American Nursing 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 (EP) plan that must be reviewed and updated at least every 2 years (See E 0004); failed to develop and maintain an EP plan that was based on both agency-based and community-based risk assessments (See E 0006); failed to ensure their emergency plan includes a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency (See E 0009); failed to develop written EP policies and procedures that were based on an EP plan, risk assessment, and communication plan (See E 0013); failed to develop EP policies/procedures that addressed the use of volunteers or other emergency staffing strategies during an emergency (See E 0024); failed to develop and maintain an EP communication plan that complies with Federal, State, and local laws, and must be reviewed and updated at least every 2 years (See E 0029); failed to ensure its EP plan documented a means to provide information concerning the agency’s needs, and its ability to provide assistance to the local Incident Command Center or designee (See E 0034); failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan (See E 0036); and failed to perform testing of their EP program as required (See E 0039). 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 are not properly prepared for an emergency for the Condition of Participation of 42 CFR §484.102, Emergency Preparedness.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Quality Assessment and Performance Improvement (QAPI) program documented actions to measure, track and analyze quality indicators for improvement of patient care services (See G 642); failed to develop a program of relevant data collection used to monitor safety and effectiveness of services provided, and failed that all data collection was approved by the Governing Board (GB) (See G 644); failed to develop performance improvement activities that were based on high risk, problem-prone areas affecting the quality of patient care services (See G 646); failed to develop performance improvement activities to track and trend adverse patient events, analyze potential causes and implement preventive interventions (See G 654); failed to take actions geared for performance improvement and then monitor any improvements made are sustained (See G 656); failed to develop the required performance improvement projects with reasoning why they were chosen (See G 658); and failed to ensure its GB assumed overall responsibility for the regulatory requirements needed for a QAPI program (See G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.65 – Quality Assessment and Performance Improvement (QAPI).”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aides were qualified to provide home health aide service (See 754), failed to ensure the home health aide competency evaluation addressed each of the subjects listed in paragraph (b)(3)(1), (iii), (ix), (x), and (xi) of this section and completed through observation, the aide’s performance of each task, with a patient by a registered nurse prior to being deemed competent as described in this section (See G768), failed to maintain documentation of competency evaluations (See G772), failed to maintain documentation of the required 12 hours of annual Home Health Aide in-services (See 774). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of safe and quality services by competent home health aides, for all patients receiving aide services, for the Condition of Participation of 42 CFR §484.80, Home Health Aide Services.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included all clinical notes and complete medical record (See G1012); and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge and 2 days of transferring to an inpatient facility, resulting in the potential for unidentified continuing health care concerns and unmet care needs (See G1022); and failed to ensure documents in the clinical records were complete and appropriately authenticated with a signature and title, dated, and timed (See G1024). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.110 Clinical Records.”

“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 (EP) plan that must be reviewed and updated at least every two years, resulting in no directions for agency personnel in the event of an actual emergency or disaster and the potential for poor patient outcomes. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder revealed the agency’s Administrator (Staff-A) last reviewed policies and procedures on 7/16/25. However, further review found the last all-hazards risk assessment (HRA) was conducted on 1/3/22, which the agency’s EP plan is based on. In addition, no EP drills or testing exercises of the EP plan had occurred since 11/12/21. Also, the EP communication plan has had 1 (Director of Nursing) of 2 names listed incorrectly since the “Fall of 2024” per Staff-A during an interview on 7/6 26 at 10:20 AM. The agency’s last Governing Body meeting minutes (no signatures) were on 7/16/25 which documented, “Annual agency evaluation and HRA reviewed with no revisions made.” Subsequently, credit could not be given for the 7/16/25 policy/procedure approval due to the deficient findings above. During an interview on 7/8/26 at 1:56 PM, the above findings were reviewed with and acknowledged by Staff-A.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness (EP) plan that utilized and incorporated a facility and community-based all-hazards risk assessments, resulting in the potential for staff being unprepared to respond effectively during an actual or simulated emergency and the potential to negatively affect the health and safety of all patients currently serviced by this agency. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder found no evidence that the agency had assessed and updated its facility and community-based risk assessments which are required at least every 2 years, since 1/3/22. Findings of collaborative efforts to participate with other healthcare entities at the community level to promote an integrated response were not evidenced. The agency failed to develop a risk assessment that was comprehensive, which identified the likeliness of emergencies that would endanger patient care within the agency and the community itself. The above findings were reviewed with and acknowledged by the agency’s Administrator (Staff-A) during an interview on 7/8/26 at 1:56 PM.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the agency’s efforts of contacting these officials to engage in planning for an integrated response, resulting in ineffective emergency preparedness planning. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder found no evidence that the agency had tried to collaborate with authorized emergency preparedness officials on any level (local/regional/State/Federal) during the last 3 years. The above findings were reviewed with and acknowledged by the agency’s Administrator (Staff-A) during an interview on 7/8/26 at 1:56 PM. Staff-A further acknowledged this did not meet the 2-year requirement or agency expectations when asked.”

