Richard Health Systems, LLC

“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 facility documentation and staff interview, the facility failed to review and maintain an emergency preparedness program that meets all of the standards specified within the condition/requirement of CFR 484.102. The emergency preparedness program must describe a facility’s comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. The program must also address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). The emergency preparedness (EP) program must be reviewed annually. This deficient practice had the potential to affect all residents. Findings include: Record review on 04/22/25 at 10:45 A.M. noted the facility inspection, provider plans and procedures and test records from the previous 12 months. Further review, when requested, revealed the lack of documentation on a facility specific EP plan. No additional documentation was provided, at the time of survey, to validate the provider has established a comprehensive all hazards approach emergency preparedness plan to include but not limited to a full scale and tabletop exercises to test the plan. Furthermore, the documentation lacked staff training, emergency contact information, and hazardous vulnerability assessment information. Interview with the Administrator verified the findings at the time of record review.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review, interview and policy review, the agency failed to consult the physician when changes were made to the plan of care. This affected four (Patients #1, #2, #4 and #6) with the potential to affect all patients cared for by this agency. See G572”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to consult the physician when changes were made to the plan of care. This affected four (Patients #1, #2, #4 and #6) with the potential to affect all patients cared for by this agency. Findings include: 1. Record review revealed Patient #1 had a start of care date of 2/05/24 with a primary diagnosis of hypertension (high blood pressure), asthma and on dialysis. The certification periods reviewed were 01/30/25 through 03/30/25 and 03/31/25 through 05/29/25. The plan of care stated for Home Health Aide (HHA) services two hours per day seven days per week. Review of the medical record revealed HHA visits were completed Monday through Saturday for a total of 33 hours per week instead of the ordered 14 hours. During an interview on 04/14/25 at 5:40 PM, Staff A stated the Patient #1’s case manager had changed the hours sometime ago and the physician was not notified. 2. Record review revealed Patient # 2 had a start of care date of 09/17/24. The certification period reviewed was 03/16/25 through 05/14/25. Skilled nursing was ordered daily for dressing changes seven days per week and HHA services 14 hours per week. Review of the medical record revealed visits were completed for 20-27 hours per week instead of the ordered two hours seven days per week. Record review revealed skilled nurse visits were missed on 02/28/25, 03/01/25, 03/02/25, 03/11/25, 03/12/25, 03/14/25, 03/17/25, 04/01/25 through 04/05/25 and 04/07/25. Review of wound care orders from the wound clinic, dated 03/20/25, were to complete wet to dry dressings to the right ankle, cleanse with normal saline then cover with an ACE wrap. Measurements were completed for the right ankle bi-weekly until 03/23/25 when only one measurement was competed. The next measurement was not completed until 04/15/25 with the same measurements documented as on 03/23/25. During an interview on 04/17/25 at 6:00 PM, Staff A stated they found no missed visit documentation and did not know why the daily visits were not completed, the wound measurements were not completed as ordered and the physician was not notified. Review of the policy titled “Patient Not Found at Home”, no date, stated the purpose to provide clinicians guidelines for appropriate actions when the patient does not answer the door. If the patient doesn’t respond to the door, call the residence, then the emergency contact, and notify the immediate supervisor. Review of the policy titled “Wound Measurement and Documentation” stated to complete wound measurements at least bi-weekly to monitor healing progress. Documentation should include a description of the wound, its size, and any changes observed over time, along with the plan of care and any interventions implemented. Measurements should include length, width and depth if tunneling is present. 3. Record review revealed Patient #4 had a start of care date of 9/25/24 with a primary diagnosis of hypertension and Type 2 diabetes. The certification period reviewed was 01/23/25 through 03/23/25 and 03/24/25 through 05/22/25 with orders for HHA services six hours per week. 0 Record review revealed visits were missed the week of 02/09/25, 02/23/25, 03/30/25 and 4/06/25. D During an interview on 04/17/24 at 5:50 PM, Staff A stated they could find no documentation related to missed visits and the physician was not notified. 4. Record review revealed Patient #6 had a start of care date of 01/29/24 with a primary diagnosis of diabetes, hypertension and history of intellectual disabilities. The certification periods reviewed were 02/01/25 through 04/01/25 and 04/02/25-05/31/25 with skilled nursing ordered two times a day seven days a week. HHA services were ordered five hours a day seven days a week. Review of the medical record revealed no notes from the HHA. No skilled nurse visit was completed on 02/12/25 and from 02/17/25 through 0/24/25. Only one visit was completed on 02/25/25. No visit was completed on 03/07/25 and 03/08/25. During an interview on 4/17/25 at 9:30 AM, Staff A could find no documentation related the missed skilled nursing visits and the physician was not notified. Staff A stated the HHA services were being provided by a different agency. Review of the policy titled “Missed Visits” stated if a visit is missed and not rescheduled the clinician or designee will: Notify the provider and clinical supervisor of the missed visit and reason for missed visit. Document in the patient’s clinical record the date and type of visit that was missed as well as reason for the missed visit as well as provider notification including date, time, provider name, and the staff reporting this.”

