Four Seasons Home Health Care

“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 ensure an emergency plan existed that was based on a documented facility and community-based risk assessment from an all-hazards approach, including strategies for the identified potential hazards (E0006); failed to ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years (E0013); failed to develop and maintain a communication plan for emergency preparedness, that contained methods of communication that would be used during an emergency, resulting in the inability to effectively communicate with staff and local and state officials (E0029); failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under arrangement, (iii) Patients’ physicians, (iv) Other [facilities], (v) Volunteers, as appropriate (E0030); failed to establish and effective Emergency Preparedness training and testing program that was based on policies and procedures, a risk assessment from an all-hazards approach and a communication plan that had been reviewed and updated at least every 2 years (E0036); failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of training’s (E0037); failed to provide documentation for the required community/facility based full-scale exercises and failed to provide documentation of an actual event that would qualify as a test of the emergency plan (E0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by 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.”

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient and legal representative was provided with written notice of rights and information on transfer and discharge policies that was given in a manner that could be understood (G412); failed to provide the patient and legal representative with the Administrator’s full contact information in a manner that could be understood (G414); failed to obtain the patient’s or legal representative’s signature as confirmation of receipt of notice of rights (G418); failed to ensure the patient or legal representative was provided with information regarding his right to lodge a complaint with the agency (G432); and, failed to ensure that patients were included in their overall planning of care including informing the patient/caregiver in advance of potential payment charges (G434). The cumulative effect of these systemic problems could potentially have a negative effect on all patients cared for by the home health agency if the pattern consists, for the Condition of Participation of 42 CFR §484.50, Patient Rights.”

“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, including strategies for the identified potential hazards, resulting in the potential for lack of preparedness and poor patient and staff outcomes, in the event of an actual emergency. Findings include: On 1/5/26 at 11:25 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the submitted handwritten documents dated 2023, 2024 and 2025 titled, “Hazardous Vulnerability Analysis” had been copied over from the previous years. The forms had the calendar year written on the top of each form, however, neither of the forms had been authenticated by the author. Upon further review of the agency’s Emergency Preparedness Plan, it was noted that none of the identified hazards had been included that would direct staff on what steps to take in an actual emergency. The agency failed to ensure its Emergency Preparedness Plan was based on a risk assessment from an all-hazards approach. The Administrator reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:25 a.m.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness policies and procedures had been reviewed and updated at least every 2 years, resulting in the potential for ineffective staff responses and poor patient outcomes in the event of a disaster. Findings include: On 1/5/26 at 11:25 a.m., the agency’s Emergency Preparedness (EP) documents were reviewed. During the review, it was noted that the agency’s EP policy was dated for calendar year 2014. The agency failed to ensure its Emergency Preparedness policies/procedures had been reviewed and updated at least every 2 years as per this requirement. The Administrator reviewed and confirmed these findings during an interview on 1/7/26 at 9:25 a.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, resulting in the inability to effectively communicate with staff and local and state officials, uncoordinated care and unmet care needs for all patients serviced by this agency in the event of a facility emergency or disaster. Findings include: On 1/5/26 at 11:25 a.m., the agency’s Emergency Preparedness documents were reviewed. Upon review, it was noted that the agency’s plan was void of methods that would be used to communicate with staff, patients and other state and local authorities in the event of an emergency. The Administrator reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:25 a.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 complied with Federal, State and local laws, resulting in the potential for lack of effective communication and the interruption in the provision of needed care and services in the event of an emergency or disaster. Findings include: On 1/5/26 at 11:25 a.m., the agency’s Emergency Preparedness Plan was reviewed. Upon review, it was noted that the plan was void of all staff names, entities providing services under arrangements, patient Physicians and any volunteers, as appropriate. The agency failed to ensure its Emergency Preparedness plan included all the elements, as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:25 a.m.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to establish and effective Emergency Preparedness training and testing program that was based on policies and procedures, a risk assessment from an all-hazards approach and a communication plan that had been reviewed and updated at least every 2 years. On 1/5/26 at 11:25 a.m., the agency’s Emergency Preparedness documents were reviewed. During the review, it was noted that the Plan was void of any language that addressed the testing and training program requirements. Upon further review, it was noted that the required language was present in the agency’s Emergency Preparedness policy, but the policy had not been reviewed or updated since 2014. The agency failed to establish an effective testing and training program as per this requirement. The Administrator reviewed and acknowledged these findings during an interview on 1/7/26 at 9:25 a.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 training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, as appropriate, and failed to maintain documentation of training’s, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services in the event of an emergency. Findings include: On 1/5/26 at 11:25 a.m., the Administrator was asked to provide evidence of initial training for all staff employed by the agency, including contracted staff, yet was unable to do so. During an interview on 1/7/26 at 9:25 a.m., the Administrator reported, “We took over the agency in 2020, but we didn’t begin to provide staff training until 2024.” The agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of trainings. The Administrator acknowledged the above findings at the time of discovery during the above interview.”

