Maxim Healthcare Services

“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 Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to develop the E.P.P. using an all-hazards approach to potential facility and community associated risks and interruptions of essential services. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 a.m. with Staff A (Operations Manager) revealed the facility failed to develop specific emergency plans to address potential emergencies and interruptions in client care services that may be identified in an all-hazards approach. These are only some of the potential hazards and/or policies that failed to be addressed: Local flooding policies and monitoring road closures/detours; Monitoring civil disturbances and dangerous travel routes; Monitoring for severe strong storms/tornado warnings; Emerging Infectious Disease outbreaks and staff protections; Vehicle safety and preparation; Safety/emergency supplies for travel. Interview on 7/17/24 with Staff A confirmed the above findings and available E.P.P. documentation.”

“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 review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to conduct, review, or document a current facility-based risk assessment or obtain and review a current community-based risk assessment pertaining to their current business headquarters location. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed the facilities Hazard Vulnerability Assessment (HVA or Risk Assessment) available, dated 06/22/23, was a corporate generated form for Region #5, in Utah/Colorado, with a specific mention in the policies and procedures for New England locations to use the Region #1 HVA. Additionally, there failed to be a community-based Risk Assessment to address local/regional emergency disaster threats and concerns that need to be taken into account to provide for continuity of care from the current business location. Interview on 7/17/24 with Staff A confirmed the above findings and available E.P.P. documentation presented.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan, (E.P.P.) documents and interview, it was determined that the facility failed to ensure a process to communicate or collaborate with local, tribal, regional, State, and Federal emergency preparedness officials or efforts to maintain an integrated response during an emergency situation. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed that the facility failed to have a process to engage in collaborative planning for an integrated response to a widespread emergency. One policy did suggest that a downed communication system could result in using the local Fire Department as a communication center, but no documentation was located to show any communication with the local Fire Department or any fire department personnel to facilitate such a plan. Interview on 7/17/24 with Staff A confirmed the above findings and available E.P.P. documentation.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to ensure policies/procedures were in place to inform State and Local Emergency Preparedness officials about clients/residents in need of emergency evacuation assistance. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed: “...If there was a situation, and they [Maxim Healthcare] could not contact a client/staff they would call # 911...” Instructions for how long without contact, number of attempts, alternate contact attempts (additional family/friends, neighbors), communication failures, location, cell service location, and non-emergency contact numbers for a “welfare check” from local authorities failed to be included or mentioned in any detail to educate staff. Interview on 7/17/24 with Staff A confirmed the available documentation and was unaware of any other policies beyond calling #911.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to ensure that agreements with other health care services were arranged to ensure continuity of care for clients during a disaster/emergency event. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed that the facility failed to have policies to outline potential transfers of the clients for continuity of care, such as a hospitals, nursing homes, or like services’ providers, as well as policies to follow-up with staff and clients during a disaster/emergency event beyond the facilities control or when the facility is not able to provide necessary care under their control. Interview on 7/17/24 with Staff A confirmed the above findings and available documentation.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to ensure the communication plan included required names and contact information. Review of the E.P.P. between on 9:30 a.m. and 12:30 p.m. on 7/17/24 with Staff A (Operations Manager) revealed the required contact information for staff, entities providing services under arrangement, clients’ physicians, or volunteers (if used) failed to be documented in any form within the E.P.P. emergency binder. Interview on 7/17/24 with Staff A confirmed the above findings and available documentation.”