“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 develop and update its emergency preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the agency’s inability to implement appropriate emergency actions which could negatively affect the health and safety of all patients serviced by this agency. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder revealed the agency’s Administrator (Staff-A) last reviewed policies and procedures on 7/16/25. However, further review found the last all-hazards risk assessment (HRA) was conducted on 1/3/22, which the agency’s EP plan is based on. In addition, no EP drills or testing exercises of the EP plan had occurred since 11/12/21. Also, the EP communication plan has had 1 (Director of Nursing) of 2 names listed incorrectly since the “Fall of 2024” per Staff-A during an interview on 7/6 26 at 10:20 AM. The agency’s last Governing Body meeting minutes (no signatures) were on 7/16/25 which documented, “Annual agency evaluation and HRA reviewed with no revisions made.” During an interview with the Administrator (Staff-A) on 7/8/26 at 1:56 PM, Staff-A could not offer a reasonable explanation of how the EP’s policies and procedures could be approved when the significant deficient practices above were factored in. Staff-A did not contest the identified deficiencies above and further acknowledged this did not meet agency expectations when asked during the interview above.”

“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 (EP) plan that included a policy/procedure concerning the use of volunteers and/or other emergency staffing strategies to address surge needs typically experienced during an actual emergency, resulting in the potential for an interruption in needed patient care services. Findings included: On 7/7/26, review of the agency’s emergency preparedness (EP) binder, policies and procedures found no evidence of specific language that included a process for the integration or use of volunteers or other staffing strategies with local, regional, State, and Federal officials to address surge needs typically experienced during an emergency. The above findings were reviewed with and acknowledged by the agency’s Administrator (Staff-A) during an interview on 7/8/26 at 2:04 PM.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan that integrated specific roles, tasks and responsibilities of its staff in the event of an actual emergency, resulting in the agency’s inability to ensure the coordination of patient care during an emergency was appropriately in place and effective. Findings include: On 7/7/26, review of the agency’s emergency preparedness binder found its communication plan (CP) had been inappropriately approved on 7/16/25. The CP has had 1 (Director of Nursing) of 2 names listed incorrectly since the “Fall of 2024” per Staff-A during an interview on 7/6 26 at 10:20 AM. Additionally, the CP failed to detail the process of how any staff member would communicate and coordinate the support of patient care needs within the agency. Further, no evidence was found that the CP had ever been tested (drill or actual emergency) to ensure its effectiveness during the last 3 years. The above findings were reviewed with and acknowledged by the agency’s Administrator (Staff-A) during an interview on 7/8/26 at 2:04 PM.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness (EP) communication plan included a means for sharing information about the agency’s occupancy, needs and its ability to aid the Incident Command Center, or designee, resulting in the lack of essential information in the event of an actual emergency. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder found no evidence of a means of providing or sharing information about the agency’s patient population to authorized EP officials (local, regional, State, and Federal) in the event of an emergency/disaster. Further, no documentation was found that indicated the type and level of support it could provide to other related health care agencies. The above findings were reviewed with and acknowledged by the agency’s Administrator (Staff-A) during an interview on 7/8/26 at 2:06 PM.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain emergency preparedness training/testing for staff, which is based on the emergency plan, resulting in the potential for inadequate staff response during an emergency. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder found no evidence of any type of emergency training or testing during the last 3 years (required at least every 2 years). The agency’s Administrator (Staff-A) was queried about the above findings during an interview on 7/8/26 at 2:06 PM. Staff-A responded that there were no trainings or testing of any of the components that made up the EP plan since at least 11/12/21.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to provide documentation that it had participated in an agency wide and community-based full-scale exercise, each required at least every two years, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 7/7/26, review of the agency’s emergency preparedness (EP) binder found no evidence of an attempt to conduct any type of testing/drill in over 3 years (11/12/21) to help ensure its staff were effective in responding to an emergency/disaster situation. No communication or effort was evidenced that the agency had reached out to the local incident command center to participate in the community-based exercise. The above findings were reviewed with and acknowledged by the Administrator during an interview on 7/8/26 at 2:08 PM.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to identify measurable improvement indicators for the Quality Assessment and Performance Improvement (QAPI) program since February 2024, resulting in the continuance of unrecognized patient care trends and the provision of substandard patient care. Findings include: On 7/8/26, the Agency’s QAPI documentation was requested at 1:58 PM from the agency’s Administrator (Staff-A). Staff-A was unable to obtain any QAPI information and stated the Alternate Administrator/Director of Nursing (Staff-B) had all the information in her home. The next day (7/9/26) at 9:50 AM, Staff B arrived with all the agency’s QAPI documentation. During a joint review at 9:55 AM with Staff A and B, it was determined the last agency QAPI participation occurred in the 2nd quarter of 2024 (28 consecutive months). Further, none of the collected data was converted into measurable terms so it could be tracked and trended towards pre-established patient centered goals. The agency’s Governing Body (GB) meeting minutes for the last 28 months had no documentation of quantifiable results to ascertain measurable progress (or lack of) of any identified patient or non-patient clinical areas. The last GB meeting minutes were dated 7/16/25 but the date of signature and the signature(s) themselves were left blank. Subsequently, it was agreed during the joint interview (9:55 AM) that the QAPI program had ceased functioning during the last 28 months. Staff-A and B were queried during the joint interview above why the QAPI program stopped after 2/2024. Staff B responded that the agency hired an outside contractor to perform chart reviews and collect data for the QAPI program. Without reason, the contracted agency suddenly stopped being involved and the home care agency itself never restarted the QAPI program.”