“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 15 patients currently serviced by this agency. Findings include: On 1/5/26 at 11:25 a.m., the agency’s Emergency Preparedness documents were reviewed. The Administrator presented a document titled “Emergency Mock Drill” dated 10/17/25 and another document titled “Power Outage in the Office” dated 10/1/25. There was no evidence of staff participation, including contracted staff. During an interview on 1/7/26 at 9:25 a.m., the Administrator reported, “We took over the company in 2020, but we didn’t begin providing any training in Emergency Preparedness until 2024.” When asked about the required community/facility-based drills, or any event that would satisfy a test of the agency’s emergency plan prior to 2025, the Administrator was unable to provide any additional documentation. The agency failed to conduct the required drills or provide documentation of an actual event in order to test their emergency plan prior to calendar year 2025. The Administrator acknowledged the above findings at the time of discovery.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 15 active patients, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: The agency’s Quality Assessment and Performance Improvement (QAPI) documentation was reviewed on 1/7/26. There was no documentation to support the agency’s performance improvement activities regarding their efforts to systematically monitor, analyze and improve patient outcomes. The QAPI binder contained documentation of gathering quarterly statistics, but had no additional data added, thus unable to quantitively demonstrate improvements. The Clinical Manager (CM #1) was questioned regarding QAPI indicators and process to measure on 1/7/26 at 9:05 am and stated, “I just look at the data from the last quarter and see if it met the goals…I do not track the data.” The agency failed to ensure their QAPI program was at least capable of showing measurable improvements in indicators to improve patient outcomes, safety and quality of care.”

“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 for 1 (P-1) of 1 patient observed during a home visit, resulting in the potential for the development and spread of infection. Findings include: Patient #1 (P-1)’s start of care was 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. The Plan of Care ordered Physical Therapy (PT) and Speech Therapy (ST) services to be provided. A scheduled survey home visit was conducted with the Physical Therapist (PT #1) on 1/6/26 at 10:00 a.m. During the visit, PT #1 checked the patient’s vital signs (blood pressure, temperature, pulse, oxygen saturation). After the assessment, PT #1 placed the equipment (blood pressure cuff, stethoscope, thermometer, pulse oximetry unit) in her work bag, however, PT #1 did not clean the equipment before placing the items in her work bag. Upon completion of the visit, PT #1 was queried as to why she failed to clean her equipment and replied with the question, “Even if I’m not going to see another patient?” PT #1 then asked, “What if I clean the equipment when I get to my car?” This writer explained the possibility of the potential spread of infection, with verbalized understanding. PT #1 failed to utilize infection control standards of practice during the provision of care. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:56 a.m.”

“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 initial infection control education for 1 of 9 sampled staff members, including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all 60 patients serviced by the agency in the past 12 months. Findings include: On 1/7/26 at 9:30 am, an interview was conducted with the Administrator (Adm #1) regarding infection control education of staff. During the interview, a query was made regarding when the Certified Home Health Aide (HHa #2) with a hire date of 7/1/25 received the “Hand Washing” education. Adm #1 stated, “The Aides receive their annual hand washing training in February.” There was no evidence HHa #2 had received hand washing education. This finding was reviewed on 1/7/26 at the time of the finding with Adm #1.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on personnel file review and interview, the agency failed to ensure its HHa (home health aide) services had the required 12 hours of in-services during each 12-month period for 2 (HHa-1 and HHa-2) of 2 HHa personnel files reviewed, resulting in a lack of educational training and the potential for unmet patient care needs. Findings include: On 1/6/26, the agency’s HHa personnel files (2 of 2) were reviewed. The in-service education documentation noted 12 separate trainings for the year 2025. However, none of the trainings had assigned time(s) to completion values. Subsequently, determination whether the 12-hour requirement was met could not be verified. This finding was reviewed and acknowledged by the agency’s Administrator and Clinical Manager during an interview on 1/7/26 at 12:02 PM.”

