Homestead Health LLC

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on interview and record review, the agency was not in substantial compliance with the Conditions of Participation for Emergency Preparedness. - The agency failed to develop and implement an emergency preparedness plan and update the plan every two years. This had the potential to affect all the active patients who received home health services (E0004); - The agency failed to implement an all-hazard risk assessment to address emergency events (E0006); - The agency failed to implement an emergency plan, which was based on the agency’s patient population. The agency failed to identify types of services for the patient population and whether the agency could provide those services in an emergency (E0007); - The agency failed to implement an emergency preparedness plan to include a process for collaboration and communication between local, tribal, regional, State and Federal emergency officials to ensure an integrated response process (E0009); - The agency failed to ensure policies were developed, implemented and reviewed every two years (E0013); - The agency failed to develop and implement a procedure for notification of on-duty staff and patients to determine what services were needed if there was an interruption in services due to an emergency (E0021); - The agency failed to implement policies and procedures for using volunteers in an emergency or develop emergency staffing strategies (E0024); - The agency failed to develop a communication plan and failed to review and update policies and procedures every two years (E0029); - The agency failed to develop and implement a communication plan to include staff, volunteers, patients’ physician, and contracted services (E0030); - The agency failed to develop a communication plan for emergency preparedness to include Federal, State, tribal, regional and local emergency preparedness staff, and any other resources for assistance (E0031); - The agency failed to develop and implement a communication plan to include a primary and secondary means for contacting staff and emergency officials during an emergency (E0032); - The agency failed to develop and implement a communication plan to include a method for sharing information and medical documentation with other healthcare providers to ensure continuity of care (E0033); - The agency failed to develop and implement a training and testing emergency preparedness program (E0036); - The agency failed to develop, implement and evaluate an emergency preparedness training program, failed to show the training program was based off of the agency risk assessment, and failed to review and update the program (E0037); and - The agency failed to develop and implement a testing program for its emergency preparedness program (E0039).”

“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 interview and record review, the agency was found to not be in substantial compliance with the Conditions of Participation at §484.65 for Quality assessment/performance Improvement. Findings include: - The agency failed to develop and analyze measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (G0642) -The agency failed to monitor the effectiveness and safety of services and quality of care to identify opportunities for improvement. (G0644) -The agency failed to identify performance improvement activities focusing on high risk, high volume, and problem prone areas. (G0646) - The agency failed to track adverse patient events, analyze their causes, and implement preventive actions. (G0654) - The agency failed to implement, measure, and track performance improvement activities to ensure improvements were sustained. (G0656) - The agency failed to develop and implement any performance improvement projects. (G0658); and - The agency’s governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; failed to develop, implement, and maintain clear expectations for patient safety. (G0660).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on interview and record review, the agency was not in substantial compliance with§484.70 of the Conditions of Participation for Infection Control. Findings include: - The agency failed to ensure staff sanitized or washed hands in between glove changes and failed to ensure equipment was cleaned prior to putting the equipment back in the bag. (G0682); and - The agency failed to develop and implement an infection control program which identified infections, communicable diseases, and failed to implement a plan to control and improve disease results. (G0684).”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on interview and record review, the agency was not in substantial compliance with §484.105 of the Conditions of Participation for Organization and administration of services. Findings include: - The agency’s governing body failed to assume responsibility for the agency’s overall management and operation, including QAPI, Infection Control, Emergency Preparedness programs, implementation of a fiscal budget/Capital Expenditures, and adoption of policies and procedures. (G0942); - The agency failed to appoint a qualified person to assume the responsibilities and obligations of the administrator, if the administrator of record was not available. (G0954); and - The agency and governing body failed to prepare an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (G0988).”

“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 interview and record review, the agency failed to develop and implement an emergency preparedness plan and update the plan every two years. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the agency had a binder of policies and procedures from three years ago, but had not implemented the policies for an emergency preparedness plan. Review of the policy and procedures binder, no date, showed the agency had not implemented an emergency plan to include an all-hazards approach risk assessment, completed every two years. Review of the agencies Hazard Vulnerability Analysis showed the risk assessment was last reviewed on 6/9/23.”

