Home and Care Billings

“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 complete an all-hazards assessment to incorporate into the Emergency Preparedness Plan, every two years. This deficient practice has the potential to increase negative outcomes to agency patients in an emergency. Findings include: During an interview on 6/18/26 at 10:15 a.m., staff member A stated all staff were new to the agency and put in a PIP for emergency preparedness for information not up to date in March 2026, when they reviewed the plan, but were still working on parts of the Emergency Plan. Staff member A stated the hazards vulnerability assessment had not been completed yet. Review of the agency’s Emergency Preparedness Plan on 6/17/26 did not show that an all-hazards facility-based risk assessment, unique to the facility, had been completed since 12/14/22.”

“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 complete a second emergency preparedness exercise as required within the two-year timeframe. This deficient practice had the potential to increase the risk of negative outcomes to agency patients in an emergency. Findings include: During an interview on 6/18/26 at 10:09 a.m., staff member A stated all current staff were new and they had only had one real-life event they used the emergency plan for in March 2026. Staff member A stated with the organization changing names, and staff, they could not find documentation of any other emergency preparedness exercises completed. Staff member A stated the agency had identified the issue during their review in March 2026. Staff member A stated they were actively working on a PIP. Staff member A stated the agency did not have a second exercise in place yet. Review of the facility Emergency Preparedness Program, on 6/17/26, showed one real-life event for a power outage documented on 3/26/26. No other exercises were documented for the last two years.”

“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 submit their Outcome and Assessment Information Set (OASIS), within 30 days of the assessment for 72 submissions, between 10/1/25 and 6/11/26. The agency had not identified a role responsible for managing OASIS submissions. Findings include: Review of the agency’s Error Report for their OASIS submissions, showed the code -3330, “Record Submitted Late: The Submission date is more than 30 days after the M0090 [OASIS completion date] on this new record.” The number of assessments with the error code was 72. During an interview on 6/16/26 at 9:48 a.m., staff member B stated the workflow for OASIS submissions started with the clinician completing the assessment, then a case manager, then to the coder to review, and then sent to the biller to be submitted. During an interview on 6/16/26 at 9:53 a.m., staff member D stated she would go through the OASIS to review coding and verify it was signed off by the clinician before locking for submission. Staff member D stated the EHR system automatically submitted batches nightly of any completed OASIS. Staff member D stated she was new to the role and the agency was still working out job duties for her role and another new hire related to OASIS. During an interview on 6/17/26 at 9:45 a.m., staff member M stated the agency had hired a new person who would be taking over the OASIS submission process. Staff member M stated prior to the new hire, the agency had a third party submitting the OASIS assessments, and the person was no longer with the agency. Review of the agency policy and procedure titled, OASIS Data Collection and Submission, showed: “B. Pre-Submission Review - Every completed OASIS assessment shall be reviewed by the DPCS or designated OASIS reviewer before submission to CMS - The reviewer shall check for: completeness (all required items answered), internal consistency (OASIS items must be consistent with each other and with visit note documentation), accuracy (coding reflects actual patient status), and compliance with OASIS guidance... C. Submission to CMS - OASIS data shall be encoded and transmitted using the agency’s approved OASIS software (HAVEN or EHR-integrated OASIS module) - OASIS data must be submitted to the CMS OASIS repository within 30 days of the assessment completion date...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the individualized plan of care included the ordered skilled nursing services to show the frequency and duration of skilled nursing visits, patient-specific interventions, education, measurable outcomes, and identified goals for 1 (#2) of 7 sampled patients. Findings include: During an observation on 6/17/26 at 1:00 p.m., during a home visit, staff members B and G, provided wound care to a coccyx pressure injury, an indwelling catheter change, medication management, and education for patient #2. During an interview on 6/17/26 at 1:38 p.m., staff member B stated patient #2 had been receiving skilled nursing services once a week. Review of patient #2’s Current and Updated Plan of Care (485), with a certification period of 4/28/26 to 6/26/26, did not include the ordered skilled nursing services to show the frequency and duration of skilled nursing visits, patient-specific interventions, education, measurable outcomes, and identified goals. During an interview on 6/18/26 at 9:22 a.m., staff member B stated the patient’s plan of care should reflect the services being provided. Staff member B stated patient #2’s plan of care did not include the provided skilled nursing services to include the frequency and duration of visits, orders, education, and goals. A review of the agency’s policy and procedure, titled, Plan of Care Development, with a revision date of 4/27/26, showed, “… The plan of care must include, at minimum, the following elements: - Types of services required (skilled nursing, therapy, HHA, social work) and the frequency and duration of each service. - All medications and treatments, including the dosages and administration schedules. - Patient and caregiver education goals and methods. Measurable outcomes and goals expected from care: - For [Home Health Agency] services: specific tasks authorized for the [Home Health Agency] and frequency…””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to update the patient’s Plan of Care with treatment orders for ordered wound care and catheter management for 1 (#2) of 7 sampled patients. Findings include: During an observation on 6/17/26 at 1:10 p.m., during a home visit, staff members B and G, provided a catheter change and wound care to a coccyx pressure injury for patient #2. The patient had both 14 and 16 French sized urethral catheter sizes available. While gathering supplies, for the indwelling catheter change, staff member B asked NF3 which size indwelling catheter the patient was using. Staff member B examined the patient’s catheter tubing to determine which catheter size was currently placed. Staff member B stated patient #2 currently had a 14 French indwelling catheter inserted. Staff member B did not check the plan of care to verify the orders for the appropriate size catheter. During an observation on 6/17/26 at 1:35 p.m., staff member B provided patient #2 with wound care to a coccyx pressure injury. Staff member B removed the previous dressing, cleansed the wound, and applied a new dressing. During an interview on 6/17/26 at 1:38 p.m., staff member B stated patient #2 had been receiving skilled nursing services to include wound care and catheter changes. Staff member B stated there were wound care orders in patient #2’s medical record but would need to check to see if there were orders for the urinary catheter management. Review of patient #2’s Current and Updated Plan of Care (485), with a certification period of 4/28/26 to 6/26/26, did not include the ordered skilled nursing services to show the treatment orders for wound care and urinary catheter management. During an interview on 6/18/26 at 9:20 a.m., staff member B stated the orders for patient #2’s catheter management and current wound care orders were not updated on the patient’s plan of care. She stated the expectation would be to ensure all treatment orders were updated on the patient’s plan of care. A review of the agency’s policy and procedure, titled, Plan of Care Development, with a revision date of 4/27/26, showed, “… The plan of care must include, at minimum, the following elements: - All medications and treatments…””