“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 for all patients serviced by this agency. Findings include: On 1/5/26 at 9:20 a.m. during the Entrance Conference, the Administrator (Adm #1) was asked what services were provided by the agency and responded, “Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) and Home Health Aide (HHa) services.” When asked if the agency utilized contracted employes, Adm #1 said, yes and said that RN, OT and PT were contracted services. When asked what skilled service (s) were directly provided by the agency, Adm #1 stated, SN, PT, HHa and ST services were direct hires. On 1/5/26 at 1:30 p.m., during a review of the agency’s contracts, it was noted that all disciplines were listed. The agency failed to ensure that at least one skilled qualifying service was a direct hire of this agency, as per this requirement. The Administrator reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:25 a.m.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient and legal representative was provided with written notice of rights and information on transfer and discharge policies that was given in a manner that could be understood for 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments, from a total of 7 sampled records reviewed. Findings include: Patient #1 (P-1) was a 98-year-old male who was admitted to the agency on 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. During the clinical record review on 1/5/26 at 2:25 p.m., it was noted that the patient was deemed legally blind and was hard of hearing bilateral ears. The Start of Care assessment documented, “Patient is legally blind; bilateral macular degeneration and hard of hearing both ears.” On 1/6/26 at 10:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that P-1 was visually impaired and presented with significant difficulty hearing. There were 2 male attendants present in the group home where P-1 resided. It was further noted that the 2 attendants had limited English speaking/comprehension abilities and had to have conversations repeated and restated in different ways in order to understand what was being said. This assessment was based on direct observation and conversation with one of the male attendants (MA #1). When asked for permission to review P-1’s admission packet, MA #1 did not understand the request. Gestures were then used to make the request and MA #2 retrieved the admission packet for review. During a continued review of the clinical record, it was noted that all P-1’s admission documents had been signed by MA #1 (male employee at the group home). There was no way to ascertain if P-1 had been provided with notice of rights or information on transfer and discharge policies, in a manner that could be understood, in light of his visual and hearing impairments, in addition to the male attendant’s (MA #1) language barrier. It was further noted that P-1 had an established Durable Power of Attorney (DPOA) on file to act as his legal representative. MA #1 was not listed as the DPOA; Nor any person authorized to sign documents on P-1’s behalf. The agency failed to provide evidence that P-1 or his legal representative was provided with written notice of rights and information on transfer and discharge policies, in a manner that could be understood. These findings were discussed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/6/26 at 1:25 p.m. to which Adm #1 responded, “The Speech Therapist even said she had a problem communicating with him (MA #1).””

“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 observation, interview and record review, the agency failed to provide the patient and legal representative with the Administrator’s full contact information in a manner that could be understood by 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments, resulting in the potential for unaddressed concerns and complaints. Findings include: Patient #1 (P-1) was a 98-year-old male who was admitted to the agency on 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. During the clinical record review on 1/5/26 at 2:25 p.m., it was noted that the patient was deemed legally blind and was hard of hearing bilateral ears. The Start of Care assessment documented, “Patient is legally blind; bilateral macular degeneration and hard of hearing both ears.” On 1/6/26 at 10:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that P-1 was visually impaired and presented with significant difficulty hearing. There were 2 male attendants present in the group home where P-1 resided. It was further noted that the 2 attendants had limited English speaking abilities and had to have conversations repeated and restated in different ways in order to understand what was being said. This assessment was based on direct observation and conversation with one of the male attendants (MA #1). When asked for permission to review P-1’s admission packet, MA #1 did not understand the request. Gestures were then used to make the request and MA #2 retrieved the admission packet for review. During a continued review of the clinical record, it was noted that all P-1’s admission documents had been signed by MA #1 (male employee at the group home). There was no way to ascertain if P-1 had been provided with the Administrator’s full contact information in light of his visual and hearing impairments, as well as the male attendant’s (MA #1) language barrier and limited English speaking and comprehension. It was further noted that P-1 had an established Durable Power of Attorney (DPOA) on file to act as his legal representative. MA #1 was not listed as the DPOA and was not authorized to sign documents on P-1’s behalf. The agency failed to ensure that P-1 or his legal representative was provided with the Administrator’s full contact information. These findings were discussed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/6/26 at 1:25 p.m. to which Adm #1 responded, “The Speech Therapist even said she had a problem communicating with him (MA #1). I’ll have to get a copy of the DPOA papers to keep on file here at the agency.””

