Silver Touch Home Health Care

“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 review of the Emergency Preparedness Program (E.P.P.), it was determined that the Home Health Agency (HHA) failed to ensure the E.P.P. received a documented bi-annual review and update to reflect potential changes within the community, staffing personnel, and facility functions. Findings include: Review on 05/29/25 of the E.P.P. manual and records with Staff F (Administrator and Emergency Preparedness Coordinator) revealed the last documented updates and comments recorded within the E.P.P. manual were as follows: 02/2022 Governing Body review, no changes.04/2022 Governing Body review, “A change in the Financial Manager”.04/2022 Homecare E.P.P. assessment, all policies reviewed.Staff F provided a paper record with generic monthly comments: “all facility policies were reviewed” with no additional supporting information. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m. with Staff F confirmed the above findings. Staff F was unable to provide documentation of comments, dates, reviews, or references to any updates or potential changes presented within the E.P.P. manual.”

“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 review of the Emergency Preparedness Program (E.P.P.) emergency communication plan, it was determined the Home Health Agency (HHA) failed to ensure a bi-annual review of the emergency communication plan. Findings include: Review on 05/29/25 of the E.P.P. communication plan with Staff F (Administrator and Emergency Preparedness Coordinator) revealed the communication plan, located within the E.P.P. binder, failed to show any documented evidence of a bi-annual review since 04/2022 Governing Body. Potential changes in connectivity, communication challenges, and population increases could pose a risk not identified before. Staff F provided a piece of paper with generic monthly comments: “all facility policies were reviewed” with no additional supporting information. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m. with Staff F confirmed the above findings. Staff F was unable to provide additional supporting information.”

“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 review of the Emergency Preparedness Program (E.P.P.) and interview, it was determined that the Home Health Agency (HHA) failed to ensure contact information for the State Emergency Management Officials and the Department of Health and Human Services Officials were included in the facility’s E.P.P. communication plan. Findings include: Review on 05/29/25 of the E.P.P. communication plan with Staff F (Administrator and Emergency Preparedness Coordinator) revealed that there was no contact information for the State Emergency Management Officials and the Department of Health and Human Services Official. The E.P.P. binder failed to show any documented evidence of a bi-annual review since 04/2022 Governing Body (review, no changes). Potential changes in connectivity, communication challenges, and population increases in the service area could pose a risk not identified before within the E.P.P. communication assessment. Staff F provided a paper record with generic monthly comments: “all facility policies were reviewed” with no additional supporting information. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m. with Staff F confirmed the above findings. Staff F was unable to provide additional supporting information.”

“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 review of the Emergency Preparedness Program (E.P.P.), it was determined that the Home Health Agency (HHA) failed to ensure the alternate means of emergency communication received a documented bi-annual review and update to reflect potential challenges or unknown current challenges with an emergency communication process. Findings include: Review on 05/29/25 of the E.P.P. alternate means of communication plan with Staff F (Administrator and Emergency Preparedness Coordinator) revealed the facility is registered and enrolled with the Government Emergency Telecommunications Services (GETS) plan. Further review of the E.P.P. binder revealed that the GETS card was issued to four employees of the facility and were last revalidated (re-issued) on 03/24/2022 (by mail). There were no documented evidence of a bi-annual review since 03/24/2022. Staff F provided a paper record with generic monthly comments: “all facility policies were reviewed” with no additional supporting information. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m. with Staff F confirmed the above findings. Staff F was unable to provide additional supporting information.”

“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 review of the Emergency Preparedness Program (E.P.P.) training documents, it was determined that the Home Health Agency (HHA) failed to ensure bi-annual staff training and testing documents were presented or available for review. Findings include: Review on 05/29/25 of the E.P.P. bi-annual staff training and testing program with Staff F (Administrator and Emergency Preparedness Coordinator) revealed some training materials and certificates located within the E.P.P. binder were dated 2019, 2020, and 2022, with no additional supporting documents presented. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m. with Staff F confirmed the above findings. Staff F stated that staff trainings were conducted. Staff F was unable to provide documentation of staff trainings during the survey.”

“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 review of the Emergency Preparedness Plan (E.P.P.), it was determined that the Home Health Agency (HHA) failed to ensure exercises to test the effectiveness of the E.P. plans and policies are conducted at least annually. Findings include: Review on 05/29/25 of the E.P.P. disaster drills, disaster events, and training documents with Staff F (Administrator and Emergency Preparedness Coordinator) revealed the only training, testing, or actual event documentation that was presented for review were three “Heat Advisory Notice Call Lists” dated 06/18/24 for two and “Heat Advisory Calls” 07/15/24 for one, where the facility made welfare check calls to enrolled clients with a notation if they were able or unable to make contact. There was no additional documented information on participants, clients, policy effectiveness, potential revisions and/or changes in the E.P.P. Staff F was unable to provide documentation of the facility’s efforts to participate in a full-scale community-based functional exercise, A mock disaster drill, or a tabletop exercise with a facilitator led discussion. Interview on 05/29/25 between 8:00 a.m. and 10:45 a.m.with Staff F confirmed the above findings and available documentation.”