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure professional standards of care were implemented to measure, document, and correctly stage an Unstageable Pressure Injury for 1 (#2) of 7 sampled patients. Findings include: During an observation on 6/17/26 at 1:35 p.m., staff member B provided wound care to a pressure injury on patient #2’s coccyx. Staff member B removed the previous dressing, cleansed the wound, and applied a new dressing. Staff member B did not obtain measurements of the pressure injury. The pressure injury on patient #2’s coccyx was approximately the size of a quarter. The wound bed was 95% covered and obscured with a thick white/yellow drainage. During an interview on 6/17/26 at 1:38 p.m., staff member B stated patient #2 had been receiving skilled nursing services for wound care to manage the pressure injury on the patient’s coccyx. Staff member B stated she did not obtain any measurements on the patient’s coccyx wound. She stated it was the expectation for nursing to obtain wound assessments which should include the measurement of the wound and document those findings in the patient’s medical record. Review of patient #2’s Orders, dated 4/10/26, showed, “Pressure Ulcer to [right and left] buttock. Cleanse with [normal saline], apply barrier cream to periwound, Medi-Honey to wound, cover with silver alginate, and bordered foam bandage. [Home Health Registered Nurse] to change [one time] week and [NF3] [one time a week] and [as needed] for dislodgement and drainage until new orders obtained.” [sic]. Review of patient #2’s Wound Record Report, from 4/28/26 to 6/18/26, showed, pressure injury to patient #2’s coccyx, to have “partial thickness skin loss and drainage” (Stage II Pressure Injury is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough)¹. The Wound Report showed the pressure injury on the patient’s coccyx was staged at I (Stage I Pressure Injury is defined as: Intact skin with non-blanchable redness of a localized area)¹. According to the National Pressure Ulcer Staging, when slough obscures the wound bed, the injury must be documented as an Unstageable Pressure Injury¹. Review of patient #2’s Wound Record Report, from 4/28/26 to 6/18/26, did not show any wound measurements were documented for patient #2’s coccyx wound. During an interview on 6/18/26 at 9:20 a.m., staff member B stated the wound care for patient #2’s coccyx pressure injury did not have any measurements of the wound for the current certification period (4/28/26 to 6/18/26). Staff member B stated it was the expectation to document wound characteristics as well as wound measurements at least weekly. A review of the agency’s policy and procedure titled, Wound Care Protocol, with a revision date of 4/27/26, showed: “A comprehensive wound assessment shall be performed at Start of Care and at each wound-related visit. The assessment must document all of the following: - Wound type/etiology - surgical, pressure injury (stage I-IV, unstageable, deep tissue injury) ... - Wound dimensions - length x width x depth in centimeters… - Exudate - amount (none, scant, small, moderate, large), type (serous, serosanguineous, sanguineous, purulent), and odor… [Agency name] staff shall use the National Pressure Injury Advisory Panel (NPIAP) staging system for all pressure injuries… - Stage I: Non-blanchable erythema of intact skin - Stage II: Partial-thickness skin loss - shallow open ulcer or intact/ruptured blister… - Unstageable: Full-thickness tissue loss - wound base covered by slough or eschar; true depth cannot be determined until debrided…” References: ¹ Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Table 2, [National Pressure Ulcer Staging System]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/”