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to obtain the patient’s or legal representative’s signature as confirmation of receipt of notice of rights for 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments. Findings include: Patient #1 (P-1) was a 98-year-old male who was admitted to the agency on 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. During the clinical record review on 1/5/26 at 2:25 p.m., it was noted that the patient was deemed legally blind and was hard of hearing bilateral ears. The Start of Care assessment documented, “Patient is legally blind; bilateral macular degeneration and hard of hearing both ears.” On 1/6/26 at 10:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that P-1 was visually impaired and presented with significant difficulty hearing. There were 2 male attendants present in the group home where P-1 resided. It was further noted that the 2 attendants had limited English speaking abilities and had to have conversations repeated and restated in different ways in order to understand what was being said. This assessment was based on direct observation and conversation with one of the male attendants (MA #1). When asked for permission to review P-1’s admission packet, MA #1 did not understand the request. Gestures were then used to make the request and MA #2 retrieved the admission packet for review. During a continued review of the clinical record, it was noted that all P-1’s admission documents had been signed by MA #1 (male employee at the group home). There was no way to ascertain if P-1 had been provided with notice of rights in light of his visual and hearing impairments as well as the male attendant’s (MA #1) language barrier and limited English. It was further noted that P-1 had an established Durable Power of Attorney (DPOA) on file to act as his legal representative. MA #1 was not listed as the DPOA or any person authorized to sign documents on P-1’s behalf. The agency failed to obtain signatures from the patient, or his legal representative as confirmation of receipt of notice of rights. These findings were discussed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/6/26 at 1:25 p.m. to which Adm #1 responded, “The Speech Therapist even said she had a problem communicating with him (MA #1).””

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient or legal representative was provided with information regarding his right to lodge a complaint with the agency for 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairments. Findings include: Patient #1 (P-1) was a 98-year-old male who was admitted to the agency on 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. During the clinical record review on 1/5/26 at 2:25 p.m., it was noted that the patient was deemed legally blind and was hard of hearing bilateral ears. The Start of Care assessment documented, “Patient is legally blind; bilateral macular degeneration and hard of hearing both ears.” On 1/6/26 at 10:00 a.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, it was noted that P-1 was visually impaired and presented with significant difficulty hearing. There were 2 male attendants present in the group home where P-1 resided. It was further noted that the 2 attendants had limited English speaking abilities and had to have conversations repeated and restated in different ways in order to understand what was being said. This assessment was based on direct observation and conversation with one of the male attendants (MA #1). When asked for permission to review P-1’s admission packet, MA #1 did not understand the request. Gestures were then used to make the request and MA #2 retrieved the admission packet for review. During a continued review of the clinical record, it was noted that all P-1’s admission documents had been signed by MA #1 (male employee at the group home). There was no way to ascertain if P-1 had been provided with information on how to lodge a formal complaint with the agency in light of his visual and hearing impairments as well as the male attendant’s (MA #1) language barrier and limited English comprehension. It was further noted that P-1 had an established Durable Power of Attorney (DPOA) on file to act as his legal representative. MA #1 was not listed as the DPOA or any person authorized to sign documents on P-1’s behalf. The agency failed to ensure the patient, or his legal representative were provided with information on how to lodge a complaint with the agency. These findings were discussed with the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 1/6/26 at 1:25 p.m. to which Adm #1 responded, “The Speech Therapist even said she had a problem communicating with him (MA #1).””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that 1 (P-1) of 1 patient observed during a home visit with visual and auditory impairment, and his legal representative was including in the overall planning of care; and, failed to ensure that 1 (Patient/P-7) patient was included in their overall planning of care including informing the patient/caregiver in advance of potential payment charges, from a total of 7 sampled records reviewed, resulting in a lack of inclusion in planning, lack of informed consent and unmet care needs. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 12/2/25. The Plan of Care (POC) identified diagnoses Vertigo, Atrial Fibrillation, Hypertension and Diabetes Type 2. During record review on 1/6/26, it was noted that the signed “Consent for Treatment” was blank under the sections “Assignment of Benefits” section that designates who will be responsible for payment of the services. The agency failed to notify the patient in advance of possible payments required. Additionally, the “Initial Services and Frequency” stated, “SN (Skilled Nursing) 1wk4 (1 time a week for 4 weeks). It was noted that the SN completed a total of 3 visits: 12/2/25, 12/8/25 and 12/18/25. The SN failed to complete the frequency that the patient consented to. A review of the agency policy occurred on 1/7/26 titled “Patient Bill of Rights” (Revised 2014). The policy states, “…To be notified in advance about the care that is to be furnished, the types (disciplines) of the caregivers who will furnish the care and the frequency of the visits that are proposed to be furnished…To be informed of the extent to which payment may be expected from Medicare, Medicaid or any other payor known to the Agency. To be informed of any charges that will not be covered by Medicare. To be informed of the charges for which the patient may be liable and to receive this information, orally and in writing, before care is initiated and within 30 calendar days of the date the Agency becomes aware of any changes...” The Administrator (Adm #1) and Clinical manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 1/7/26 at 11:30 am.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 1 (Patient/P-7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: Patient #7’s (P-7) Start of Care (SOC) was dated 12/2/25. The Plan of Care (POC) identified diagnoses Vertigo, Atrial Fibrillation, Hypertension and Diabetes Type 2. During record review on 1/6/26, it was noted that the SOC comprehensive assessment dated 12/2/25, documented under “Primary Diagnosis and Other Diagnoses”, all 14 diagnoses had an exacerbation date of 12/2/25. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. A review of the agency policy occurred on 1/7/26 titled “Initial Assessment/Comprehensive Assessments” (Revised October 2014). The policy states, “Procedure: 1. Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient’s current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes… 8. The Initial Comprehensive Assessment also includes: Relevant diagnoses, relevant medical history...Physical assessment/review of systems and pertinent physical findings...” The Administrator (Adm #1) and Clinical manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 1/7/26 at 11:30 am.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s activity of daily living needs were adequately met in the patient’s home for 1 (P-2) of 1 patient who required assistance with grooming, resulting in the potential for low self-esteem, poor hygiene and unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 2/24/25 with diagnoses that included Hypertension and Diabetes Mellitus. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Medical social Work (MSW) services to be provided. During the clinical record review on 1/5/26 at 4:00 p.m., it was noted that section M1800 of the Initial Comprehensive Assessment dated 2/24/25, completed by the SN revealed the patient required assistance with grooming, dressing and toileting hygiene. Section M1100 (supportive assistance) documented the patient lived with other persons in the home around the clock, however, there was no documented, willing or available caregiver to assist with grooming. Upon further review, there was no documented evidence that a home health aide had been provided or offered. The agency failed to ensure the patient’s activity of daily living needs were adequately met in the patient’s home. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:36 a.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient’s clinical record documented all medications with a complete reconciliation and interactions for 2 (Patient/P-3 and P-7) of 7 records reviewed. This deficient practice resulted in the potential for unrecognized side effects and complications that could affect all 15 patients currently serviced by the agency. Findings included: Patient #7’s (P-7) Start of Care (SOC) was dated 12/2/25. The Plan of Care (POC) identified diagnoses Vertigo, Atrial Fibrillation, Hypertension and Diabetes Type 2. During record review on 1/6/26, it was noted that the Electronic Medical Record (EMR) documented discrepancies from the hospital discharge instructions dated 11/25/25 and the medication profile. The missing medication from the hospital discharge instructions were Carvedilol 25mg bid (two times daily). The hospital discharge instructions contained Metformin 500mg bid and the medication profile contained Metformin 1000mg bid. Furthermore, the Skilled Nurse (SN) completed the comprehensive assessment on 12/2/25 and stated, “Physician Contacted Rd: SOC (Start of Care), POC (Plan of Care), Multiple drug interactions and refusal of OT (Occupational Therapy) service.” The medication profile completed on 12/2/25 by the SN stated, “Physician notified of severe medication interactions? Yes. Please explain: Blank.” There is no documented medication reconciliation completed with the physician to determine an accurate home medication regimen and what mediation interactions were reported to the physician and their response. A review of the agency policy occurred on 1/7/26 titled “Medication Reconciliation” (Revised October 2014). The policy states, “Procedure: 1. At time of admission, the admitting