“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 interview and record review, the agency failed to implement an all-hazard risk assessment to address emergency events. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the agency had a binder containing policies and procedures for emergency preparedness but had not implemented the policies for implementation of the plan. Review of the agencies Hazard Vulnerability Analysis, dated 6/9/23, showed the agency developed a risk assessment, but it did not identify when the agency updated the assessment or when it was implemented.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and record review, the agency failed to implement an emergency plan based on the agency’s patient population. The agency failed to identify types of services for the patient population and whether the agency could provide those services in an emergency. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the agency had policies and procedures for an emergency plan but had not implemented those policies and procedures. Review of the agency’s policies and procedures manual, no date, showed emergency plans for addressing patient populations and the services which could be provided in an emergency. The plans had not been approved by the governing board and had not been implemented.”

“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 interview and record review, the agency failed to implement an emergency preparedness plan to include a process for collaboration and communication with local, tribal, regional, State and Federal emergency officials to ensure an integrated response process. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the Governing Board had not approved all the policies for an Emergency Preparedness Plan and the agency had not implemented an emergency plan. Review of the agency’s policy and procedures binder, no date, showed there were policies, but they had not been approved by the board. The process for collaboration and communication of the agency’s EP plan had not been implemented.”

“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 interview and record review, the agency failed to ensure policies were developed, implemented and reviewed every two years. Findings include: During an interview on 2/24/26, staff member A stated the agency had a policies and procedures manual for emergency preparedness, but the governing board had not reviewed and approved the policies and procedures. Staff member A stated an emergency plan had not been implemented and the agency had no plan for communication during an emergency. Staff member A stated the medical director had signed off on the policies and procedures, but the governing board had not reviewed or approved the policies. Review of the agency’s policy and procedure manual showed policies for a communication plan, but the policies had not been reviewed, approved and implemented by the governing board.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a procedure for notification of on-duty staff and patients to determine what services were needed if there was an interruption in services due to an emergency. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated none of the agency’s policies had been reviewed and approved by the governing board. Staff member A stated the agency had not implemented any procedures for notification of on-duty staff and patients. Review of the policy and procedure manual, no date, did not show implementation of procedures to notify on-duty staff and patients to determine the needs of the patients in the event of an emergency.”

“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 interview and record review, the agency failed to implement policies and procedures for using 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. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the agency and governing board had not reviewed and approved the policies. Staff member A stated the policies and procedures had not been implemented for staffing in emergency situations. Staff member A could not show an emergency plan to include staffing strategies in an emergency. Staff member A could not produce a emergency plan for the agency. Review of the policies and procedures binder, no date, failed to show the agency implemented policies and procedures for using 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.”

“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 interview and record review, the agency failed to develop a communication plan and failed to review and update policies and procedures related to the communication plan every two years. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the policies for developing a communication plan were not implemented and had not been reviewed and approved by the governing body. Review of the Communication Plan policies and procedures binder, no date, failed to show the agency Communication Plan was reviewed and updated by the governing board at least every two years.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a communication plan to include staff, volunteers, patients’ physician, and contracted services. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated an agency communication plan had not been developed and implemented. Staff member A stated an agency communication plan had not been presented to the governing board for review and approval. Review of the agency’s policies and procedures for emergency preparedness, no date, failed to show review, approval, updated and implemented procedures for a communication plan to include the names and contact information for the following: staff, entities providing services under arrangement, patients’ physicians and others, including facilities, and volunteers.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop a communication plan for emergency preparedness to include Federal, State, tribal, regional and local emergency preparedness staff, and any other resources for assistance. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated there was not a communication plan for contacting emergency preparedness officials for Federal, State, tribal, regional and local authorities. Review of the agency’s emergency preparedness policies and procedures, no date, failed to show a communication plan was approved and implemented for contacting emergency officials, including Federal, State, tribal, regional and local emergency preparedness staff, and any other resources for assistance.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a communication plan to include a primary and secondary means for contacting staff and emergency officials during an emergency. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated there was not a communication plan for primary and secondary means for contacting staff and emergency officials. Staff member A stated the policies for a communication plan had not been implemented. Review of the agency’s emergency preparedness policies and procedures, no date, showed the policies had not been reviewed or approved by the governing board. Review of the emergency preparedness plan showed the plan lacked primary and secondary means for contacting staff and emergency officials during an emergency.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a communication plan to include a method for sharing information and medical documentation with other healthcare providers to ensure continuity of care. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated there was not a communication plan developed and implemented for the sharing of information and medical documentation. Review of the agency’s emergency preparedness policies and procedures, no date, showed the communication plan was not developed, implemented and reviewed by the governing board. Review of the plan showed the lack of a method for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care.”