“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 develop a program of data collection and failed to ensure governing body approval of the frequency and detail of the data collection for the Quality Assessment Performance Improvement (QAPI) program for the last 28 months. Findings include: On 7/8/26, the Agency’s QAPI documentation was requested at 1:58 PM to the agency’s Administrator (Staff-A). Staff-A was unable to obtain any QAPI information and stated the Alternate Administrator/Director of Nursing (Staff-B) had all the information in her home. The next day (7/9/26) at 9:50 AM, Staff B arrived with all the agency’s QAPI documentation. During a joint review at 9:55 AM with Staff A and B, it was determined the last agency QAPI participation occurred in the 2nd quarter of 2024 (28 consecutive months). Further review noted no QAPI program data was discussed, reviewed and approved by the agency’s Governing Body (GB) over the last 28 months. Subsequently, no evidence was found regarding the frequency, detail, evaluation, and GB approval of any QAPI data. During an interview on 7/9/26 at 9:57 AM, Staff-A and B were queried why the QAPI program data collection had stopped after 2/2024. Staff B responded that the agency hired an outside contractor to perform chart reviews and collect data for the QAPI program. Without reason, the contracted agency suddenly stopped being involved and the home care agency itself never restarted the QAPI program.”

“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 initiate any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the provision of substandard care and unmet patient care needs. Findings include: On 7/9/26, review of the agency’s QAPI program found no evidence that the agency has developed any of the required program activities needed for an effective functioning QAPI program since 2/2024 (28 consecutive months). This finding was reviewed and acknowledged by the agency’s Administrator (Staff-A) and Alternate Administrator/Director of Nursing (Staff-B) during a joint QAPI review and interview on 7/9/26 at 9:58 AM.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop any performance improvement activities with its Quality Assessment Performance Improvement (QAPI) program to track and trend adverse patient events, analyze potential cause(s) and implement preventive actions, resulting in the potential for substandard care and unmet patient care needs. Findings include: On 7/9/26 at 9:55 AM, a joint review and interview was conducted with the agency’s Administrator (Staff-A) and Alternate Administrator/Director of Nursing (Staff-B) of the agency’s QAPI program. No evidence was found of the agency having a PIP (performance improvement project) in place to track any adverse patient events, analyze their causes, and implement preventive actions since 2/2024 (28 consecutive months). This finding was reviewed and acknowledged by Staff-A and Staff-B during an interview on 7/9/26 at 9:58 AM.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct a performance improvement project (PIP) as required since 2/2024, resulting in the lack of quality improvement measures concerning patient care services. Findings include: On 7/9/26 at 9:55 AM, a joint review and interview was conducted with the agency’s Administrator (Staff-A) and Alternate Administrator/Director of Nursing (Staff-B) of the agency’s QAPI program. No evidence was found that indicated a PIP was chosen and approved by the agency’s Governing Body to gather measurable data. Further, documentation to track and trend collected data towards pre-established goals that reflected the scope and context of previous patient care services was not found for the last 28 consecutive months. This finding was reviewed and acknowledged by Staff-A and Staff-B during an interview on 7/9/26 at 9:58 AM.”

“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 agency failed to ensure its Governing Body (GB) was involved in the Quality Assessment and Performance Improvement (QAPI) program since 2/2024, resulting in the lack of oversight concerning the quality of patient care services rendered. Findings include: On 7/9/26 at 9:55 AM, a joint review and interview was conducted with the agency’s Administrator (Staff-A) and Alternate Administrator/Director of Nursing (Staff-B) of the agency’s QAPI program. No evidence was found that indicated the GB was actively involved in its QAPI program since 2/2024. The last GB meeting minutes were dated 7/16/25 but the date of signature and the signature(s) themselves were left blank. Subsequently, it was agreed during the joint interview (9:55 AM) that the QAPI program had ceased functioning during the last 28 months along with the executive responsibilities to provide QAPI oversight and supervision. Staff-A and B were queried at 9:58 AM during the joint interview above why the QAPI program stopped after 2/2024. Staff B responded that the agency hired an outside contractor to perform chart reviews and collect data for the QAPI program. Without reason, the contracted agency suddenly stopped being involved and the agency’s GB failed to restart the QAPI program.”

“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 annual infection control education for 7 of 7 sampled staff members, including those employed through an arranged contract, which has the potential to negatively impact the safety and well-being of all patients serviced by the agency. Findings include: On 7/7/26 at 12:00 PM, an interview was conducted with the Administrator (Staff-A) regarding infection control education of staff. During the interview, a query was made regarding when staff members received infection control education. Staff-A stated all staff receive infection control training at orientation and annually. Staff-A could not provide documented evidence that staff had been trained in infection control.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individuals who furnished Home Health Aide services on its behalf met the competency evaluation requirements of this section by ensuring the required skills were evaluated by a Registered Nurse, who observed the Aide’s performance of the required tasks with a patient for 1 (Staff-C) of 1 aides, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: During the home health aides’ personnel file review on 7/7/26 at 12:15 PM, Staff-C file was noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 7/7/26 at 12:30 PM and stated, “Staff-C has been an aide for like 40 years. I will contact Staff-C to obtain documentation.” No further evidence was provided by the agency prior to exit on 7/9/26. The agency failed to ensure the home health aide was qualified and competent to provide patient focused home health aide care.”