RN (Registered Nurse), PT (Physical Therapist), or SLP (Speech-Language Pathologist) will create and document a complete list of medications that patient is taking at home, including dose, route, and frequency. Any discrepancies will be reconciled by RN with the patient’s physician. Discrepancies include duplication, omissions, changes, contraindications and/or unclear information.” The Administrator (Adm #1) and Clinical manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 1/7/26 at 11:30 am. P-3 was admitted to the agency on 7/17/25 with a diagnosis of Parkinson’s disease, dysphagia, and urinary retention. On 1/6/26 during a home visit with SN (Skilled Nursing) at 12:18 PM, the following was noted while reviewing P-3’s current medications in the home. A medication discrepancy was found when comparing the medication list on P-3’s the current plan of care (POC) to the current medication list used at the AFC (Adult Foster Care) home. There was no evidence of Cariprazine (atypical antipsychotic medication) being listed and administered by the AFC. This finding was reviewed and confirmed by SN during an interview on 1/6/26 at 12:46 PM. The home care agency’s SN failed to ensure all the medications ordered matched the current medications being administered. This finding was reviewed and acknowledged by the administrator (ADM #1) and clinical manager (CM #1) during an interview on 1/7/26 at 12:15 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 that the agency failed to ensure the plan of care (POC) included patient specific measurable goals in 4 (Patient/P-3, P-4, P-5, P-6) of 7 records; and failed to ensure the POC provided clear instructions concerning safety precautions when drinking fluids in 1 (P-3) of 1 record reviewed with dysphagia, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals and insufficient safety precautions. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 12/2/25. The Plan of Care (POC) identified diagnoses Vertigo, Atrial Fibrillation, Hypertension and Diabetes Type 2. During record review on 1/6/26, it was noted that the goals on the POC were not measurable, for example the Skilled Nursing goals stated, “Patient will remain free of infection during this episode of care.” Additionally, another goal stated, “Patient skin integrity will remain intact during this episode.” There was no evidence of how these goals could be quantitatively measured. The Administrator (Adm #1) and Clinical manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 1/7/26 at 11:30 am. Patient #5 (P-5) was admitted to the agency on 10/16/25 with a diagnosis of cervicalgia (neck pain). On 01/07/26, a review of the Plan of Care (POC) effective 10/16/25, revealed 21 out of 21 listed goals were not written in objective measurable terms. For example, “Patient/Caregiver will demonstrate competence with self-management of Cervicalgia as evidenced by patient’s pain relief, improving function, adherence to medication regimen and no unplanned hospitalization by 11/01/2025. Another goal stated, “The Patient/Caregiver will verbalize/demonstrate understanding of fall prevention/safety as evidenced by patient no falls, no injury and no unplanned hospitalization by 11/01/2025. [sic] Patient #6 (P-6) was admitted to the agency on 4/03/25 for skilled nursing care with a primary diagnosis of a left heel, stage 3 pressure ulcer. On 01/07/26 a review of the Plan of Care (POC) effective 04/03/25 revealed the 25 out of 25 goals were not written in objective measurable terms. For example, one goal stated, “Wound(s) will heal without complication by 5.17.25.” Another goal stated, “Caregiver will demonstrate competence with self-management of Stage 3 Pressure ulcer as evidenced by adherence to treatment regimen, ability to identify s/s necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management and no unplanned hospitalization by 5.17.25.” [sic] During the interview on 1/7/26 at 1:30 PM with the administrator (ADM #1) and clinical manager (CM #1), both acknowledged the findings above and expressed understanding that without objective, measurable goals, progress toward intended outcomes cannot be assessed. Patient #3 (P-3) was admitted to the agency on 7/17/25 with a diagnosis of Parkinson’s disease, dysphagia, and urinary retention. On 1/6/26, a record review of P-3’s recertification (11/14/25 through 1/12/26) found P-3’s POC (effective 11/14/25), noted 16 of 16 listed patient goals were not written in objective measurable terms. Examples include: “Patient will be free from signs and symptoms of respiratory distress during the episode; Patient will remain free from increased confusion during the episode.” Further review of the POC found under SN (skilled nursing) “Orders and Treatments” the following documentation: “SN to instruct Patient/Caregiver on heart-healthy, mashed, thick liquid diet.” During a home visit with SN, it was noted SN confirmed with P-3’s caregivers that P-3 was still coughing and having positive signs of aspiration (when food/liquids enter the lungs). During a home visit interview with SN at 12:18 PM, it became evident that SN was unsure what level of thickening needed to be added to the patient’s liquid to mitigate the chances of aspiration. When the consistency of liquids in P-3 ‘s mug was checked with SN, it was acknowledged the consistency was thin like water. When asked what level the liquids should be thickened to, the SN was unaware and that the POC just said thickened with no specific level found. Patient #4 (P-4) was admitted to home care on 12/12/25 with a diagnosis of hypertensive heart disease with heart failure, osteoarthritis, and generalized muscle weakness. On 1/6/26, a record review of P-4’s POC (effective 12/12/25), noted 20 of 20 listed patient goals were not written in objective measurable terms. Examples include: “Patient will be free from signs and symptoms of respiratory distress during the episode; Patient will remain free from increased confusion during the episode.” During the interview on 1/7/26 at 12:10 PM, both the administrator (ADM #1) and clinical manager (CM #1) reviewed and acknowledged the findings above. CM #1 further acknowledged the POC expectation would be that the level of thickening would need to be specified for patient safety.