“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 failed to follow infection control procedures during a dressing change. This affected one (Patient #3) with the potential to affect all patients cared for by this agency. Findings include: Record review revealed Patient #3 had a start of care date of 09/15/24. The primary diagnosis listed was hypertension, pressure ulcer, stage 4 and a history of paraplegic. Orders were received for skilled nursing once per day. Dailyi dressing changes were ordered to pressure ulcers on the left and right ischium, cleanse with wound cleanser, apply Silvercel rope and a dry sterile dressing. A home visit was completed on 04/15/25 at 12:00 PM. Staff D, a Licensed Practical Nurse (LPN) was observed completing the dressing change. Staff D applied gloves, opened the dressings and put the supplies at the foot of the bed. Staff D removed the old dressings. The wound areas were washed with soap and water. A four by four gauze saline was used to clean inside the wound then dried. Without changing gloves or washing hands, Staff D packed the wounds with Silvercel rope, applied skin prep and a dry dressing. During an interview at 12:15 PM, Staff D stated “I would change my gloves if I was changing a wound somewhere else like his leg”. Review of the policy titled “Application of an Absorbent Dressing” stated to confirm the physicians order, gather the necessary supplies, position the patient, apply gloves, remove the old dressing and place in a plastic bag. Cleanse the wound with normal saline or other prescribed wound cleaning solution, assess wound size, color, depth, drainage, odor and condition of surrounding tissue. Removed gloves wash hands with antibacterial soap or solution, apply new gloves, apply the absorbent dressing, cover the wound as ordered.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review, observation and interview, the facility failed to ensure patients had an accurate medication profile. This affected three (Patients #1, #2 and #3) with the potential to affect all patients cared for by this agency. The facility census was 80. Findings include: 1. Record review revealed Patient #1 had a start of care date of 02/05/24. Primary diagnoses were hypertension (high blood pressure), asthma and on dialysis. The certification periods reviewed were 01/30/25 through 03/30/25 and 03/31/25 through 05/29/25. The plan of care had orders for Home Health Aide (HHA) services two hours per day seven days per week. A re-certification was completed on 02/28/25 along with a supervisory visit. A home visit was completed on 04/15/25 at 10:30 AM. Medications were reviewed in the home with Patient # 1 and compared with the plan of care and medication profile. Patient # 1 verified the following: Auryxia (treats low iron) 1 gram which was on the medication profile to take three tablets three times a day. Patient #1 stated they have been taking four tablets three times a day for some time now. Patient #1 stated they had stopped taking Carveldilol (treats heart failure) three weeks ago,stopped taking Clonidine (for high blood pressure) BP) over one month ago, stopped taking Lanthanum carbonate (antiphosphate) one year ago, stopped taking Minoxidil (for high blood pressure) four months ago and stopped taking Tizanidine (muscle relaxer) months ago. Metoprolol tartrate (treat high BP) 25 mg was ordered two times per day and Patient # 1 stated they never took this medication. 2. Record review revealed Patient # 2 had a start of care date of 09/17/2. The certification period reviewed was 03/16/25 through 05/14/25. Skilled nursing was ordered daily for dressing changes seven days per week and HHA services 14 hours per week. Medications were reviewed in the home with Patient #2 on 04/15/25. Enoxaparin Sodium 1 injection daily was listed on the medication profile. Patient #2 stated they stopped this medication as well as a daily Aspirin when they came home form the hospital. Lasix 40 mg was listed as prescribed three times per day and the patient took it twice per day. The medication profile listed Predisone 10 mg daily but the patient’s prescription bottle listed the dose as 5 mg daily. Toujeo solostar (long acting insulin) subcutaneous 90 units daily was on the medication profile