Oh, I was just cleaning them when I got to my car.” LPN #1 failed to utilize Infection Control standards of practice. The Administrator reviewed and acknowledged these findings during an interview on 8/1/25 at 12:20 p.m.”

“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 develop an effective 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. Findings included: On 7/29/2025 The Administrator (ADM#1) was asked to provide all documents related to the agency Quality Assessment an Performance Improvement (QAPI) program. During a review of the agency’s documents, it was noted the program was void of any collected data for surveillance, identification, and investigation of infectious and communicable diseases. This finding was reviewed and acknowledged by the Administrator on 8/1/25 at 1:00 p.m.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include contact information for the Home Health Agency’s Administrator in the Patient Admission/Orientation Packets, resulting in the potential for unaddressed concerns. Findings include: On 7/30/25 at 10:35 a.m., the agency’s Admission Packet (for Physical Therapy openings) was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms. Upon further review, there was no contact information for the agency’s Administrator. The Administrator reviewed and acknowledged these findings during an interview on 8/1/25 at 1:05 p.m..”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Registered Nurse conducted the Initial Comprehensive Assessment within 48 hours of the date of referral for 3 (P-1, P-2, P-7) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: Patient #7 (P-7)’s start of care was 7/11/25 with diagnoses that included Uncontrolled Hypertension, Hip Pain and Osteoarthritis. During the record review on 7/31/25 at 2:40 p.m.., it was noted that the referral for home care was dated 5/14/25 and ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The SN did not conduct the Initial Comprehensive Assessment until 7/11/25. This was 58 days after the date of the referral. There was no documented rationale for the delay in services and no evidence that the patient declined or requested that services be delayed. Additionally, there was no documented evidence that the Physician was made aware of the delay in the provision of services. The Administrator reviewed and confirmed the above findings during an interview on 8/1/25 at 12:55 p.m. P-1: The Start of Care was dated 7/8/2025. The Plan of care for the certification period 7/8/25 to 9/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis of knee. The patient was receiving Skilled Nursing services 1xweekx5 weeks, and Physical Therapy Services 1xweekx1 week. Upon review of the record, it was noted the referral was dated 6/27/2025, however, the Start of Care Assessment was dated 7/8/2025, seven days after the date of referral. Further review of the record failed to find any communication or physician order relating to a delayed Start of Care Date, or requests from the patient for a delay in the Start of Care. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapist conducted the Initial Comprehensive Assessment within 48 hours of the date of referral for 1 (P-6) of 1 record reviewed with PT services only ordered, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: Patient #6 (P-6)’s start of care was 7/11/25 with diagnoses that included Lumbago with Sciatica and Left Hip Pain. During the record review on 7/31/25 at 1:50 p.m.., it was noted that the referral for home care was dated 7/17/25 and ordered Physical Therapy (PT) services to be provided. The PT did not conduct the Initial Comprehensive Assessment until 7/29/25. This was 12 days after the date of the referral. There was no documented rationale for the delay in services and no evidence that the patient declined or requested that services be delayed. Additionally, there was no documented evidence that the Physician was made aware of the delay in the provision of services. The Administrator reviewed and confirmed the above findings during an interview on 8/1/25 at 12:45 p.m.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure Activity of Daily Living needs were adequately met in the patient’s home for 1 (P-4) of 1 patient assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline, and unmet care needs. Findings include: Patient #4 (P-4)’s start of care was 12/14/24 with diagnoses that included Congestive Heart Failure and Osteoarthritis Bilateral Knees. The Plan of Care ordered Skilled Nursing and Physical Therapy services to be provided. During the record review on 7/30/25 at 1:50 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment dated 12/14/24 indicated that the patient required assistance with grooming, dressing and toileting hygiene, was chairfast and required human assistance. The section titled, “Supportive Assistance” was void of a willing and available caregiver. Upon further review, there was no documented evidence that a Home Health Aide was offered or provided to assist with grooming needs. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:05 p.m.