Zutan Home Healthcare, Inc.

“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 review of the agency’s emergency preparedness policies and procedures and staff interview, the agency failed to review and update the emergency preparedness plan at least every 2 years and the agency’s policies and procedures failed to include this process. Findings are: A. Review of the agency’s policies and procedures titled Zutan Home HealthCare, Inc. Emergency Preparedness Policy, effective 1/3/2022, revealed the agency’s emergency preparedness policies and procedures were to be reviewed and updated at least every 2 years. B. The agency’s emergency preparedness plan failed to include documentation when the policies and procedures were reviewed. C. During an interview on 6/9/26 at 12:15 PM, the Administrator confirmed the agency failed to review and update the agency’s emergency preparedness plan at least every 2 years and the agency’s policies and procedures failed to include this process.”

“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 review of the agency’s emergency preparedness policies, procedures, and documentation, and staff interview, the agency’s policies and procedures failed to include conducting a community based full-scale exercise every 2 years, and the agency failed to conduct a community based full-scale exercise every 2 years. The agency has 28 direct care staff and 4 contracted staff. Findings are: A. Review of the agency’s policies and procedures titled Zutan Home HealthCare, Inc. Emergency Preparedness Policy, effective 1/3/2022, revealed: 1. The agency will develop and maintain an emergency preparedness training and testing program based on the emergency plan, risk assessment, policies and procedures, and the communication plan. 2. The training program will provide emergency preparedness training at least every 2 years. B. Review of the agency’s policies and procedures titled Zutan Home HealthCare, Inc. Emergency Preparedness Plan, date not available, revealed agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current plan and any forms developed for use in a disaster. C. Review of the agency’s documentation of emergency preparedness training and testing exercises revealed: 1. 4/10/24 a weather related mock drill. 2. 7/10/25 a weather related mock drill. 3. 5/22/26 a weather related mock drill. D. During an interview on 6/9/26 at 12:15 PM, the Administrator confirmed the agency’s emergency preparedness policies and procedures failed to include conducting a community based full-scale exercise every 2 years, and the agency failed to conduct a community based full-scale exercise every 2 years.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to notify the patient’s physician when visits were not conducted as ordered on the plan of care, for 3 of 9 clinical records reviewed (Patient 1, 2, and 4). The census was 6. Findings are: A. Review of the agency’s policy and procedure titled Clinical Documentation, date not available, revealed: 1. All skilled services were to be documented in the clinical record. 2. Documentation, of services ordered on the plan of care, was to be completed on the day service was rendered and incorporated into the clinical record within 7 days after the care is provided. 3. Services not provided and the reason for the missed visits were to be documented and reported to the physician. B. Review of the contract agreements between Zutan Home Healthcare, Inc. and MEDLINK, LLC revealed the contractor was to complete clinical and progress notes after each contact with the client and these notes were to be filed in the client’s folder. All paper work was to be submitted to the agency withing 7 days. C. Review of Patient 1’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 3/25/26 through 5/23/26 included orders for Occupational Therapy (OT) to evaluate and treat. 2. The initial Occupational Therapy Evaluation and Physician Certification, dated 3/26/26, included orders for OT 2 X weekly X 8 weeks. 3. There were no OT visit notes the week of 4/5/26. There was 1 missing OT visit note the week of 4/12/26. 4. There was no documentation in the clinical record to indicate the physician was notified of the missed visits. 5. OT discharged the patient from services on 4/21/26. D. Review of Patient 2’s clinical record revealed: 1. The POC for the resumption of care post hospital orders, dated 3/25/26, included orders for OT to evaluate and treat. 2. The initial OT Evaluation and Physician Certification, dated 3/31/26, included orders for OT 2 X weekly x 7 weeks. 3. The POC for the resumption of care post hospital orders, dated 4/20/26, included orders OT 2 X weekly x 7 weeks. 4. The OT interim OT Evaluation and Physician Certification, dated 4/21/26, included orders for OT 2 X weekly X 7 weeks. 5. The POC for the certification period of 4/28/26 through 6/26/26 included orders for OT 2 x weekly X 7 weeks. 6. There was 1 missing OT visit note the week of 4/19/26. There were no OT visit notes from 4/22/26 through 6/6/26. 7. There was no documentation in the clinical record to indicate the physician was notified of the missed visits. E. Review of Patient 4’s clinical record revealed: 1. The POC for the resumption of care post hospital orders, dated 3/02/26, included orders OT to evaluate and treat. 2. The initial OT Evaluation and Physician Certification, dated 3/5/26, included orders for OT 2 X weekly X 8 weeks. 3. The interim OT Evaluation and Physician Certification, dated 4/9/26, included orders for OT 2 X weekly X 8 weeks. 4. The POC for the certification period of 4/12/26 through 6/10/26 included orders for OT to evaluate and treat. 5. There was 1 missing OT visit note the weeks of 4/12/26 and 4/26/26. There were 2 missing OT visit notes the week of 4/18/26. 6. There was no documentation in the clinical record to indicate the physician was notified of the missed visits. F. During an interview on 6/9/26 at 12:15 PM, the Administrator confirmed the agency contracts OT services from MEDLINK, LLC. The Administrator also confirmed the agency failed to provide OT services as ordered by the physician and failed to notify the physician of missed visits for Patients 1, 2, and 4.”