but Patient #2 stated they are taking only 50 units and have been for the past three months. Vitamin D3 was listed on the medication profile and Patient #2 stated they stopped taking this some time ago. 3. Record review revealed Patient #3 had a start of care dare of 09/15/24. The primary diagnosis listed was hypertension, pressure ulcer, stage 4 and a history of paraplegic. The certification period reviewed was for 01/13/25 through 03/13/25 and 03/14/25 through 05/12/25. Orders were received for skilled nursing once per day and HHA services 40 hours per week. A home visit was completed on 04/15/25. The medication profile was reviewed with Patient #3. Patient #3 stated they do not take any medications and have not for months. This was verified during the visit with Licensed Practical Nurse Staff D. During an interview on 04/15/25 at 5:40 PM, Staff A and Staff B verified the above findings. Review of the policy titled “Medication Profile”, revised 02/06/23 , revealed staff are to update the medication profile to reflect current medications, new, and/or discontinued medications. This review will be performed at the time of admission, when updates to the comprehensive assessment are performed, when care is resumed and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy and noncompliance with drug therapy.”

“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 a review of the Emergency Preparedness Plan and staff interview, the agency failed to ensure the Emergency Preparedness Plan was reviewed and updated at least every two years. This had the potential to affect all patients and staff. The agency census was sero. Review of the agency Emergency Preparedness Plan revealed it was last reviewed on 08/16/2017. Interview on 01/09/23 at 2:30 PM, Staff A confirmed the above.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to provide procedures to inform state and local emergency preparedness officials about homebound patients in need of evacuation from their residences during an emergency situation. This has the potential to affect all patients receiving services at the agency. The agency census was zero. Review of Emergency Preparedness Plan was completed on 01/09/24. There was no procedure, policy or plan on how to inform officials if patients need to be evacuated. Interview on 01/10/24 at 10:00 AM with Staff A and B confirmed there was no process for informing officials in the event of a patient needing to be evacuated from their residence.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to procedures in place in the event on-duty staff or patients could not be contacted. This has the potential to affect all patients. The agency census was zero at the time of survey. Review of the Emergency Preparedness Plan revealed it was lacking a procedure on follow-up with on-duty staff or patients in an emergency and on informing officials of the same. Interview on 01/10/23 at 10:00 AM, with Staff A and B confirmed the Emergency Preparedness Plan had no procedure in place in the event on-duty staff or patients could not be contacted.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to ensure the plan contained contact information to identify state and local officials to request assistance to provide care for homebound patients in need of evacuation. This could affect all patients receiving services from this agency. The census was zero. Review of the Emergency Preparedness Plan revealed no contact information to identify state and local officials to request assistance to provide care for homebound patients in need of evacuation. Interview on 01/09/24 at 1:30 PM, Staff A and B confirmed there was no contact list for for use by the staff.”

“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 a review of the Emergency Preparedness Plan, review of emergency drills, and staff interview, the agency failed to conduct emergency drills as required. This has the potential to affect all patients cared for by this agency. The current census was zero. Review of the Emergency Preparedness Plan revealed the last practice drill for this agency was a fire drill completed on 08/14/17. The findings of not completing practice drills annually with staff was verified with Staff A and B on 01/10/24 at 10:15 AM.”

