Caring Nurses Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure a comprehensive Emergency Preparedness program was reviewed and updated every two years. This deficient practice had the potential to affect all patients and staff in the event a disaster occurred. Findings include: Review of the undated agency’s “Emergency Preparedness Plan,” indicated the plan had been reviewed for a comprehensive risk assessment that included the elements of natural disasters, man-made disasters, and facility-based disasters. During an interview on 06/11/2025 at 2:42 PM, the Chief Financial Officer (CFO) who was the emergency preparedness coordinator, could not recall the last time a comprehensive review of the plan occurred. The CFO stated there was no documentation to indicate it had occurred.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the facility failed to ensure comprehensive Emergency Preparedness program policies were developed and reviewed every two years. This deficient practice had the potential to affect all patients and staff in the event a disaster occurred. Findings include: Review of the undated facility’s “Emergency Action Plan,” revealed policies and procedures based on the emergency plan were completed to include how often the plan and policies should be reviewed every two years. During an interview on 06/11/2025 at 2:42 PM, the Chief Financial Officer (CFO), who was the emergency preparedness coordinator, could not recall the last time a comprehensive review of the policies occurred. The CFO stated there was no documentation to indicate it had occurred.”

“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 record review and interview, the Home Health Agency (HHA) failed to ensure staff received emergency preparedness training biannually as required by the agency’s policy and failed to maintain documentation of all emergency preparedness training. This deficient practice had the potential to affect all patients and staff in the event a disaster occurred. Findings include: Review of the undated agency’s “Emergency Action Plan,” indicated the plan required all staff to receive emergency preparedness training on orientation and annually. The agency did not provide documented evidence that all staff members had received emergency preparedness training annually. During an interview on 06/12/2025 at 2:27 PM, the Chief Executive Officer (CEO) stated there was no documentation the staff had received continued training after orientation.”

“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 document review, interview, and policy review, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all 138 patients receiving services from the HHA who require evaluation and care. Findings include: Review of the agency’s policy titled, “Reporting OASIS Information,” reviewed October 2020, revealed “Policy…must electronically report all OASIS data collected in accordance with Conditions of Participation…must electronically transmit each completed OASIS assessment to CMS [Centers for Medicare and Medicaid] system regarding each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary…” The agency’s OASIS submission data since June 2021 was reviewed for timely transmission to IQIES. The data revealed late transmissions over the state’s threshold of 10.0% per quarter. This resulted in an error code of -3330 (late submission). During an interview on 06/11/2025 at 10:34 AM, a Physical Therapy Assistant (PTA) who was also the Administrator Assistant in charge of payroll, was asked about the delays. The PTA stated, “Staff turnover and trying to get staff to get their paperwork timely has been a challenge. Several staff went on vacation all at the same time at one point also.””