“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 Plan (E.P.P.) and interview, it was determined the facility failed to ensure a list of contact information for local, regional, State, and Federal emergency officials was documented and available for review. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed the facility failed to develop an emergency contact information list for Emergency Officials that should include but was not limited to: local, regional, State, and Federal Emergency Managers, Federal Emergency Management Agency, Department of Health and Human Services State Licensing and Certification Units, Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, Utility companies, medical equipment suppliers, etc. Interview on 7/17/24 with Staff A confirmed the above findings and available documentation.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to include policies and procedures for sharing sensitive patient information with authorized personnel, facilities, emergency officials, and/or authorities. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed that documentation of the methods or procedures to handle sensitive client information in order to ensure continuity of care, with authorized persons, facilities, or authorities during a disaster/emergency event beyond the facilities control was unable to be provided. Interview on 07/17/24 with Staff A confirmed the above findings and available E.P.P. policies and procedures.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined that the facility failed to include any policies or procedures to inform emergency managers and officials of the facilities emergency needs. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed that the facility failed to develop policies and/or procedures to inform emergency officials if the facility needs or requires assistance to protect the continuity of client care during a disaster/emergency beyond their control. Interview with Staff A confirmed the above findings and available E.P.P. documentation.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to ensure a training and testing program was developed for all staff based on a complete and comprehensive emergency plan and risk assessment. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed a comprehensive testing program for any/all staff providing care under the facilities’ direction, failed to be documented or available for review and compared to a developed risk assessment. Interview on 7/17/24 with Staff A confirmed the available documentation.”

“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 review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to ensure that all new and existing staff and any individuals providing services under the facilities direction, were trained in the E.P.P. policies and procedures. Review of the E.P.P. on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed the facility failed to ensure that all new and existing staff or individuals providing services, received an initial and bi-annual training and reviews according to the facilities specific emergency plan policies and procedures. Interview on 7/17/24 with Staff A confirmed the available E.P.P. documentation.”

“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 Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to conduct the required disaster/emergency drills, or properly document actual events with new and existing staff or individuals providing services on behalf of the facility. Review of the E.P.P. disaster drills on 7/17/24 between 9:30 a.m. and 12:30 p.m. with Staff A (Operations Manager) revealed the facility failed to ensure new and existing staff participated in a tabletop training or actual live events to test the competency of the disaster policies and procedures on an annual basis. The disaster/emergency events and documents that were presented during survey are as follows: 5/23/24- Office evacuation/fire drill; 4/24/24- Snowstorm event, with no staff signatures, no after-action write-up, no policy corrections or changes in the program; 8/25/23- Office evacuation/fire drill; 3/14/22- Snowstorm event, with no staff signatures, no after-action write-up, no policy corrections or changes in the program; 8/8/22- Annual emergency preparation task and evaluation form, incomplete with no signatures; 1/28/22- Snowstorm event, with no staff signatures, no policy corrections or changes in the program. The after-action write-up consisted of a paragraph “All HC members called through the active patients to alert of upcoming storm, encourage them to reach out if anything is needed, and make sure they have all needed supplies, majority of families answered, no one needed anything”; 1/14/22- Snowstorm event, with no staff signatures, no policy corrections or changes in the program. The after-action write-up consisted of a paragraph “All HC members called active patients to alert of upcoming snowstorm encourage them to reach out if anything needed and make sure they have needed supplies, majority of families answered the phone”. There was no additional documentation provided for specific staff trainings, staff participation, or bi-annual staff reviews of the E.P.P. Interview on 7/17/24 with Staff A confirmed the available disaster/emergency 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 5 records out of 101 assessments between 7/14/23 through 7/15/24. Findings include: Review on 7/15/24 of the Center for Medicare and Medicaid Services (CMS) “HHA [Home Health Agency] Error Summary by Agency” Report for the time frame of 7/14/23 through 7/15/24, 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 5 records of 101 assessments. Interview on 7/16/24 at approximately 8:30 a.m. with Staff A (Operations Manager) confirmed the above findings.”