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions, reportable parameters, and objectively measurable goals specific to the needs of the patient for 5 (P-1, P-2, P-3, P-4, P-7) of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: Patient #4 (P-4)’s start of care (SOC) was 12/14/24 with diagnoses that included Congestive Heart Failure and Osteoarthritis Bilateral Knees. During the clinical record review on 7/30/25 at 1:50 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The POC was void of any interventions, reportable parameters or associated measurable goals that addressed the patient’s diagnosis of Congestive Heart Failure. The Administrator (Adm #1) reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:05 p.m. P-7’s SOC was 7/11/25 with diagnoses that included Uncontrolled Hypertension, Hip Pain and Osteoarthritis. During the record review on 7/31/25 at 2:40 p.m., it was noted that the POC ordered SN and PT services to be provided. The SN interventions listed in the POC were vague such as “SN to assess cardiovascular status, identify any signs and systems of impaired cardiovascular function..., SN to instruct patient on disease process.” There was no mention of what signs to look for or what disease process was taught. The SN goals were not measurable such as, “Patient/caregiver will be able to demonstrate pain relief measures to mitigate pain within 5 weeks of care.” There was no quantitative/measurable pain goal listed. The POC further documented, “Patient/caregiver will verbalize understanding and demonstrate compliance with prescribed care to improve health status and minimize long-term debilitating diabetes complications within 5 weeks of care.” There was no documented evidence of how these goals would be attained. Adm #1 reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:55 p.m. P-1: The Start of Care was dated 7/8/2025. The Plan of care for the certification period 7/8/25 to 9/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis of knee. The patient was receiving Skilled Nursing services 1xweekx5 weeks, and Physical Therapy Services 1xweekx1 week. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable. Examples included: “Patient/Caregiver will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse, or 911 within 5 weeks of care; Patient/Caregiver will be able to demonstrate pain relief measures to mitigate pain within 5 weeks of care; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by the physician. These goals are not specific to the patient’s needs or objectively measurable to determine the patient’s progress towards obtaining the goals. P-2: The Star of Care was dated 6/19/2025. The Plan of Care for the certification period 6/19/25 to 8/17/25 identified diagnoses of Bilateral Primary Osteoarthritis of the Knee; Hypertensive and Chronic Kidney Disease with Heart Failure, stage 5 (CKD); Type 2 Diabetes with Diabetic Neuropathy (DM2), Chronic Combined Systolic and Diastolic Heart Failure (CHF). The patient was receiving Skilled Nursing and Physical Therapy services. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals throughout the course of care. Examples included: “Patient/Caregiver will demonstrate ability to manage pain medication regimen within 5 weeks of Care; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by Physician; Patient/Caregiver will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 within 5 weeks of care. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-3: The Start of Care was dated 3/13/2025. The Plan of Care for the certification period 3/13/25 to 5/11/25 identified diagnoses of Type 2 diabetes (DM2), Hypertensive Heart Disease without heart failure (HHD), Bilateral osteoarthritis of knee (OA), Schizophrenia, Hypothyroidism, Abnormal gait and mobility, Asthma with acute exacerbation, Pain in low back, right and left knees, right and left lower legs. The patient was receiving Skilled Nursing (SN) 1xweekx5weeks and evaluation and treatment by Physical Therapy (PT) services. Upon review of the Plan of Care, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals throughout the course of care. Examples Included: “Patient/Caregiver will demonstrate knowledge of pain medication and proper administration within 6 weeks of care {sic}; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician; Patient/Caregiver demonstrate competence with self-management of hypertension as evidenced by adherence to medication regimen, ability to identify signs/symptoms necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management within 5 weeks of care. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include contact information for the Home Health Agency’s Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 7/30/25 at 10:35 a.m., the agency’s Admission Packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice, patient rights and responsibilities forms and Emergency Preparedness documents. Upon further review, there was no contact information for the Agency’s Clinical Manager. The Administrator reviewed and confirmed the above findings during an interview on 8/1/25 at 1:05 p.m.”