“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 record review and interview, it was determined the agency failed to ensure that 1 (Staff-C) of 1 Home Health Aide received the required 12 hours of annual in-service training, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: During the home health aides’ personnel file review on 7/7/26 at 12:15 PM, Staff-C files were noted to not contain any annual in-service documentation. Adm #1 (Administrator) was questioned on 7/7/26 at 12:30 PM and stated, “…I will contact Staff-C to obtain documentation.” No further evidence was provided by the agency prior to exit on 7/9/26. The agency failed to ensure the home health aide was qualified and competent to provide patient focused home health aide care. A review of the agency policy occurred on 7/9/26 titled “Job Description: Home Health Aide” (10/17/18). The policy states, “14… Provide agency with proof of 12 CEU/HOURS/credits per calendar year.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure documents in the clinical records were complete and appropriately authenticated with a signature and title, dated, and timed in 3 (P-2, P-3, P-7) of 7 records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care provided by the agency. Findings include: Patient #7 (P-7): The start of care was dated 5/13/26 with diagnoses which included diabetes type-2, obesity, and hypertension. During record review on 7/8/26 at 10:18 AM, it was noted P-7 was discharged from the agency on 7/6/26 and there was no evidence that a physician signed off on the plan of care (POC) effective 5/13/26. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and verified this finding during an interview on 7/9/26 at 10:45 AM, that all treatments and interventions throughout the entire certification period were performed without a physician’s authentication. Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, it was noted that the POC completed by the Registered Nurse (RN) was not signed once completed. The agency failed to accurately authenticate the record within the EMR (Electronic Medical Record) as stated within the policy. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the POC completed by the RN was not signed once completed. The agency failed to accurately authenticate the record within the EMR as stated within the policy. A review of the agency policy occurred on 7/9/26 titled “Clinical Records” (Effective date: 10/10/18). The policy states, “Purpose: Signed and dated client clinical notes written on the day the service is rendered… Client clinical records contain: Client plan of care. .” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM. Staff-B stated, “The POC needs to be signed by the RN.””

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to inform the patient in advance of the disciplines that will furnish care in 2 (P-1, P-3) of 7 patient records reviewed, resulting in the patient not having knowledge of the plan for treatment and the potential for unmet care needs. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that the referral stated, “…I will order physical therapy to help improve pain and mobility. I will order occupational therapy (OT) to help improve her function...” The consent signed by the patient on 5/29/26 and the comprehensive assessment completed by skilled nursing on 5/29/26 were blank under the OT section and there was no documentation of the patient refusing OT services. The agency failed to provide services as ordered. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the referral stated, “…I will order physical therapy to help improve pain and mobility. I will order occupational therapy to help improve the patient’s function...” The consent signed by the patient on 5/4/26 and the comprehensive assessment completed by skilled nursing on 5/4/26 were blank under the OT section and there was no documentation of the patient refusing OT services. The agency failed to provide services as ordered. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the written NOMNC (Notice of Medicare Non-Coverage) form in advance of terminating home care services in 3 (P-1, P-2, P-4) of 7 patient records reviewed, resulting in patients not having the right or opportunity to dispute the termination of Medicare covered services. Findings include: Patient #4’s (P-4) Start of Care (SOC) was dated 6/8/26. The Plan of Care (POC) identified diagnoses of hypertension, generalized weakness and osteoarthritis in lower back. During record review on 7/7/26 at 9:06 AM, it was noted that the “Notice of Medicare Non-Coverage” form was signed at the SOC and was blank under the section when the skilled services will end. In addition, by having the patient sign in advance at the SOC, it deprived the patient of the opportunity to give informed consent of when treatments should end before they even started. This finding was reviewed and acknowledged by the Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) during an interview on 7/9/26 at 10:05 AM. Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that the “Notice of Medicare Non-Coverage” form was signed at the SOC and was blank under the section when the skilled services will end. The agency failed to document when the skilled services will end. Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, it was noted that the “Notice of Medicare Non-Coverage” form was signed at the SOC and was blank under the section when the skilled services will end. The agency failed to document when the skilled services will end. A review of the agency policy occurred on 7/9/26 titled “Notification of Financial Responsibility and Non-Coverage, HHABN” (10-31-2018). The policy states, “…the Agency shall provide written notice to beneficiaries at least 48 hours prior to discharge, to notify the client and/or caregiver of plans to discharge the client.” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to inform all patients of the required State of Michigan’s toll-free hotline regarding complaints/grievances in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unresolved patient care concerns to the State authority. Findings include: Patient numbers #’s 1-7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7): On 7/6/26, review of the agency’s home care admission packet noted an absence of the State of Michigan hotline devoted to investigation of patient/caregiver complaints. The admission packet did refer to the State’s complaint hotline but failed to list the actual number to call. This finding was reviewed and acknowledged by the Administrator (Staff-A) after time of discovery on 7/6/26 at 12:42 PM. Staff-A also acknowledged when queried that all the admission packets were identical and there were no other current means that provided patients with the State’s complaint hotline number.”

