Premier Home Health, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the implementation of a comprehensive EPP that included the HHA’s approach to meet the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. This failure had the potential to affect the current 49 patients receiving care by the HHA as well as agency staff, patients receiving care by other agencies, and emergency response personnel. Findings include: 1. The HHA failed to establish and maintain a comprehensive EPP that was reviewed and updated at least every two years. (Refer to E0004). 2. The HHA failed to develop an EEP that was based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (Refer to E0006). 3. The HHA failed to develop an EPP that addressed the population, type of services the agency could provide in an emergency, and continuity of operations, that included delegations of authority and succession plans. (Refer to E0007). 4. The HHA failed to ensure the EPP included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. (Refer to A0009). 5. The HHA failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan. (Refer to E0013). 6. The HHA failed to develop plans for the HHA’s patients during a natural or man-made disaster. (Refer to E0017). 7. The HHA failed to develop procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences during a natural or man-made disaster. (Refer to E0019). 8. The HHA failed to develop an EPP with procedures to inform State and local officials of any on-duty staff or patients the agency was unable to contact. (Refer to E0021). 9. The HHA failed to develop an EPP that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. (Refer to E0023). 10. The HHA failed to develop and maintain an emergency preparedness communication plan. (Refer to E0029). 11. The HHA failed to develop a communication plan that included the names and contact information for staff, entities providing services under arrangement, patients’ physicians, and volunteers. (Refer to E0030). 12. The HHA failed to develop primary and alternate means for communicating with staff and Federal, State, tribal, regional, and local emergency management agencies. (Refer to E0032). 13. The HHA failed to develop an EPP that included a method to share information. (Refer to E0033). 14. The HHA failed to develop an EPP that included occupancy needs. (Refer to E0034). 15. The HHA failed to develop an EPP that included a training and testing program. (Refer to E0036). 16. The HHA failed to develop an EPP that included initial training in emergency preparedness policies and procedures to all new and existing staff, and staff providing services. (Refer to E0037). 17. The HHA failed to develop an EPP that included conducting exercises to test the emergency plan annually. (Refer to E0039).”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the Agency failed to ensure an EPP was developed, reviewed, and updated at least every two years. This failure had the potential to affect the 49 patients receiving services from the HHA as well as facility staff. Findings include: Review of the agency’s Emergency Preparedness Plan revealed a thorough and comprehensive EPP plan had not been developed by the agency and was not reviewed and updated every two years. During an interview on 01/28/2025 at 11:30 AM, the Administrator confirmed a comprehensive EPP had not been established by the agency.”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP included an all-hazards approach based on a facility and community risk assessment. This failure had the potential to affect the current 49 patients receiving care provided by the agency as well as all agency staff. Findings include: Review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and the Director of Nursing (DON). During the review, documentation failed to reveal the EPP was developed using a facility-based and community-based risk assessment. During an interview on 01/28/2025 at 11:10 AM, the Administrator confirmed the agency’s EPP did not include a facility-based and community-based risk assessment.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies identified the patient population that would be at risk during an emergent event, the services able to be provided by the agency during an emergency, how the agency planned to continue operation in the event of an emergency, or the delegation of authority in the event of an emergency. This failure had the potential to affect the current 49 patients receiving care by the agency. Findings include: Review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the EPP did not address the patient population that would be at risk in the event of an emergency event, the services able to be provided by the agency during an emergency, how the agency planned to continue operation in the event of an emergency, or the delegation of authority in the event of an emergency. In an interview on 01/28/2025 at 11:10 AM, the Administrator did not know if the at-risk patient population was identified with strategies to address at risk patient needs.”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies identified the 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. This failure had the potential to affect the current 49 patients receiving care by the agency, as well as facility staff. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the agency’s EPP did not address a process for cooperation and collaboration with local, state and federal officials during an emergency. In an interview on 01/28/2025 at 11:10 AM, during review of the agency’s EPP, the Administrator stated in the event of an emergency the plan was to call the local police department.”