“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 interview and record review, the agency failed to develop and implement a training and testing emergency preparedness program. This deficient practice had the potential to affect the safety of patients and delay patient care and services. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the agency had not developed and implemented a training and testing program. Staff member A stated the staff had assigned annual training on [program name] every year. Staff member A stated the training and testing had not been implemented, reviewed or updated every two years. Review of the policies and procedures, no date, and emergency preparedness program requirements, the agency had not provided the required training and testing for staff.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop, implement and evaluate an emergency preparedness training program, failed to show the training program was based off of the agency risk assessment, and failed to review and update the program. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated the staff were assigned emergency preparedness training through [program name]. Staff member A stated there was not any other training provided to the staff on emergency preparedness. Review of the agency’s policies and procedures binder, no date, showed policies for an emergency preparedness program. The policies were not approved, implemented or evaluated. There was no documentation of the agency staff training on emergency preparedness or an emergency plan based on the hazard vulnerability assessment.”

“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 interview and record review, the agency failed to develop and implement a testing program for its emergency preparedness program and conduct exercises annually. Findings include: During an interview on 2/24/26 at 2:10 p.m., staff member A stated there was not a testing program implemented for the emergency preparedness program. Review of documentation in the emergency preparedness binder, no date, failed to show a testing program for emergency preparedness. The agency failed to conduct exercises annually for its emergency preparedness program.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system for start of care assessments within 30 days after admission for 96 of 212 assessments during the last fiscal year. Findings include: Review of the agency’s, HHA Error Summary by Agency Report, dated 1/1/25 - 12/31/25/26, showed, “Error code -3300 record submitted late: The submission date is more than 30 days after M0090 on this new record.” for 96 of 212 assessments processed, equaling 45.28% of assessments submitted were late submissions. During an interview on 2/25/26 at 9:03 a.m., staff member A stated a staff nurse was not completing assessments timely and due to staffing difficulties, she was unable to submit the assessments on time. Staff member A stated the agency was aware the late submissions would be a concern during the recertification survey. Review of the agency’s policy, “Timely Submission of Patient Documentation Oasis Assessment Reference Sheet,” not dated, showed, “start of care assessments were to be completed within 30 days after the start of care.””

“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 interview and record review, the agency failed to develop and analyze measurable improvement in indicators for which there was evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. This deficient practice had the potential to result in decreased quality of care, health outcomes, and patient safety for all agency patients. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency did not have a QAPI program implemented. Staff member A stated the agency included QAPI as part of the bi-annual meetings. Staff member A stated the current focus for QAPI was reviewing CMS denials for payment and correcting the issues resulting in denials. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Review of the agency’s QAPI book, not dated, contained denials for payment from CGS with notes of necessary corrective actions to paperwork required. The book did not contain measurable improvement in quality indicators for improved health outcomes, patient safety, and quality of care. Review of the agency’s Board of Directors Regular Meetings, dated 1/26/23 - 11/11/25, reflected: - 1/26/23: no mention of QAPI, - 2/27/23: QAPI was tabled, - 10/8/24: “QAPI-updated and document” was only statement on the minutes, and - 11/11/25: “QAPI-audits and getting OASIS assessments turned in on time. CGS notices.””

“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 interview and record review, the agency failed to monitor the effectiveness and safety of services, quality of care provided, and identify opportunities for improvement. This deficient practice had the potential to result in decreased quality of care for all agency patients. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency had not implemented a QAPI program. Staff member A stated the agency included QAPI as part of the bi-annual Board of Directors meetings. Staff member A stated the current focus for QAPI was reviewing CMS denials for payment and correcting the issues. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Staff member A stated the agency had not developed monitoring for patient care areas. Review of the agency’s QAPI book, not dated, contained denials for payment from CGS with notes of necessary corrective actions. The book did not contain measurable quality indicators identified for tracking and analysis of improved health outcomes, patient safety, or quality of care for patients served. Review of the agency’s policy, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” not dated, reflected: “...2. The Agency must measure, analyze and track quality indicators, including adverse patient events and other aspects of performance that enable the Agency to assess processes of care, services and operations. ...””