“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 Physical Therapy services were provided as ordered for 1 (P-5) of 7 records with Physical Therapy services ordered from a total of 7 sampled records reviewed, resulting in the potential for physical decline, and unmet care needs. Findings include: Patient #5 (P-5)’s start of care was 7/18/25 with diagnoses that included Hypertension, Osteoarthritis and Cervicalgia. The referral for home care was dated 7/2/25 and ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. On 7/30/25 at 4:00 p.m., during the clinical record review, it was noted that PT services had not yet begun. There was no documented evidence that the patient refused services. The agency failed to ensure services were provided as ordered by the Physician. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:20 p.m.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure there was a written contract established with/for individuals who were granted clinical privileges and provided home health services to the agency’s patients, resulting in lack of administrative responsibility, patient oversight and the potential for poor patient outcomes. Findings include: On 7/30/25 at 11:08 a.m., during the Entrance conference, the Administrator (Adm #1) was asked what services the agency provided and responded, “Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW) and Home Health Aide (HHa) services. We use Top Health Care Staffing. We haven’t had an MSW or ST case in a while. Our last patient was to receive HHa services, but they declined.” When asked what services/s were direct hires of the agency, Adm #1 reported, “Nursing. All other services are contracted.” On 7/31/25 at 2:00 p.m., 3:40 p.m. and again at 4:02 p.m., a request was made to review the agency’s contract. Adm #1 initially stated she was unable to locate the staffing agency’s contract. At 4:07 p.m., the Office Manager (OM #1) presented a contract for Strategic Health Care Staffing. The contract was dated 5/24/18 and included the provision of PT, OT, HHa and ST services. At 4:20 p.m., Adm #1 was observed with a document titled, “Top Healthcare Staffing, LLC” that stated, “This agreement is made this 1 day of Jan 2024...” The contract made provisions for PT, OT and ST services to be provided. The document had not been signed or dated by the contracting company. Adm #1 then acknowledged, “I don’t have a current contract. They changed their names from Strategic to Top Healthcare. The members parted ways, and I haven’t had time to establish a new contract. I was just going to do it now.” The agency failed to ensure there was a written agreement established with individuals who provided services under arrangement and who were granted clinical privileges. Adm #1 reviewed and acknowledged the above findings at the time of discovery.”

“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 summaries were complete, provided the patient’s current health status at the time of transfer, progress toward goals, and forwarded to the Physician within 5 days of the date of discharge in 2 (P-3 and P-4) of 2 records in which the patient was discharged from the agency’s services, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #4 (P-4)’s start of care was 12/14/24 with diagnoses that included Congestive Heart Failure and Osteoarthritis Bilateral Knees. The clinical record review was conducted on 7/30/25 at 1:50 p.m. The plan of care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. During the review, it was noted that the patient was discharged from SN services on 1/10/25. The SN Discharge Summary dated 1/10/25 was void of a summary of care that detailed the course of care provided with responses and the patient’s overall health status at the time of discharge. Further, the patient was discharged from PT services on 1/29/25. There was no documented evidence that the SN or PT Discharge Summaries were sent to the Physician within 5 days of the date of discharge. The Administrator reviewed and acknowledged the above findings during an interview on 8/1/25 at 12:05 p.m. P-3: The Start of Care was dated 3/13/2025. The Plan of Care for the certification period 3/13/25 to 5/11/25 identified diagnoses of Diabetes type 2, Hypertensive Heart Disease without Heart Failure, Bilateral primary osteoarthritis of knee, ADHD (Attention-deficit hyperactivity disorder), Schizophrenia, Hypothyroidism, abnormal gait, Asthma, and Pain in lower-back, pain in right and left knees, pain in right and left lower leg. The patient was receiving Skilled Nursing (SN) services 1xweekx5 weeks, and Physical Therapy (PT) Services. This patient was discharged from the agency on 4/17/2025. Upon review of the record, it was noted the following areas of the discharge summary were blank of information: Cardiac Status and Genitourinary Status for this patient with diagnosis of Hypertensive Heart Disease and Heart Failure. In addition, there was no documentation found in the record that the Discharge Summaries for Skilled Nursing and Physical Therapy Services were sent to the Physician within 5 days of the date of discharge. These findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 8/1/25 at 1:30 p.m.”