“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 review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP policies and procedures were developed based on a risk assessment and communication plan. This failure had the potential to affect the current 49 patients provided with care by the agency as well as all agency staff in the event of an emergency. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and the Director of Nursing (DON). The review did not reveal documentation to show the agency’s EPP used a risk assessment to develop the plan. During an interview on 01/28/2025 at 11:10 AM, the Administrator confirmed the EPP was not developed with the use of a risk assessment.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP policies addressed a system to ensure each patient’s record included an assessment to determine an individual plan for the patient in the event of an emergency or disaster. This failure had the potential to affect the current 49 patients receiving care from the agency. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review did not reveal the EPP included policies to ensure all patients had an individualized plan incorporated in the comprehensive assessment in the event of an emergency or disaster. During an interview on 01/28/2025 at 11:15 AM, the Administrator confirmed the agency did not have a policy to incorporate an individual emergency plan for each patient in the event of an emergency or disaster in the patient’s comprehensive assessment.”

“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 Home Health Agency ‘s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP policies addressed a system to ensure procedures were in place to inform State and local emergency preparedness officials about 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 failure had the potential to affect the current 49 patients receiving care from the agency. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review failed to reveal a policy to address the procedure to inform State and local emergency preparedness officials about patients in need of evacuation from their homes in the event of an emergency or disaster. During an interview on 01/28/2025 at 11:15 AM, the Administrator confirmed the agency did not have a policy to address how the agency would inform State and local officials about patients needing evacuation from their homes in the event of an emergency or disaster.”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies identified the process for follow up with on-duty staff and patients to determine what services were needed, in the event there was an interruption in services during or due to an emergency. The EPP failed to reveal how to inform State and local officials of any on-duty staff or patients the agency was unable to contact. This failure had the potential to affect the current 49 patients receiving care by the agency, as well as facility staff. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the EPP did not address a process to ensure follow up with on duty staff to ensure what services were required for patients and to inform State and local officials of staff or patients that were unable to be contacted in the event of an emergency. During an interview on 01/28/2025 at 11:20 AM, while reviewing the agency’s EPP, the Administrator did not know how the agency would follow up with on duty staff or local officials to ensure the services needed were provided in the event of an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies identified a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of medical records. This failure had the potential to affect the current 49 patients receiving care by the agency. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the EPP did not address a system to ensure the availability and safeguarding of patient medical records during an emergency. During an interview on 01/28/2025 at 11:20 AM, while reviewing the EPP, the Administrator was not sure how patient records would be accessed or protected in the event the agency’s Electronic Medical Record (EMR) was not available during an emergency. The Administrator confirmed the agency did not have a consistent method to access patient records other than the agency’s EMR.”

“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 review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies included an emergency communication plan, and the communication plan was reviewed and updated at least every two years. This failure had the potential to affect the current 49 patients receiving care by the agency as well as agency staff. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the agency’s EPP did not include an emergency communication plan. During an interview on 01/28/2025 at 11:20 AM, while reviewing the EPP, the Administrator was not able to find documentation to show the agency had developed and routinely reviewed an emergency communication plan as part of the agency’s EPP.”

“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 Home Health Agency’s Emergency Preparedness Plan (EPP) and interview, the agency failed to maintain a current list of names and contact information in an “Emergency Preparedness Communication Plan” that included all facility staff members, patient physicians and providers, and all entities providing services to the agency under arrangement. This failure had the potential to affect the 49 patients receiving care by the facility. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:30 AM with the Administrator and the Director of Nursing (DON). The review revealed the EPP did not contain an effective communication plan, including identification of all the facility’s staff and their contact information (only administrative and office staff were identified), did not include a list of patient physicians or entities providing services under arrangement and their contact information. In an interview on 01/28/2025 at 11:30 AM, the Administrator confirmed only the agency administrative and office staff communication information was identified in the agency’s EPP. The Administrator was not sure why other staff or providers were not included on a contact list in the emergency plan.”