“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 interview and record review, the agency failed to identify performance improvement activities focusing on high risk, high volume, and problem prone areas. This deficient practice had the potential to result in missed opportunities to improve quality of care for agency patients. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency had not implemented a QAPI program. Staff member A stated the current focus for QAPI was denials for payment and correcting the issues resulting in denials. Staff member A stated the agency had purchased a book of policies and procedures for home health agencies but had not implemented the program. Staff member A stated she did not have data for patient care that was being followed by a QAPI team other than the denial for payment letters. Review of the agency’s QAPI book, not dated, contained many denials for payment from CGS with notes of necessary corrective actions. The book did not contain measurable indicators for monitoring improvement in health outcomes, patient safety, and quality of care, including high risk, high volume, and problem-prone areas. Review of the agency’s policy, Quality Assurance and Performance Improvement (QAPI) Plan and Program, no date, reflected: “... 6. The Agency’s performance improvement activities will: Focus on high risk, high volume, and problem-prone areas, consider incidence, prevalence and severity of problems in those areas, and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. ...””

“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 interview and record review, the agency failed to track adverse patient events, analyze their causes, and implement corrective and preventive actions. This deficient practice had the potential to result in adverse events not followed up on to prevent further adverse events. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency did not have a QAPI program implemented. Staff member A stated the agency included QAPI as part of the bi-annual Board of Director meetings. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Review of the agency’s QAPI book, not dated, did not contain any tracking of adverse patient events, analyze their causes, and implement preventive actions. Review of the agency’s policy, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” not dated, reflected: “... 7. Performance improvement activities must track adverse patient events, analyze their causes and implement preventive actions. ...””

“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 interview and record review, the agency failed to develop and implement any performance improvement projects. This deficient practice had the potential to result in missed opportunities for improved quality care and patient safety. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency had not implemented a QAPI program. Staff member A stated the current focus for QAPI was reviewing CMS denials for payment and correcting the issues. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Staff member A stated the agency had not completed any performance improvement projects to date. Review of the agency’s QAPI book, not dated, contained many denials for payment from CGS but book did not contain performance improvement projects. Review of the agency’s policy, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” not dated, showed: “... 9. The defined processes needing improvement will be described, along with any patient, staff and/or regulatory requirements, project goals and improvement activities. ...””