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that Physical Therapy services were provided at the ordered frequency for 1 (P-2) of 6 patients who required therapy services and, failed to ensure that speech therapy (ST) performed an initial evaluation as ordered for 1 (Patient/P-3) of 2 records reviewed with speech therapy services, resulting in the potential for unmet care needs. Findings include: Patient #2 (P-2)’s start of care was 2/24/25 with diagnoses that included Hypertension and Diabetes Mellitus. The Plan of Care (POC) ordered Physical Therapy (PT) services to be provided at a frequency of 2x/wk. x 2 wks., 1x/wk. x 5 wks. During the record review on 1/5/26 at 4:00 p.m., it was noted that PT failed to conduct 3 of the 5 visits to be conducted weekly. PT then discharged the patient from the agency’s services on 3/25/25. There was no documented evidence that the Physician had been notified that the services had ended and no Physician’s order to end therapy prior to the ordered frequency. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:36 a.m. Patient #1 (P-1): The patient’s start of care date to home care was 7/17/25, with diagnoses that included dysphagia (difficulty in swallowing), BPH (Benign Prostatic Hyperplasia), and Parkinson’s disease. The plan of care ordered speech therapy (ST) services during a recertification period (effective 11/14/25) to perform an evaluation and treat. However, during record review on 1/6/25, it was noted that the ST evaluation occurred on the seventh day (11/20/25) after the recertification order. There was no documentation in the record indicating the patient had requested a delay in ST services or that the physician had been notified of this delay. During an interview on 1/7/25 at 11:57 AM, The agency’s Administrator and Clinical Manager reviewed and acknowledged the above findings. Both further acknowledged this did not meet agency expectations or its policy referenced below. Agency Policy: “Initial Assessments/Comprehensive Assessments” (Revised 2014) 9.6.1 stated, “PT, OT or SLP (Speech-Language Pathologist), if ordered by a physician, must conduct the Initial Evaluation within five (5) days after the “start of care” date ...””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-1) of 1 patient observed during a home visit with complaints of abdominal discomfort, resulting the potential for unidentified, untreated health concerns and unmet patient care needs. Findings include: Patient #1 (P-1)’s start of care was 11/24/25 with diagnoses that included Spinal Stenosis, Urinary Tract Infection and Heart Failure. The Plan of Care ordered Physical Therapy (PT) and Speech Therapy (ST) services to be provided. On 1/6/26 at 10:00 a.m., a scheduled survey home visit was conducted with PT #1. During the visit, the patient (P-1) exhibited facial grimaces and complained of discomfort related to not having a bowel movement in the past 3 days. P-1 stated, “They (group home staff) gave me cereal and milk this morning and it filled me up.” PT #1 proceeded with the therapy session. Upon completion of the visit, PT #1 did not notify the Physician. On 1/7/26 at 9:00 a.m., during a review of the PT visit notes, there was no documented evidence that PT #1 had promptly notified the Physician of P-1’s complaints of abdominal discomfort. An interview was conducted with the Administrator (Adm #1) and the Clinical Manager (CM #1) on 1/7/26 at 9:56 a.m. During the interview, CM #1 stated, “PT #1 texted me last night and I told her to notify the doctor and to document it.” During the interview, Adm #1 reviewed the clinical record and confirmed there was no documentation of Physician notification. At the conclusion of the survey, there was no documented evidence that PT #1 promptly notified the Physician of P-1’s abdominal discomfort related to not having a bowel movement in 3 days. Additionally, there was no documented evidence that CM #1 notified the Physician once becoming aware of the patient’s concerns. Adm #1 and CM #1 reviewed and acknowledged the above findings during the above interview on 1/7/26 at 9:56 a.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 folder/patient handbook, resulting in the potential for unaddressed patient concerns. Findings include: On 1/5/26 at 10:55 AM, the agency’s admission folder/patient handbook was reviewed. Upon review, it was noted there was no contact information for the Agency’s Clinical Manager. The administrator (ADM #1) acknowledged and verified findings at time of discovery. During an interview with ADM #1 and (clinical manager) CM #1 on 1/7/26 at 1:15 PM, both acknowledged the findings noted above.”