“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 review of the Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies included primary and alternate means for communicating with facility staff as well as Federal, State, tribal, regional, and local emergency management agencies in the event of an emergency. This failure had the potential to affect the current 49 patients receiving care by the agency as well as agency staff. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the plan lacked information to indicate the primary and alternate means of communication with staff and federal, State, tribal, regional, and local emergency management agencies in the event of an emergency. During an interview on 01/28/2025 at 11:20 AM, while reviewing the EPP, the Administrator stated the agency had walkie-talkies to use for alternate means of communication during an emergency. The Administrator was able to locate one walkie-talkie and was not able to get it to work during the interview. The Administrator did not know how many additional walkie-talkies were owned by the agency or which field staff had a walkie-talkie. The Administrator confirmed the agency did not have an alternate way to communicate with outside agencies in the event of an emergency.”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP Communication Plan included a written policy or procedure that addressed the sharing of information and medical documentation for patients receiving care by the agency. This failure had the potential to affect the current 49 patients receiving care by the agency. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the documentation lacked a written policy or procedure for the sharing of patient information and medical documentation with another provider in the event of an emergency. In an interview on 01/28/2025 at 11:30 AM, the Administrator confirmed the agency EPP did not included an identified method for sharing information and/or medical documentation in the event of an emergency.”

“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 Home Health Agency’s (HHA) Emergency Preparedness Plan (EPP) and interview, the agency failed to ensure the EPP, and policies included a method for providing information regarding the agency’s needs and ability to assist the authority having jurisdiction over the emergency or the Incident Command Center in the event of an emergency. This failure had the potential to affect the current 49 patients receiving care by the agency as well as agency staff and patients receiving care from other agencies. Findings include: A review of the HHA’s EPP was conducted on 01/28/2025 at 11:00 AM with the Administrator and Director of Nursing (DON). The review revealed the agency’s EPP lacked information to identify a method to provide information regarding the agency’s needs and the agency’s ability to assist in the event of an emergency. During an interview on 01/28/2025 at 11:20 AM, while reviewing the EPP, the Administrator confirmed the agency’s EPP did not include how the agency would provide information regarding the agency’s needs and the agency’s ability to assist the authority having jurisdiction in the event of an emergency.”

“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 Emergency Preparedness Plan (EPP) review and interview, the Home Health Agency (HHA) failed to ensure an EPP training and testing program was in place and reviewed at least every two years by Administration. This deficient practice had the potential to affect the 49 patients receiving services from the agency as well as all facility staff. Findings include: Review of the HHA’s EPP failed to reveal documentation the agency had a functioning EPP testing and training program in place or the EPP testing program was reviewed at least every two years. The EPP policies did not reveal the required EPP staff training, or that the agency reviewed staff training and testing procedures at least every two years. During an interview on 01/28/2025 at 11:30 AM, the Administrator was unable to provide evidence to show the agency had developed a functional EPP training and testing program or to show an EPP training and testing program had been reviewed at least every two years.”

“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 the agency’s Emergency Preparedness Plan (EPP) review, policy review, and interview, the Home Health Agency (HHA) failed to ensure ten of ten agency staff (Administrator, Director of Nursing (DON), Physical Therapist (PT) 1, Occupational Therapist (OT) 1, Physical Therapy Assistant (PTA) 1, Master Social Work (MSW), Certified Nurse Assistant (CNA) 1, Registered Nurse (RN) 1, Licensed Practical Nurse (LPN) 1, and Office Staff 1) reviewed for training received initial EPP training and routine EPP training every two years. The agency also failed to maintain documentation of any staff EPP training. This deficient practice had the potential to affect 49 patients receiving services from the agency. Findings include: Review of the agency’s EPP failed to reveal documentation that the Administrator, DON, PT 1, OT 1, PTA 1, MSW, CNA 1, RN 1, LPN 1, and Office Staff 1 received initial EPP training and training at least every two years. Review of the agency’s EPP policies failed to include documentation to identify the required EPP staff training and how frequently the EPP training was expected to be conducted. During an interview on 01/28/2025 at 11:30 AM, the Administrator was unable to produce evidence to show agency staff received initial or routine EPP training.”

“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 Emergency Preparedness Plan (EPP) review and interview, the Home Health Agency (HHA) failed to conduct an exercise to test the agency’s EPP annually and failed to conduct a facility-based functional exercise every two years. This deficient practice had the potential to affect the 49 patients receiving services from the agency. Findings include: Review of the agency’s undated “Emergency Preparedness Disaster Plan” failed to reveal documentation an annual exercise or a facility-based functional exercise was performed every two years. Review of the agency’s EPP failed to reveal a current policy to indicate when and how the agency was to perform an annual and/or biannual EPP functional exercises. During an interview on 01/28/2025 at 11:30 AM, the Administrator confirmed an annual test, and a facility-based functional exercise was not performed every two years. The Administrator was unsure as to when the last test was performed and was unable to provide documentation that an exercise had been performed.”