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, record review, interview, and policy review, the Home Health Agency (HHA) failed to provide a medication profile for one of seven patients (Patient (P) 3) observed during seven home visits completed on 06/10/2025 to 06/12/2025. This deficient practice had the potential to affect the current 138 patients, and any future patient admitted to the HHA in need of services. Findings include: Review of agency’s undated policy titled, “Home Health Folder Forms,” revealed under “Purpose…To notate what forms stay in the client [patient] home after the start of care visit.” The policy indicated which forms were to be on the left side of the folder and which were to be in the right side of the folder. The list for the right side included, “Medication Profile.” Review of P3’s plan of care under the electronic medical record (EMR) tab “Care Plan” revealed that the current care plan was for the certification period of 04/11/2025 - 06/09/2025. During the home visit in P3’s home on 06/10/2025 beginning at 4:00 PM, with Registered Nurse (RN) 2. A review of the in-home health folder revealed there was no medication profile in the folder. When RN2 looked at the folder, RN2 verified there was no medication profile. During an interview with P3 during the visit, P3 stated, “I typed my own medication list in my computer, and I keep it on top of the medication keeper so I can fill my medications in the medication planner.” P3 verified there was no medication profile in the home from the home health agency.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure that one of six staff, Certified Nursing Assistant (CNA)1 followed agency policy for hand hygiene and gloving during one home visit observation for one patient (Patient (P) 6) and failed to ensure that two of six staff observed followed agency policy for bag technique for cleaning reusable supplies observed, for three patients (P1), P3, and P5) during seven home visits completed on 06/10/25 to 06/12/25. This deficient practice had the potential to affect the current 138 patients, and any future patient admitted to the HHA in need of services. Findings include: Review of the agency’s undated policy titled, “Hand Washing,” revealed under procedure “Proper Hand Washing Technique: Wet hands, lather hands, scrub hands, rinse hands, dry hands-Use a clean paper towel or air dryer to dry hands, if using a paper towel, turn off the tap with towel to avoid re-contaminating your hands.” Review of the agency’s undated policy titled, “Glove Technique,” revealed under procedure, “Gloves must be worn during personal care tasks such as toileting, bathing, or perineal care. During use change gloves between tasks and procedures on the same patient when moving from a contaminated to a clean body site. Do not touch clean items (e.g., medical supplies, doorknobs, or phones) with contaminated gloves.” Review of agency’s undated policy titled, “Bag Technique,” revealed “The home health bag shall be maintained in a clean, organized, and ready-to-use condition at all times. Proper hand hygiene and aseptic techniques must be observed when accessing supplies to prevent contamination. All reusable items must be properly cleaned and disinfected after each use.” 1. During the home visit observation in P6’s home on 06/12/25 beginning at 12:15 PM, Certified Nursing Assistant (CNA) 1 cleansed hands with alcohol gel and put on gloves. CNA1 completed a shower for P6 which included washing the patient’s hair, face, trunk, legs, feet, and cleaning the perianal area last. Without removing the gloves, CNA1 towel dried P6, had P6 ambulate to P6’s bedroom and sit on a stool. While wearing the same gloves used to give the patient a shower and dry the patient. CNA1 picked up a container of lotion, and applied lotion to trunk and all extremities. CNA1 then picked up a comb and combed P6’s hair. CNA1 put a dress on P6. After completing the shower, drying the patient, applying lotion to the patient’s trunk and extremities, combing the patient’s hair and dressing the patient. CNA1 removed the gloves and washed their hands. After rinsing the soap from their hands, CNA1 turned off the faucets with clean hands. CNA1 used a towel hanging by P6’s sink to dry their hands. CNA1 acknowledged the observed breaks in infection control. During an interview with Licensed Practical Nurse (LPN)/Quality Assurance (QA) Nurse on 06/12/25 at 8:47 AM, the observations regarding CNA1 were discussed. The LPN indicated that CNA1 should not have used P6’s bar soap to wash hands, should not have turned off the faucets with clean hands and should not have dried hands on P6’s used bathroom towel but rather should have used alcohol-based hand sanitizer before and after the providing the shower and removing gloves. 2. During the home visit observation in P1’s home on 06/10/25 beginning at 2:20 PM, Registered Nurse (RN) 1 removed a blood pressure cuff and stethoscope from their backpack, cleansed it with an alcohol wipe, and applied the cuff to P1’s right arm, checking the blood pressure with the stethoscope, then placed the cuff into the backpack. RN1 checked P1’s temperature and pulse oximeter placing the oximeter device on P1’s finger. RN1 then placed the pulse oximeter into the backpack. RN1 did not follow the policy to clean reusable equipment after use. During an interview with RN1 at 11:10 AM on 06/12/25, RN1 verified the above observations and verified that the bag technique was not followed. 3. During the home visit observation in P3’s home on 06/10/25 beginning at 4:10 PM, RN2 removed a wrist blood pressure cuff case from their bag, opened the case, and removed the cuff, placing it on P3’s right wrist. Without cleaning the cuff, RN2 placed the cuff back into the case. RN2 removed a pulse oximeter from a cloth bag and applied the device to P3’s finger. RN2 then placed the pulse oximeter into the cloth bag and placed the pulse oximeter and blood pressure devices into their bag. During an interview with RN2 on 06/12/25 at 9:35 AM, RN2 verified the above findings. 4. During the home visit observation in P5’s home on 06/12/25, beginning at 10:10 AM RN1 removed a blood pressure cuff from a bag inside of the backpack and stethoscope from their backpack, RN1 cleaned the blood pressure cuff and stethoscope an alcohol wipe and took P5’s blood pressure. RN1 placed the blood pressure cuff back into its bag and placed it into RN1’s backpack. RN1 removed a pulse oximeter from the backpack, cleaned it with an alcohol wipe, and placed the device on P5’s finger, and without cleaning the oximeter, placed it into the backpack. During an interview on 06/12/25 at 11:10AM, RN1 reviewed the printed policy for bag technique and verified the policy to clean reusable devices after use was not followed.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on staff file review, interview, and policy review, the Home Health Agency (HHA) failed to provide documentation for in-service training for three of four Certified Nursing Assistants (CNA). This deficient practice had the potential to allow CNA staff to provide care without updated information. Findings include: Review of the facility’s policy titled, “Home Health Aide Services,” revised October 2020 revealed, “Policy: Home Health Aides will be employed if they meet the competency evaluation criteria required by Health Care Finance Administration…4. Aides will receive at least 12 hours in service training every 12 months…5. Documentation of all testing and in-service training will be maintained in the personnel file or CNA [Certified Nursing Aide] in-service book.” Review of HHA staff revealed the following: -CNA1 date of hire was 03/10/14. -CNA2 date of hire was 11/03/14. -CNA3 date of hire was 08/26/22. During an interview on 06/12/25 at 2:27 PM, a Licensed Practical Nurse (LPN), who was also the Clinical Assistant, stated there had been no in-services for the CNA’s and tracking had not been done.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and policy review, the Home Health Agency (HHA) failed to reconcile medications and update the medication profile for one of seven patients (Patient (P) 3) observed during seven home visits completed 06/10/2025 - 06/12/2025. This deficient practice had the potential to affect the current 138 patients and any future patients. Findings include: Review of the agency’s undated policy titled, “Medication Profile-Updating,” revealed “Updating the medication profile form after verifying a medication change. Updates include new medications (name, dose, route, frequency, indication), Discontinued medications…” On 06/10/25 at approximately 3:30 PM, the agency was not able to provide P3’s medication profile. The Chief Executive Officer (CEO) indicated the 485 Plan of Care had the patient’s medication list. During the home visit on 06/10/25 beginning at 4:00 PM, the medications on the 485 Plan of Care were reviewed with P3. P3 was not taking the medications that were listed on the 485 Plan of Care which were: Multivitamin one daily, Furosemide 20 mg (milligram) one daily, and Potassium Chloride 10 MEQ (milliequivalents) one daily. P3 indicated that they printed the current medications by computer and the list was on top of the “medi-planner” in a cabinet. Registered Nurse (RN) 1 retrieved the list and verified that none of the medications listed on the 485 Plan of Care were what P3 was currently taking according to the list. There was no medication profile in the home folder to compare medications. P3 verified there was no list of current medications in the home other than the list P3 printed out.”