“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 interview and record review, the agency’s governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; failed to develop, implement, and maintain clear expectations for patient safety. This deficient practice resulted in the agency not implementing an active QAPI plan which included projects to ensure quality patient care and safety were developed, monitored, and maintained. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency had not implemented a QAPI program. Staff member A stated the agency included QAPI as part of the bi-annual Board of Directors meetings. Staff member A stated the current focus for QAPI was reviewing CMS denials for payment and correcting those issues. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Staff member A stated the QAPI program had been tabled during the board meetings. Review of the agency’s QAPI book, not dated, contained denials for payment from CGS with notes of necessary corrective actions. The book did not contain measurable indicators directed at improvement of patient health outcomes, patient safety, quality of care, or include high risk, high volume, or problem-prone areas. Review of the agency’s Board of Directors Regular Meetings, dated 1/26/23 - 11/11/25, showed: - 1/26/23: Minutes contained no mention of QAPI, - 2/27/23: QAPI was tabled, - 10/8/24: QAPI was tabled, and - 11/11/25: “QAPI-audits and getting OASIS assessments turned in on time. CGS notices.” This was the only mention of QAPI on the minutes. Review of the agency’s policy, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” not dated, showed: “... 1. The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented and maintained. ...””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure staff sanitized or washed hands in between glove changes for 1 (#5), and failed to ensure equipment was cleaned prior to putting the equipment back in the supply bag for 2 (#s 5 and 6) of 7 sampled patients. This deficient practice had the potential to affect all patients of the agency for the spread of communicable diseases. Findings include: During an observation on 2/25/26 at 11:00 a.m., staff member D was observed during a wound cleansing task. Staff member D established a clean barrier for her equipment bag, which carried her supplies for the home visit, by placing a blue pad underneath the bag. Staff member D donned clean gloves and assessed areas on patient #5’s legs and feet where wounds had healed. Staff member D took her equipment out of her bag, without sanitizing her hands or donning clean gloves, and used it to assess the patient’s vital signs. When staff member D was finished with the equipment, she placed it back in her supply bag without cleaning it. Wearing the same gloves, staff member D cleansed the wound on the patient’s sacrum. Staff member D removed the gloves, did not sanitize her hands and donned clean gloves. Staff member D then removed her gloves and sanitized her hands. Staff member D assessed the patient’s lungs and placed the stethoscope back in her supply bag, sanitization was not performed on the stethoscope. Staff member D donned clean gloves and cleaned around the patient’s catheter tubing. Staff member D removed her gloves and donned clean gloves. Staff member D had not sanitized her hands between glove changes. After departing the patient’s residence, staff member D placed her bag in the back seat of her car and took the equipment out of the supply bag and cleaned it. During an observation on 2/25/26 at 11:45 a.m., staff member D removed a blood pressure cuff, pulse oximeter, and thermometer from her supply bag. She then assessed patient #6’s vital signs. When staff member D was finished with the equipment, she put it back in her supply bag, sanitization was not performed. During an interview on 2/25/26, staff member D stated she waits to clean her equipment until she gets to her car. Staff member D stated she usually sanitizes her hands between glove changes. During an interview on 2/25/26 at 5:23 p.m., staff member A stated the staff are trained for bag technique through [program name], videos, and by reviewing the policies. Staff member A stated staff are trained on infection control upon hire, annually through [program name], and as needed. Review of a policy titled, “Hand Hygiene Policy and Compliance Program, showed staff were to follow Center for Disease Control and Prevention guidelines for hand hygiene...” Under 2. “All employees are responsible for implementing hand hygiene procedures in an ongoing attempt to prevent and/or contain infectious processes and communicable diseases.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement an infection control program which identified infections, communicable diseases, and failed to implement a plan to control and improve disease results. This deficient practice had the potential to result in missed opportunities to take appropriate actions in the prevention of infections and disease. Findings include: During an interview on 2/25/26 at 2:45 p.m., staff member A stated identification of infections involved knowing your patients, assessing vital signs, and signs and symptoms of illness. Staff member A stated there were not performance improvement plans (PIPs) for corrective action on any infection control concerns. Review of the infection control binder showed a report of infections identified through the nurses EHR documentation, but no documentation was present to show identified infections were reviewed, tracked, trended, or audits conducted to determine if there was a pattern to the infections and staff infection control practices. Review of the policies and procedures manual, no date, showed a section for an infection control program. The policies had not been reviewed, updated, approved by the governing board, or implemented by the agency.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on interview and record review, the agency’s governing body failed to assume responsibility for the agency’s overall management and operation, including QAPI, Infection Control, Emergency Preparedness programs, implementation of a fiscal budget/Capital Expenditures, and adoption of policies and procedures. This deficient practice resulted in agency’s lack of a QAPI, Infection Control, or Emergency Preparedness program for quality improvement and safety for all agency patients. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency did not have a QAPI program, Infection Control program, or an Emergency Preparedness program implemented. Staff member A stated the agency included these meetings as part of the bi-annual board meetings. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the programs. Staff member A stated the current focus for QAPI was reviewing CMS denials for payment and correcting the issues resulting in denials. Staff member A stated the agency had a report for infection control that contained all infections entered by the nurses, but the agency had not implemented tracking, trending, or antibiotic stewardship of any kind yet. During an interview on 2/25/26 at 4:50 p.m., staff member A stated the agency did not have a budget or capital expenditure to date. Staff member A stated she would ask the board before making any substantial purchases, but the governing body had not established a final budget. Staff member A stated the board was working on a draft set of bylaws, however nothing was adopted or signed to date. Review of the agency’s Board of Directors Regular Meetings, dated 1/26/23 - 11/11/25, showed: - 2/27/23: Bylaws/Capital Expenditure, Infection Control, Emergency Preparedness Planning, and QAPI were tabled, - 10/8/24: Bylaws/Capital Expenditure, Infection Control, Emergency Preparedness Planning, and QAPI were tabled, and - 11/11/25: “Financials/Budget- need to find accountant vs QuickBooks,” and “QAPI-audits and getting OASIS assessments turned in on time. CGS notices.””

“Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This Standard is not met as evidenced by: Based on interview and record review, the agency and governing body failed to prepare a budget that includes an annual operating budget and capital expenditure plan. This deficient practice resulted in not having an annual budget or expenditure plan for the administrator to execute, as needed. Findings include: During an interview on 2/25/26 at 4:50 p.m., staff member A stated the agency did not have an operating budget or capital expenditure plan. Staff member A stated she would contact the governing board with any substantial expenses in advance for approval. Review of the agency’s Board of Directors Regular Meetings, dated 1/26/23 - 11/11/25, showed: - 1/26/23: “Financials/budget-will present monthly budget on what is available due to no reimbursement yet,” - 2/27/23: Bylaws/Capital Expenditure was tabled, - 10/8/24: Bylaws/Capital Expenditure was tabled, and - 11/11/25: “Financials/Budget- need to find accountant vs QuickBooks.””

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to complete the initial assessment visit within 48 hours of a referral or return to their home for 4 (#s 3, 5, 6, and 7) of 7 sampled patients. This deficient practice resulted in a delay of care for patient #s 3, 5, 6, and 7. Findings include: 1. Review of patient #3’s medical record showed patient #3 was referred for home health services on 5/27/25 and was admitted to home health services on 6/25/25. 2. Review of patient #6’s medical record showed patient #6 was referred for home health services on 3/26/25 and admitted to home health services on 4/9/25. 3. Review of patient #7’s medical record showed patient #7 was referred for home health services on 12/13/24 and admitted to home health on 12/16/24. 4. Review of patient #5’s medical record showed patient #5 was referred for home health services on 7/24/25 and admitted to home health on 8/13/25. The initial assessment was not completed within 48 hours of the referral for patient #s 3, 5, 6, and 7. During an interview on 2/24/26 at 2:44 p.m., staff member A stated the agency had lost a full-time nurse which contributed to the late admission assessments. In addition, staff member A stated the agency had difficulty with CMS denying claims due to the physician face-to-face appointment requirements. Staff member A stated the agency decided to not accept patients for admission until the physician face-to-face and all paperwork requirements were completed. Staff member A stated the agency had difficulty getting admission orders from physicians for admission. Staff member A stated the delay in admission to home health from the referral on 5/27/25 to admission on 6/25/25 for patient #3 was a result of paperwork delays. Review of the agency’s policy, “Initial Assessments/Comprehensive Assessments,” not dated, showed: “...A RN, PT, or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home, or on the physician/practitioner-ordered start of care date. ...In the absence of a physician/practitioner-specified start of care date, the initial assessment visit is conducted within 48 hours of the referral. ...””

“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 interview and record review, the agency failed to implement, measure and track performance improvement activities to ensure improvements were sustained. This deficient practice had the potential to result in on-going adverse events or substandard care. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency had not implemented a QAPI program. Staff member A stated the agency purchased a book of policies and procedures for home health agencies but had not implemented the program. Review of the agency’s QAPI book, not dated, did not contain any evidence of actions implemented for performance improvement, measurement activities, or tracking performance for sustainability. Review of the agency’s policy, “Quality Assurance and Performance Improvement (QAPI) Plan and Program,” not dated, showed: “... 8. Agency must take actions aimed at performance improvement and, after implementing these actions, must measure its success and track performance to ensure that improvements are sustained. ...””

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to appoint a qualified person to assume the responsibilities and obligations of the administrator, if the administrator of record was not available. This deficient practice had the potential to result in risks to patient safety and quality of care while not having an administrator available during an emergency, if the administrator of record was not available. Findings include: During an interview on 2/25/26 at 1:30 p.m., staff member A stated the agency did not have a person appointed by the governing board to assume the administrator responsibilities when the administrator was not available. Staff member A stated she was not aware another person needed to be appointed by the governing board and the administrator of record in writing. Review of the agency’s Board of Directors Regular Meetings, dated 1/26/23 - 11/11/25, showed: - 1/26/23: no mention of a secondary Administrator, - 2/27/23: no mention of a secondary Administrator, - 10/8/24: no mention of a secondary Administrator, and - 11/11/25: no mention of a secondary Administrator.”