“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, policy review, and interview, 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 49 patients receiving services from the HHA who require evaluation and care. Findings include: Review of the agency’s “Reporting of OASIS Information Policy” revised on 10/2017 revealed, “…The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items …Agency must encode and have the capability of transmitting OASIS data for each patient within thirty (30) days of completing any required OASIS data set assessment. Agency staff will ensure that the accuracy of OASIS data reflects the patient’s status at time of assessment and data collection.” Review of the agency’s OASIS submission data for calendar year 2024 revealed seven out of a total of 570 assessments were coded as being transmitted to IQIES past 30 days. This resulted in an error code of -3330 (late submission) for 1.20% of all assessments submitted in the 2024 calendar year. During an interview on 01/29/2025 at 1:00 PM, the Administrator, Director of Nursing (DON), and the Quality Assessment Coordinator (QA), did not know why the agency’s OASIS data was transmitted late. The QA was unaware the OASIS transmissions were late.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on policy review, review of the “Admission Packet,” and interview, the Home Health Agency (HHA) failed to ensure written information related to patient rights, care and services was routinely provided in a language that could be easily understood by each patient. The failure had the potential to affect any patient who primarily communicated in any other language than English. Findings include: Review of the agency’s “Patient Bill of Rights and Responsibilities Policy” revised on 10/2017 revealed, “…The Agency will provide each patient with a written notice of the patient’s rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment …Written notice is required to be understandable to persons who have limited English proficiency.” Review of the agency’s undated “Admission Packet,” provided to all patients upon admission to agency was reviewed. The “Admission Packet” was provided to all patients in English. The HHA was unable to provide documentation to show the agency had the capability to provide the admission information to patients with limited English proficiency. During an interview on 01/29/2025 at 11:00 AM, the Director of Nursing (DON) and the Quality Assessment Coordinator (QA) confirmed a significant number of the agency’s patients tended to have limited English proficiency, and the patients tended to primarily speak Spanish. The DON and QA were unable to provide documentation to identify the patients with limited English proficiency and whether an assessment was completed to ensure communication would be effective during care and services. The QA stated the agency previously had an admission packet that was written in Spanish, but the packet was no longer used by the agency.”