“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 record review and interview, it was determined that the facility failed to submit Outcome and Assessment Information Set (OASIS) assessments timely for 19 of 208 assessments between 3/1/24 through 3/1/25. Findings include: Review on 5/27/25 of the Center for Medicare and Medicaid Services (CMS) “HHA [Home Health Agency] Error Summary by Agency” Report for the time frame of 3/1/24 through 3/1/25, revealed the following error “-3330 Record Submitted Late: The submission date is more than 30 days after M0090 on this new record” was noted for 19 of 208 assessments, which is a 9.13% error rate. Interview on 5/27/25 at approximately 9:30 a.m. with Staff B (Licensed Practical Nurse) confirmed the above finding. Staff B revealed that he/she knew why the assessments were submitted late.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, it was determined that the Home Health Agency (HHA) failed to document the existence and resolution of client complaints. (Patient identifier is #7). Findings include: Reviewed on 5/29/25 the Agency Client Grievance Procedure, Policy Home Care Bill of Rights revealed, “ Purpose: To inform clients verbally and in writing, or by other means understood by the clients, of their right to make informed decisions regarding their care... 5, If an agency staff member receives a complaint regarding services provided, the complaint will be documented and communicated to the Clinical Director. The Clinical Director will contact the client, caregiver, and/or interested parties, and attempt to reconcile the situation. The complaint shall be documented on the Client Grievance/Complaint Form or on a Progress Communication Note...14, All complaints and status of investigation will be documented and maintained in a Confidential Administrative File.” Review on 5/29/25 of Patient #7’s skilled nursing note, dated 3/10/25, written by Staff D (Licensed Practical Nurse (LPN)) revealed that Patient #7 did not want Staff E (Physical Therapist (PT)) to provide them with therapy services anymore. Staff D notified the nursing supervisor, Staff B (LPN). Interview on 5/29/25 at approximately 11:00 a.m. with Staff B revealed that the HHA had no documented evidence of patient complaints and no documented evidence of the resolution of any complaints. Staff B revealed that they talked to Patient #7 about why they did not want Staff E but did not document the complaint or any resolution.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, it was determined that the Health Health Agency (HHA) failed to comply with physician’s orders for 1 patient in a survey sample of 7 patients. (Patient identifier is #2). Findings include: Review on 5/28/25 of Patient #2’s medical record revealed the following treatment orders during the recertification period of 4/28/25 to 6/26/25: Review on 5/28/25, Patient #2’s Plan of Care, revealed, under Wound: Wound vac [vacuum] SN [skilled nursing] to remove and dispose of old dressing. Using aseptic technique perform wound care 3 times a week to coccyx as follows: ...Apply Skin prep [preparation] to periwound... Review on 5/28/25, of Patient #2’s medical record revealed on the following days: 5/5, 5/7, 5/9, 5/12, 5/14, 5/16, 5/19, 5/21 no skin prep was administered to wound. Interview on 5/28/25 with Staff B (Licensed Practical Nurse) confirmed the above findings and revealed that there was no skin prep available for Patient #2.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review it was determined the Home Health Agency (HHA) failed to alert the physician to any changes in the patient’s condition and/or the plan of care should be altered for 1 patient in a survey sample of 7 patients. (Patient identifiers is #6). Findings include: Review on 5/28/25, Patient #6’s Plan of Care, for the recertification period of 5/12/25 to 7/10/25 revealed an order to “Assess wound(s) for s/s (sign and symptoms) infection, changes in wound apperence [sic], drainage, odor, pain, q [every] dressing change. Notify agency WCC/MD [Wound Care Consultant/Medical Doctor] for changes. Review on 5/28/25 of Patient #6’s wound assessment note, dated 5/19/25, revealed Resident #6’s wound deteriorated, increasing in size. Review on 5/28/25 of Patient #6’s License Practical Nurse (LPN) visit note, dated 5/26/25 revealed, “Patient reports some discomfort at times with toe and mobility...Wound care as follows: old dressing removed and discarded. Old hydrofera blue dressing showing heavy drainage and moisture on wound bed. Slight maceration and deterioration of skin rounded wound bed. Wound bed weeping slightly with cleaning today. Minimal dressing applied to wound and wound continues to show deterioration.” Interview on 5/28/25 with Staff B (LPN) confirmed there was no documentation the physician was notified of Patient #6’s significant wound changes.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview it was determined that the Home Health Agency failed to make on-site supervisory visits no less frequently than every 14 days for 1 patient recieving home health aide services in a survey sample of 7 patients. (Patient identifier is #7). Findings include: Review on 5/29/25 of Resident #7’s plan of care revealed the following treatment and orders for disciplines during the recertification period of 2/1/25 to 4/1/25: Skilled Nursing: 3 times a week for 10 weeks to start on 2/2/2025 Home Health Aide: 1-2 times a week for 1 week and 2-6 times a week for 9 weeks to start on 2/1/25 Review on 5/29/2025 of Resident #7’s medical record revealed there were no supervisory visits made for the Home Health Aides during the recertification period of 2/1/25 to 4/1/25. Interview on 5/29/25 at approximately 10:37 a.m. with Staff B (License Practical Nurse) confirmed there was no supervisory visits conducted for Home Health Aides during certification period of 2/1/25 through 4/1/25.”

“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, it was determined that the facility failed to ensure that a multidose vial of medication with a shortened life was labeled with an expiration date, and failed to ensure expired medications were removed. Findings include: Observation on 5/28/25 at approximately 9:30 a.m. with Staff A (Billing Specialist) of the medication refrigerator revealed: 1 opened vial of Tuberculin Purified Protein Derivative with no open expiration date. 2 Epinephrine Pens with an expiration date of February 2022. Interview on 5/28/25 at approximately 10:00 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings. Review on 5/28/25 of the manufacturer’s instructions for Tuberculin Purified Protein Derivative (Mantoux) dated October 2021 revealed: ... A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Review on 5/28/25 of the Patient Information for Epinephrine Injection, dated 2019 revealed: ... Your epinephrine injection, USP (United States Pharmacopeia) auto-injector has an expiration date. Replace it before the expiration date.”