“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 all diagnoses in 5 (P-1, P-2, P-3, P-4, P-6) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: Patient #4 (P-4): The start of care (SOC) to home health was dated 6/8/26. The SOC comprehensive assessment performed by skilled nursing (SN) on 6/8/26, left the diagnosis and current medication fields blank. The home care referral dated 5/27/26 (delay in SOC approved by physician) stated, “The patient has a medical history of hypertension, osteoarthritis in bilateral shoulder, dementia, depression, neck pain, unstable gait, and vertigo. In addition, SN failed to document dates of onset, severity and effectiveness of current treatments under all bodily systems. Patient #6 (P-6): The SOC to home health was dated 5/11/26. The SOC comprehensive assessment performed by SN on 5/11/26, left the diagnosis field blank. The physician home care referral dated 5/10/26, stated under “Diagnosis” the following: Type 2 diabetes with hyperglycemia, obesity, blindness in right eye, low vision left eye, essential hypertension, osteoarthritis in knee, bilateral shoulder, dementia, depression, neck pain, unstable gait, and vertigo. In addition, SN failed to document dates of onset, severity and effectiveness of current treatments under all bodily systems. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 10:49 AM. Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that the POC only contained the primary diagnosis. The referral dated 5/26/26 stated, “Diagnosis: Essential (primary) Hypertension, Chronic Diastolic (congestive) Heart Failure, Primary Osteoarthritis, Right Shoulder, Radiculopathy, Lumbar Region, Achilles tendinitis, left leg.” Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, it was noted that the referral dated 2/18/26 stated, “Diagnosis: …Chronic Obstructive Pulmonary Disease (COPD) …” The comprehensive assessment completed by the Registered Nurse (RN) on 2/28/26 failed to document and assess the COPD diagnosis. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the referral dated 4/21/26 stated, “Diagnosis: …Hypertensive Heart Disease with Heart Failure, COPD, Chronic Systolic (congestive) Heart Failure…” The comprehensive assessment completed by the Registered Nurse (RN) on 5/4/26 failed to document and assess the Hypertensive Heart Disease with Heart Failure, COPD, Chronic Systolic (congestive) Heart Failure diagnoses. A review of the agency policy occurred on 7/9/26 titled “Comprehensive Assessment and OASIS Data Collection Start of Care” (Undated). The policy states, “The comprehensive assessment will include: Primary and secondary diagnoses, co-morbidities affecting care…” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record documented all medications with a completed reconciliation and failed to provide documented evidence that the physician was notified of identified drug interactions in for 4 (P-1, P-2, P-3, P-5) of 7 records reviewed. This deficient practice results in the potential for unrecognized side effects and drug interactions that could affect all patients serviced by the agency. Findings included: Patient #5 (P-5): The start of care was dated 11/25/24, with diagnoses of diabetes-type-2, hypertensive heart disease without failure, and chronic obstructive pulmonary disease. During record review on 7/7/26 at 1:18 PM, it was noted on the medication reconciliation performed by skilled nursing on that there were no discrepancies, duplications or issues noted. However, during a joint review/interview with the Director of Nursing (Staff-B) on 7/9/26 at 10:31 AM, it was discovered P-5 had 4 separate hypertensive medications prescribed at the same time. Staff-B acknowledged the physician should have been made aware with a documented physician response in the medical record if the patient’s medications should be continued as is or not. Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis (OA). During record review on 7/6/26 at 2:00 PM, it was noted that there were discrepancies from the medication profile provided to the patient and the medication profile in the Electronic Medical Record (EMR). The missing medications from the EMR are the following: Lasix, Ibuprofen, and Prolia (injection for OA). The medications that were in the mediation profile but not on the referral are the following: Amlodipine Besylate, Flonase, and Prilosec. Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, a medication interaction check was ran through the EMR which produced 1 major medication interaction between Aspirin and Diclofenac Sodium. The Medication Profile stated, “Drug Regimen Review: E. Have potential adverse effects, significant drug interactions, duplicate/ineffective drug therapy and potential contraindications been identified? No.” The comprehensive assessment completed by the Registered Nurse (RN) on 2/28/26 stated, “M2001 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? No.” The Electronic Medical Record (EMR) had no evidence that the physician was made aware of the major medication interaction. Furthermore, the referral noted “Allergies: Penicillin’s” and the POC stated, “Allergies: ampicillin.” The agency failed to document the allergy accurately. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that there were discrepancies from the medication profile provided to the patient and the medication profile in the EMR. The missing medications from the EMR are the following: Nitroglycerin, Levothyroxine, Roflumilast, Digoxin, Tradjenta, Magnesium oxide, Vitamin D2 (med profile has D3), Fluorometholone, Flomax, Claritin, Ventolin HFA, and Pantoprazole. The medications that were in the mediation profile but not on the referral are the following: Oxygen (Documented within referral 3L at rest, 4L with movement), Metoprolol Tartrate, Isosorbide Mononitrate, and Glimepiride. Furthermore, a medication interaction check was ran through the EMR which produced 1 major medication interaction between Ranolazine and Metformin. The comprehensive assessment completed by the RN on 5/4/26 stated, “M2001 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? Yes. M2003 Medication Follow-up: Did the agency contact a physician by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? Yes… Medication Review Drug Reactions: Potential adverse effects. Comments: Blank.” The Electronic Medical Record (EMR) had no evidence that the physician was made aware of the major medication interaction. A review of the agency policy occurred on 7/9/26 titled “Medication Reconciliation” (Effective Date: 10/10.18). The policy states, “Current practice/outcome: Medication reconciliation is initiated at the time of entry into agency and completed within 24 hours of patient admission… Medication reconciliation is the process of identifying the most accurate list of all medication a patient tis taking upon entry into agency.” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM. Staff-B stated, “I see what the nurse is doing, they are using the medication profile from a prior admission and not updating it to the referral.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care (POC) was complete and included safety parameters to protect against injury/harm in 7 (P-1, P-2, P-3, P-4, P-5, P-6, P-7) of 7 records reviewed; failed to include a comprehensive list of current medications in 2 (P-1, P-4) of 7 records reviewed; and failed to include relevant medical diagnoses in 4 (P-1, P-4, P-6, P-7) of 7 records reviewed, resulting in the potential for unreported clinical results and an incomplete picture of the patient’s clinical needs. Findings include: Patient numbers #’s 1-7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7): Record review on 7/6/26 through 7/8/26 noted all 7 records failed to incorporate vital sign, pain, weight gain/loss, and blood oxygen saturation parameters in the event a patient would go outside of baseline and need physician notification for potential orders/treatments. Patient numbers #’s 1, 4, (P-1, P-4): Record review on 7/6/26 through 7/8/26 noted both specified records above failed to include all listed medications when compared to the current medication profile filled out by skilled nursing (SN) during start of care (SOC) home care admission. Examples below include: P-4 had no listed medications on the POC, while the SOC (6/8/26) medication profile had listed 11 medications by SN services that helped treat blood pressure, diabetes, memory, thyroid, pain and other ailments. Patient numbers #’s 1, 4, 6, 7 (P-1, P-4, P-6, and P-7): Record review on 7/6/26 through 7/8/26 noted each of the 4 specified records above failed to include relevant diagnoses into the patient’s POC. Examples below include: P-4 had no listed diagnoses on the POC, and the physician referral for home care listed essential hypertension, fall risk, radiculopathy (pinched nerves) with lower back pain, osteoarthritis-generalized, and vertigo (false sensation of motion). P-6’s POC listed only the primary diagnosis of diabetes type-2 but failed to include diagnoses found in the physician referral such as blindness in right eye and low visual acuity in left eye, essential hypertension, osteoarthritis in right and left shoulder, radiculopathy-lumbar region, and obesity. P-7’s POC listed only the primary diagnosis of diabetes-type-2 but failed to include diagnoses found in the physician referral such essential hypertension, sleep apnea (breathing briefly stops and starts again during sleeping), radiculopathy-lumbar region, and gastro-esophageal reflux disease (heart burn symptoms). The findings above were reviewed and acknowledged by the Administrator (Staff-A) and Director of Nursing (Staff-B) during an interview on 7/9/26 at 10:46 AM. Both were noted this did not meet agency expectations when asked. Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that the POC only contained the primary diagnosis. The referral dated 5/26/26 stated, “Diagnosis: Essential (primary) Hypertension, Chronic Diastolic (congestive) Heart Failure, Primary Osteoarthritis, Right Shoulder, Radiculopathy, Lumbar Region, Achilles tendinitis, left leg.” Furthermore, it was noted that the POC was blank under the following sections: DME (Durable Medical Equipment) and Supplies, Safety Measures, Nutrition Requirements, Allergies, Functional Limitations, Activities Permitted, Mental Status, Orders for Discipline and Treatments, Goals/Rehabilitation Potential/Discharge Plans. Additionally, it was noted that the Physical Therapy (PT) evaluation completed on 6/1/26 was blank under the section “Short Term and Long Term Outcomes: Goals: blank… Goals: Physical Therapy: Other Goals/Dates: Blank.” A review of the agency policy occurred on 7/9/26 titled “Professional/Ancillary Care Plans” (Undated). The policy states, “An individualized plan of care (also called the care plan) shall be developed and implemented by each professional discipline providing service… Each plan will include: Identified problems and needs, Diagnosis/prognosis, if relevant to care, Allergies, Functional limitation, Specific, individualized, measurable goals and interventions, Activities permitted, Nutritional requirements, Safety measures including use of specific equipment…” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“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 visit frequencies were provided only as ordered by the physician for 1 (P-3) of 7 records reviewed; and failed to provide skilled services as ordered in 1 (P-6) of 1 record reviewed with ordered occupational therapy (OT) services, resulting in the potential for the provision of inappropriate care and lack of skilled services. Findings include: Patient # 6 (P-6): The start of care was dated 5/11/26, with diagnoses of diabetes type-2 and hypertension. During record review on 7/8/26 at 9:07 AM, it was noted on the physician referral (4/30/26) that OT services were needed. The physician documented, “I will order occupational therapy to help improve the patient’s function.” However, record review noted OT services were never provided. No physician notification or patient refusal of OT services was found in the medical record. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 7/9/26 at 10:49 AM. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the Registered Nurse (RN) completed a resumption of care on 5/20/26 and ordered RN at a frequency of 1w3 (1 visits a week for 3 weeks). The Electronic Medical Record (EMR) contained no documented evidence that any further RN visits were completed. The RN failed to provide the services and frequency as ordered by the physician. A review of the agency policy occurred on 7/9/26 titled “Professional/Ancillary Care Plans” (Undated). The policy states, “Each pan will include: Specific services to be provided including frequency and duration.” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and caregiver were provided diagnosis teaching/instructions as requested within the referral for 4 (P-2, P-3, P-5, P-6) of 7 records reviewed, for a potential of unmet care needs. Findings include: Patient #5 (P-5): The start of care (SOC) was dated 11/25/24, with diagnoses of diabetes-type-2, hypertensive heart disease without failure, and chronic obstructive pulmonary disease. During record review on 7/7/26 at 1:18 PM, it was noted the physician referral documented under “Care Plan” the following: “I will order a nursing evaluation to assess and teach Re: diabetes.” Further record review found skilled nursing (SN) only performed 1 visit at SOC and then discharged P-5 from SN services. No evidence was found in the medical record of SN performing any education or teaching concerning diabetes to P-5 prior to discharge. Patient # 6 (P-6): The start of care was dated 5/11/26, with diagnoses of diabetes type-2 and hypertension. During record review on 7/8/26 at 9:07 AM, it was noted the physician referral documented under “Care Plan” the following: “I will order a nursing evaluation to assess and teach Re: diabetes. He checked a random blood sugar of 283 on his CGM (continuous glucose monitor.” Further record review found skilled nursing (SN) only performed 1 visit at SOC and then discharged P-6 from SN services. No evidence was found in the medical record of SN performing any education or teaching concerning diabetes to P-6 prior to discharge. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 7/9/26 at 10:45 AM. Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, it was noted that the referral dated 2/18/26 stated, “I will order nursing evaluation to assess and teach Re: hypertension. She may need to start medication.” The RN completed an evaluation on 2/28/26 with the frequency of 1w1 (1 visit a week for 1 week). The Electronic Medical Record (EMR) contained no documentation on hypertension education. The RN failed to educate the patient as ordered. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the referral dated 4/21/26 stated, “I will order nursing evaluation to assess and teach Re: diabetes.” The RN completed an evaluation on 5/4/26 with the frequency of 1w1. The Electronic Medical Record (EMR) contained no documentation on diabetes education. The RN failed to educate the patient as ordered. A review of the agency policy occurred on 7/9/26 titled “Nursing Services” (Effective date: 10/10/18). The policy states, “Health promotion services shall be offered as part of the nursing care to stimulate the individual and/pr family to a course of action for the promotion and maintenance of physical or emotional health. The approach may include guidance and counseling on health matters, special diets, introduction to community resources, and home evaluation.” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“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 provide all patients with written documentation of the correct contact information regarding the agency’s Clinical Manager in 7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7) of 7 records reviewed, resulting in the potential for unaddressed patient concerns. Findings include: Patient numbers #’s 1-7 (P-1, P-2, P-3, P-4, P-5, P-6, and P-7): On 7/6/26, review of the agency’s home care admission packet noted the listing for the agency’s CM was wrong. The current listing referred to a CM who has not worked for the agency since 11/2023. During an interview with the Administrator (Staff-A) on 7/6/26 at 11:12 AM, Staff-A reviewed and acknowledged the admission packet had listed the wrong CM for over the last 3 years and acknowledged the admission packets were identical. Subsequently, all patients had the wrong CM contact information.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Quality Assessment Performance Improvement (QAPI) program performed actions to measure the effectiveness of a chosen PIP (performance improvement project), developed to track improvements and a process to ensure improvements are sustained. Findings include: On 7/9/26 at 9:55 AM, a joint review and interview was conducted with the agency’s Administrator (Staff-A) and Alternate Administrator/Director of Nursing (Staff-B) of the agency’s QAPI program. No documentation was found of any performance improvement actions taken by the agency that were tracked to evaluate intended improvements in patient care and outcomes. In addition, no processes were found that would help ensure any potential improvements would be ongoing and sustained. These findings were reviewed and acknowledged by Staff-A and Staff-B during an interview on 7/9/26 at 9:58 AM. Both were noted that this did not meet agency expectations when asked.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that physical therapy (PT) services appropriately supervised the care provided by the physical therapy assistant (PTA) in 1 (P-5) of 4 records with PTA services, resulting in the potential for poor clinical outcomes. Findings include: Patient #5 (P-5): The start of care was dated 11/25/24, with diagnoses of diabetes-type-2, hypertensive heart disease without failure, and chronic obstructive pulmonary disease. During record review on 7/7/26 at 1:18 PM, it was noted the PTA visit note on 12/27/24 documented “Yes” on the question, “Has the patient experienced a fall since last visit?” No other documentation concerning the fall was found in the visit note. In addition, the PTA documented under “Care Coordination” was performed with the “Therapy Supervisor”. Further review of the PT supervisory note on 12/30/24 which evaluated the previous 2 weeks of PTA therapy documented “Meets Requirements” on following agency policy and procedures; shows sufficient communication skills; and keeps clinical supervisor informed about client needs and conditions in timely fashion. No evidence was found that indicated PT services had reviewed the PTA notes on 12/27/24 and followed up to ascertain potential injury and causes of the documented fall. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 7/9/26 at 10:37 AM. Both further acknowledged this did not meet agency expectations when asked.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aides were qualified to provide home health aide service for 1 (Staff-C) of 1 aides providing service, for a potential of substandard aide services. Findings include: During the home health aides’ personnel file review on 7/7/26 at 12:15 PM, Staff-C’s file did not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 7/7/26 at 12:30 PM and stated, “Staff-C has been an aide for like 40 years. I will contact Staff-C to obtain documentation.” No further evidence was provided by the agency prior to exit on 7/9/26. The agency failed to ensure the home health aide was qualified and competent to provide patient focused home health aide care. A review of the agency policy occurred on 7/9/26 titled “Plan of Care – CMS #485 and Physician Orders Job Description: Home Health Aide (HHA)” (10/17/18). The policy states, “Qualifications: 3. Certified as a home health aide.””