“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 record review, policy and procedure review, and staff interview, the agency failed to include wound care orders on the Plan of Care for 1 of 3 patient records reviewed with wound care orders (Patient 7). The total sample size was 9. The census was 6. Findings are: A. Review of the agency’s policy and procedure titled Plan of Care, date unavailable, revealed: 1. The plan of care is based on comprehensive patient assessment and information provided by the health care team. 2. Planning patient care is a process that addresses the care, treatment and services to be provided. 3. The agency staff was to develop an individualized plan of care to meet specific, identified patient needs. 4. The patient’s plan of care was to include treatments and procedures. B. Review of Patient 7’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 11/28/25 through 1/26/26 and 1/27/26 through 3/27/26, included orders for Skilled Nursing (SN) to wash reddened areas to pannus folds and groin with Hibiclens (antiseptic skin cleanser) and allow to sit for 1-2 minutes, then rinse well and pat dry. Apply Desenex crusting (antifungal powder) to reddened areas. Wick Interdry (a fabric to manage moisture, friction and odor in skin folds) between folds. 2. Orders from Nebraska Medical Internal Medicine, dated 10/8/25, revealed: a. Wound care to right ischium (lower back), wash with soap and water, rinse well and pat dry. Apply skin prep (protective barrier on intact skin prior to applying new wound dressing) to peri wound. Apply Triad (zinc oxide based cream) to wound bed cover with Aquacel AG (wound dressing containing silver), cover with Drawtex (cover dressing to manage moisture) or baby diaper, and secure with friendly tape. b. Wash reddened areas to pannus folds and groin with Hibiclens and allow to sit for 1-2 minutes, then rinse well and pat dry. Apply Desenex crusting to reddened areas. Wick Interdry between folds, 3. Orders from Nebraska Medicine Wound and Ostomy Clinic, dated 11/11/25, revealed: a. Wound care to right ischium, wash with soap and water, rinse will and pat dry. Apply Calmoseptine (zinc oxide ointment) to peri wound and wound bed, cover wound with Aquacel AG, cover with Drawtex or baby diaper, and secure with friendly tape. b. Apply A & D ointment or Aquaphor to unaffected areas on buttocks and posterior thighs. c. Wash reddened areas to pannus folds and groin with Hibiclens and allow to sit for 1-2 minutes, then rinse well and pat dry. Apply Desenex crusting to reddened areas. Wick Interdry between folds. 4. The POC for the certification period of 11/28/25 through 1/26/26 and 1/27/26 through 3/27/26, failed to include wound care orders to right ischium and to apply A & D ointment or Aquaphor to unaffected areas on buttocks and posterior thighs. C. During an interview on 6/9/26 at 12:15 PM, the Administrator confirmed the wound care orders for the right ischium and to apply A & D ointment or Aquaphor to unaffected areas on buttocks and posterior thighs failed to be included on Patient 7’s POC.”