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on record review, grievance documentation, policy review, and interview, the Home Health Agency (HHA) failed to ensure multiple grievances were addressed and resolved for 1 of 8 Patients (P3) reviewed in the sample. This deficient practice had the potential to affect all 49 patients receiving services from the HHA. Findings include: Review of the agency’s “Patient Bill of Rights and Responsibilities Policy” revised on 10/2027 revealed, “Patients have the right: To voice and report grievances or complaints related to treatment or care that are (or fail to be) delivered …Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.” Review of P3’s “Home Health Certification and Plan of Care” found in P3’s Electronic Medical Record (EMR) revealed P3 was admitted to the agency on 08/07/2024 and discharged from the agency on 10/06/2024. The record indicated P3 had diagnoses including pressure sores to the right and left buttocks. The record indicated P3 was admitted to the agency to receive skilled nursing, home health aide, and physical therapy (PT) services. The record indicated durable medical equipment (DME) supplies required by P3 included incontinence supplies (including wipes and briefs/incontinence pads), a hospital bed, an electric scooter, and a Hoyer mechanical lift. Review of a “Patient Grievance/Complaint Form,” dated 08/27/2024, completed by P3’s family member, and located in the Agency’s “Grievance Binder,” indicated, “Description: [Family Member] called and complaining about the DME request which is incontinent supplies, hospital bed, Hoyer lift and electric scooter, why until now they don’t have it [sic]. Explained to [Family Member] that the DME company is waiting for the updated prescription. But (Family Member) didn’t want to hear any excuses;” and “Resolution: DON [Director of Nursing] explained to the patient that are some delay [sic] in the processing of the order. The patient accepted the explanation.” Review of a “Patient Grievance/Complaint Form,” dated 08/29/2024, completed by P3’s family member, and located in the agency’s “Grievance Binder,” revealed, “Description: [Family Member] called and complaining why it takes a while for the doctor to send the update prescription to the DME company [sic]? Explained to her that last Tuesday we informed the provider about the changes of (DME) and of her additional request to include wipes and chucks … Resolution: DON explained to the patient that because of the change in the order, it created some delay in the processing. Patient accepted the explanation.” Review of a “Patient Grievance/Complaint Form,” dated 09/03/2024, completed by P3’s family member, and located in the agency’s “Grievance Binder,” revealed, “Description: [Family Member] called and upset about their incontinence supplies request. They called the DME company and (DME company) informed them [the patient’s family member] that the updated prescription is not there yet …Resolution: DON explained to the patient that because of the change in the order, it created some delay in the processing. Patient accepted the explanation.” Review of a “Patient Grievance/Complaint Form,” dated 09/16/2024, completed by P3’s family member, and located in the agency’s “Grievance Binder,” revealed, “Description: (Family Member) called and stated that we are unprofessional, why it takes a while for sending the order. [sic] She also stating that we don’t know what we are doing. Explained to [P3’s family member] that we are communicating with the provider and DME company, but she is not listening to me …Resolution: DON explained to the patient that because of the change in the order, it created some delay in the processing. Patient accepted the explanation.” The agency was unable to provide any documentation to show the required supplies were provided to R3 during admission to the agency. During an interview on 01/29/2025 at 12:00 PM, the DON and Administrator confirmed the agency did not have any documentation to show the follow-up that was conducted related to the grievances filed on the behalf of P3. The DON stated the patient should have had the DME and supplies immediately after admission to the agency. During an interview on 01/29/2025 at 12:04 PM, the Intake Coordinator was responsible for ordering and coordinating patient DME. The Intake Coordinator stated the patient’s urinary pads and shower chair were delivered to P3 on 09/17/2024 and the other requested incontinence supplies (chucks and Pull-Ups) and wipes were not received by the patient prior to discharge from services. The Intake Coordinator stated the patient’s physician did not send the updated order for supplies to the agency, until 09/27/2024, one month after the first grievance was filed by P3’s family member. The Intake Coordinator stated, at that point, the DME company stated they would send the supplies, but that did not occur until after P3 was discharged from the agency on 10/06/2024. The Intake Coordinator confirmed P3’s DME and supplies were initially ordered by the agency on 08/22/2024. The Intake Coordinator confirmed the delivery of P3’s supplies and DME was delayed.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on employee file review, policy review, and interview, the Home Health Agency (HHA) failed to ensure required in-service training for 2 of 10 employees (Administrator and Director of Nursing (DON)) were completed. This deficient practice had the potential to affect all 49 patients receiving services from the HHA who require nursing evaluation and care. Findings include: Review of the agency’s “Inservice Education Policy” revised on 10/2017 revealed “…Regularly scheduled and appropriate in-service programs will be made available for all employees …Certain in-service programs are determined by the Agency to be mandatory initially and annually for all staff. These include but are not limited to: - OSHA bloodborne pathogens …TB (tuberculosis) risk program …Hazardous materials in the workplace (Right-to-Know Program.) …Emergency Operations Plan …The annual education plan minimally addresses: -Emergency/disaster training …How to handle complaints/grievances …Infection control training …Cultural diversity …Communication barriers …Ethics training …Workplace and patient safety …OSHA (Right to Know laws) …Patient Rights and Responsibilities….” Review of the DON’s employee record did not reveal documentation the required annual training was completed. Review of the Administrator’s employee file did not reveal documentation the agency’s mandatory annual in-service trainings were completed. During an interview on 01/27/2025 at 4:30 PM, the Administrator was an RN and provided routine direct care to agency patients. The Administrator was unable to provide documentation to show the required mandatory annual in servicing was completed within the last 12 months. During an interview on 01/27/2025 at 4:30 PM, the DON provided direct care to agency patients. The DON was unable to provide additional documentation to show the required annual in-service training was completed within the last 12 months.”