“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 and interview, it was determined that the Home Health Agency (HHA) failed to advise and educate the patient on the potential impacts of missed visits and failed to notify the physician of missed visits for 2 patients in a survey sample of 7 patients (Patient Identifiers are #5 and #7). Findings include: Review on 7/17/24 of the facility’s policy “Patient/Client Scheduling” revised date 7/14/23, revealed the “ 2. Purpose 2.1 To ensure patient/client shifts are scheduled and completed according to the plan of care/plan of service... 3.2 The office operations leader or designee shall ensure that adequate resources are available to provide qualified Direct Care Staff to cover scheduled and unscheduled absences so that ordered and/or authorized services are not interrupted...4.2 Missed Shift: A deviation from the plan of service. A missed shift occurs when the scheduled shift is not completed according to the plan of service or the ordering practitioner order(if applicable) for a particular previously assigned date and hours...5.7 If at any time the services provider do not match the ordering practitioner order (or range of orders) as required by the plan of care, A Missed Shift/Visit Note and notification to the ordering practitioner is required. The medical record will include all documentation related to the missed shift including alternative care for the patient. Patient #5 Record review on 7/17/24 of the “Addendum to Plan of Treatment” for Patient #5 for the “Certification Period From 7/4/24 to 9/1/24”, revealed nursing frequency visits ordered as “Frequency and Duration Maxim Healthcare Services to provide skilled nursing services 33-55 hour per week for 60 days”. Further review of Patient #5’s medical record revealed one skilled nursing visit completed in the time frame from 7/4/24 to 7/16/24 on 7/5/24. The skilled nursing visit on 7/5/24 was documented as completed for 4.47 hours. The skilled nursing visits on 7/4/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/15/24, and 7/16/24 were canceled. There was no other documented skilled nursing hours. There was no documented evidence that the facility notified the physician that Patient #5 did not receive 33-55 hours per week until the end of the month. Patient #7 Record review on 7/17/24 of the “Addendum to Plan of Treatment” Patient #7 for the “Certification Period from 4/6/2024 to 6/4/2024”, revealed nursing frequency visits ordered as “Frequency and Duration Maxim Healthcare Services to provide skilled nursing services for 27-45 hours per week for 60 days.” Further review of Patient #7’s medical record revealed no skilled nursing services had been completed since 10/9/23 at the start of care. The majority of missed visits were documented as “No Qualified Caregiver Available.” Medical record review of the 4/5/24 recertification for skilled nursing services completed for Patient #7 revealed the following: “but there is no nursing at this time. Recruiting efforts made daily.” Further review of Patient #7’s record revealed that Patient #7 requested to be discharged on 5/31/24 due to staffing issues. There was no documented evidence that the facility notified the physician until the end of the month. Further review of Patient #7’s medical record revealed no documentation of education on the potential impacts of missed visits. Interview on 7/17/24 at approximately 10:00 a.m. with Staff A (Operations Manager) and Staff B (Clinical Supervisor) confirmed the above missed visits and no documented notification to the physician for the missed visits.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, it was determined that the Home Health agency failed to ensure that patients receive skilled nursing services as outlined in the plan of care for 2 patients out of a survey sample of 7 patients (Patient Identifiers are #5 and #7). Findings include: Patient #5 Record review on 7/17/24 of the “Addendum to Plan of Treatment” for Patient #5 for the “Certification Period From 7/4/24 to 9/1/24”, revealed nursing frequency visits ordered as “Frequency and Duration Maxim Healthcare Services to provide skilled nursing services 33-55 hour per week for 60 days”. Further review of Patient #5’s medical record revealed one skilled nursing visit completed in the time frame from 7/4/24 to 7/16/24 on 7/5/24. The skilled nursing visit on 7/5/24 was documented as completed for 4.47 hours. The skilled nursing visits on 7/4/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/15/24, and 7/16/24 were canceled. There was no other documented skilled nursing hours. Patient #7 Record review on 7/17/24 of the “Addendum to Plan of Treatment” Patient #7 for the “Certification Period from 4/6/2024 to 6/4/2024”, revealed nursing frequency visits ordered as “Frequency and Duration Maxim Healthcare Services to provide skilled nursing services for 27-45 hours per week for 60 days.” Further review of Patient #7’s medical record revealed no skilled nursing services had been completed since 10/9/23 at the start of care. The majority of missed visits were documented as “No Qualified Caregiver Available.” Medical record review of the 4/5/24 recertification for skilled nursing services completed for Patient #7 revealed the following: “but there is no nursing at this time. Recruiting efforts made daily.” Further review of Patient #7’s record revealed that Patient #7 requested to be discharged on 5/31/24 due to staffing issues. Interview on 7/17/24 at approximately 10:00 a.m. with Staff A (Operations Manager) and Staff B (Clinical Supervisor) confirmed the above missed visits for both patients. Staff A revealed that if the agency cannot provide staff, it is up to the patient or the family to provide care.”