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on record review and interview, the agency failed to maintain documentation of competency evaluations in 1 (Staff-C) of 1 Home Health Aides whose personnel file was reviewed, resulting in the potential for the provision of substandard care and unmet care needs. Findings include: During the home health aides’ personnel file review on 7/7/26 at 12:15 PM, Staff-C files were noted to not contain any competency or training evaluation program documentation. Adm #1 (Administrator) was questioned on 7/7/26 at 12:30 PM and stated, “Staff-C has been an aide for like 40 years. I will contact Staff-C to obtain documentation.” No further evidence was provided by the agency prior to exit on 7/9/26. The agency failed to ensure the home health aide was qualified and competent to provide patient focused home health aide care.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Clinical Manager coordinated services for 2 (P-1, P-3) of 7 records reviewed, resulting in services potentially not being provided or late which could have poor patient outcomes. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that Physical Therapy (PT) completed an evaluation (EV) on 6/1/26 and ordered PT services at a frequency of 2w4 (2 times a week for 4 weeks), 1w4. It was noted that the following visits were not completed within the Electronic Medical Record (EMR) until 7/7/26: 6/1/26 (PT EV), 6/2/26, 6/8/26, 6/10/26, 6/15/26, 6/17/26, 6/22/26, 6/24/26, 6/29/26 (PT 30-day EV) and 7/1/26. The agency failed to provide oversight and coordinate patient documentation accordingly. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, the patient was transferred on 5/12/26 and resumed on 5/20/26. There is no documented evidence within the EMR or paper chart that a referral was received to resume care. Furthermore, it was noted that resumption of care POC on 5/20/26 ordered Physical Therapy (PT) at a frequency of 2w4, 1w3. PT services were completed for 4 weeks ending on 6/10/26 by a Physical Therapy Assistant (PTA). Staff-A was questioned on 7/8/26 at 11:00 AM regarding further visits and stated, “He went to the hospital again on 6/16/26 according to the PT. The patient wanted to hold off resuming care. No transfer was completed. The PT will do one now.” The agency failed to provide oversight and coordinate patient documentation accordingly. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“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, the agency failed to ensure clinical notes were complete, accurate, and maintained for 2(P-1, P-3) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 5/29/26. The Plan of Care (POC) identified diagnosis of Bilateral Primary Osteoarthritis. During record review on 7/6/26 at 2:00 PM, it was noted that Physical Therapy (PT) completed an evaluation (EV) on 6/1/26 and ordered PT services at a frequency of 2w4 (2 times a week for 4 weeks), 1w4. It was noted that the following visits were not completed within the Electronic Medical Record (EMR) until 7/7/26: 6/1/26 (PT EV), 6/2/26, 6/8/26, 6/10/26, 6/15/26, 6/17/26, 6/22/26, 6/24/26, 6/29/26 (PT 30-day EV) and 7/1/26. The agency failed to maintain a complete and accurate medical record. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the agency had no evidence of a signed consent for admission. Additionally, the patient was transferred on 5/12/26 and resumed on 5/20/26. There is no documented evidence within the EMR or paper chart that a referral was received to resume care. Furthermore, it was noted that resumption of care POC on 5/20/26 ordered Physical Therapy (PT) at a frequency of 2w4, 1w3. PT services were completed for 4 weeks ending on 6/10/26 by a Physical Therapy Assistant (PTA). Staff-A was questioned on 7/8/26 at 11:00 AM regarding further visits and stated, “He went to the hospital again on 6/16/26 according to the PT. The patient wanted to hold off resuming care. No transfer was completed. The PT will do one now.” A review of the agency policy occurred on 7/9/26 titled “Clinical Records” (Effective 10/10/18). The policy states, “Client clinical records contain: Pertinent current and past findings...” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”

“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 a discharge summary was completed, provided the patient’s current health status at the time of discharge, and progress toward goals in 2 (P-2, P-5) of 2 closed records, and failed to ensure a discharge and transfer summary was forwarded in 4 (P-2, P-3, P-5, P-6) of 7 records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #5 (P-5): The start of care was dated 11/25/24, with diagnoses of diabetes-type-2, hypertensive heart disease without failure, and chronic obstructive pulmonary disease. During record review on 7/7/26 at 1:18 PM, evidence that skilled nursing (SN) services had completed a SN discharge summary that detailed treatments, interventions, and patient education performed was not found in the medical record. Further, physical therapy (PT) discharged P-5 from the agency on 1/20/24 with no findings from SN and no clinical PT findings of measurable physical progress (or lack of) throughout admission. Also, PT services left the diabetes and cardiovascular sections of the discharge assessment blank. Patient # 6 (P-6): The start of care was dated 5/11/26, with diagnoses of diabetes type-2 and hypertension. During record review on 7/8/26 at 9:07 AM, it was noted the physician referral documented under “Care Plan” the following: “I will order a nursing evaluation to assess and teach Re: diabetes. He checked a random blood sugar of 283 on his CGM (continuous glucose monitor.” Further record review noted SN performed 1 visit at SOC and then discharged P-5 from SN services that same day. No evidence was found that the home care agency had sent a discharge summary to the physician that detailed SN treatments, interventions, and patient education as required. The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the above findings during an interview on 7/9/26 at 10:40 AM. Both Staff-A and Staff-B were noted that the findings did not meet agency expectations when asked during the interview. Patient #2’s (P-2) Start of Care (SOC) was dated 2/28/26. The Plan of Care (POC) identified diagnoses of Hypertension and Osteoarthritis. During record review on 7/7/26 at 10:00 AM, the Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Additionally, it was noted that the PT discharge summary stated, “Summary of Care: Strength training, balance training, transfer training, gait training, HEP (Home Exercise Program), fall safety.” The discharge summary failed to detail the course of care provided, responses to treatment, any potential continuing needs, and failed to document the patient’s health status at the time of discharge in measurable terms. Patient #3’s (P-3) Start of Care (SOC) was dated 5/4/26. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Osteoarthritis. During record review on 7/8/26 at 9:30 AM, it was noted that the Skilled Nurse (SN) completed a transfer on 5/12/26 and Physical Therapy (PT) completed a transfer on 6/16/26 that was completed on 7/8/26. The EMR contained no evidence that the 2 transfer summaries were sent within 2 business days of the patient’s known transfer. A review of the agency policy occurred on 7/9/26 titled “Discharge Planning, Discharge Summery, and Discharge OASIS” (Effective 10/10/18). The policy states, “The discharge summary will include but is not limited to: Reason for admission, Reason for discharge, Status of problems throughout the course of the care, A narrative summary of the care/services provided, The progress or lack of toward established goals, The client’s overall status at time of discharge, Any continuing care, instructions, or referrals regarding the needs.” The Administrator (Staff-A) and Alternate Clinical Manager (Staff-B) reviewed and acknowledged the findings listed above in an interview on 7/9/26 at 11:00 AM.”