“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 that services were provided as ordered by the Physician and in the Plan of Care for 1 (P-1) of 2 patients who required Speech Therapy services, resulting in the potential for worsening health conditions and unmet patient care needs. Findings include: Patient #1 (P-1)’s start of care was 11/24/25 with diagnoses that included Spinal Stenosis and Heart Failure. The Plan of Care (POC) ordered Physical Therapy (PT) and Speech Therapy (ST) services to be provided. On 1/5/26 at 2:25 p.m., during the clinical record review, it was noted that the POC ordered the patient to receive ST services and ordered, “ST to eval (evaluate) and treat for swallowing.” During a review of the ST initial evaluation dated 12/12/25 and the ST discharge summary dated 12/30/25, it was noted that the documentation read, “Safe swallowing evaluation - No.” The Speech Therapist failed to conduct the swallowing evaluation as ordered. The Administrator and Clinical Manager reviewed and acknowledged the above findings during an interview on 1/7/26 at 9:56 a.m.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the clinical record was complete, including assessments, communication notes and evaluations for 1 (Patient/P-3) of 1 record reviewed with ER (emergency room) admission, resulting in an incomplete depiction of the patient’s health status, and the potential for unmet care needs. Findings include: Patient #3 (P-3) was admitted to the agency on 7/17/25 with a diagnosis of Parkinson’s disease, dysphagia, and urinary retention. During a home visit (HV) with SN (Skilled Nursing) on 1/6/25 at 12:24 PM, the surveyor/writer was told by SN last Friday (1/2/26) that P-3’s peg tube (tube used for nutritional intake) had become plugged and family had requested a PRN (as needed) evening home visit to evaluate and potentially treat. SN told the family to take P-3 to the ER since he was away providing patient care and would not be able to come over right away. P-3’s daughter/MPOA (medical power of attorney) declined until the morning of 1/3/26 to take P-3 into the ER. On 1/7/26 at 12:45 PM (day of survey exit), no evidence was found in the medical record that the above had occurred. Communication notes and physician notification concerning the above were not found in the medical record. In addition, documented efforts to obtain P-3’s ER findings such as treatments, interventions and discharge instructions were also not found. During the interview on 1/7/26 at 12:22 PM, both the administrator (ADM #1) and clinical manager (CM #1) reviewed and acknowledged the findings above. Both acknowledged this did not meet agency expectations and that utilization of their EMR’s (electronic medical records) communication section would begin. Earlier in the survey on 1/6/26 at 3:20 PM, ADM #1 stated the agency uses verbal updates on cell phones for overall patient concerns instead of documenting in the EMR’s communication notes section. The agency failed to ensure the medical record was updated timely to incorporate pertinent information concerning patient care and SCIC’s (significant changes in condition).”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to send the discharge summary of care, within 5 days of discharge as required, in 2 (Patient/P-3 and P-6) of 3 records with discharge, resulting in the physician not having timely clinical information concerning the outcomes of home care services provided and the potential for unmet patient needs for all 15 patients currently receiving home care services. Patient #6 (P-6) was admitted on 06/02/25 for Physical Therapy (PT) services with the primary diagnosis of hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke). On 01/07/26, the record review noted P-6 was discharged from PT services on 07/09/25. The discharge summary was faxed to the physician on 07/18/25, 9 days after discharge. During the interview with the agency’s administrator (ADM #1) on 01/07/26 at 1:33 PM it was confirmed that the discharge summary was not sent to the physician within 5 days of the patient’s discharge. P-3 was admitted to the agency on 7/17/25 with a diagnosis of Parkinson’s disease, dysphagia, and urinary retention. The plan of care (POC) ordered ST (speech therapy) services to re-evaluate and treat effective 11/14/25. ST performed an evaluation on 11/19/25 and completed the ST discharge summary for P-3 on 11/20/25. Further record review found the agency sent the discharge summary to the physician on 12/3/25, which is 13 days after it was made available for physician review. This is 8 days beyond the required 5-day requirement. The above finding was reviewed and acknowledged by the agency’s administrator and clinical manager during an interview on 1/7/26 at 12:42 PM.”