“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 a review of medical records, staff interview, and review of agency policy, the agency failed to transmit disharge Outcomes and Assessment Information Set (OASIS) assessments for three (#2, #5, and #9) patients. This has the potential to affect all patients cared for by this agency. The agency current census was zero. 1. The medical record for Patient #2 was reviewed on 01/10/24. Patient #2 had a start of care (SOC) of 04/28/22 with a primary diagnosis of chronic myeloid leukemia. The certification period reviewed was for 04/28/22-05/19/22. Skilled visits were ordered for one time per week. Visits were completed weekly with the last visit completed on 05/13/22. Review of a discharge summary stated this patient died at home on 05/19/2022 with the primary care physician notified. No documentation was found regarding a discharge OASIS. Review of the facility policy titled “Comprehensive Assessment (OASIS)” instructs staff the comprehensive assessment (including OASIS data elements) must be updated and revised as frequently as the patient’s condition warrants due to a major improvement or decline in health status. This should be update after inpatient stays, if patient discharged from agency, transferred to inpatient facility or dies in their home. The findings of not completing a discharge OASIS and transmitting this information was verified with Staff D on 01/11/24 at 5:12 PM. 2. The medical record for Patient #5 was reviewed on 1/11/24. Patient #5 had a SOC of 12/29/21 with a primary diagnosis of chronic pulmonary obstructive disease (COPD). The plan of care (POC) had orders for skilled nursing (SN) one time per week and home health aide (HHA) seven hours per week. The medical record revealed the last skilled visit was 05/02/22 and the last HHA visit was completed on 05/06/22. No documentation was found regarding a discharge OASIS. Interview with Staff D on 01/11/24 at 1:15 PM verified no discharge OASIS was completed or transmitted for this patient. 3. The medical record for Patient #9 was reviewed on 01/11/24. Patient #9 had a SOC of 12/27/21 with a primary diagnosis of schizophrenia disorder. The certification reviewed was for 02/25/22-04/25/22 with skilled visits documented through 03/22/22. A note on 04/02/22 staed this patient was discharged from the agency. No documentation was found regarding a discharge OASIS. Interview with Staff D on 1/11/22 at 4:00 PM verified no discharge OASIS was completed.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on medical record review, staff interview, and policy review, the facility failed to follow the orders in the plan of care (POC) for visits and failed to notify the physician when the POC could not be completed. This affected Patient #1 and #4 with the potential to affect all patients cared for by this agency. The facility census was zero. 1. The medical record for Patient #1 was reviewed on 01/09/24. Patient #1 had a start of care (SOC) of 01/24/22 with a primary diagnosis of dementia and malignant neoplasm of the lung. The certification period reviewed was for 01/24/22-03/24/22. The POC orders identified skilled nursing (SN) was ordered for two times per day and home health aides (HHA) 14 hours per week. The record revealed SN visits were completed as follows; one visit was provided on 01/25/22, 01/26/22, and 01/27/22. No SN visits were completed for the dates between 01/29/22 to 02/07/22. A discharge OASIS was completed on 02/24/22 with a note stating this client’s sister was going to start caring for the patient. No HHA visits were completed for this certification period. There was no documentation the physician was contacted to modify the POC when the visits were not completed. Interview with Staff B on 1/10/24 at 12:00 PM verified Patient #1 never received aide visits due to a scheduling problem. Staff B stated no documentation found the physician or case manager were notified of the missed SN visits and no aide visits being provided to modify the POC. Review of the undated agency policy titled “Backup Plan Rule 173-39-02 © (2)” revealed if for any reason the scheduled patient care attendant (PCA) is unable to complete the visit the agency will contact the case manager/physician’s office to notify of missed visit and make record of all communications. The findings of not notifying the physician of the missed visits was verified with Staff A on 01/10/24 at 12:15 PM. 2. The medical record for Patient #4 was reviewed on 01/10/24. Patient #4 had a SOC of 12/30/21 with a primary diagnosis of chronic obstructive pulmonary disease (COPD) and high blood pressure. The certification period reviewed was for 02/28/22-04/28/22 and 04/29/22-06/27/22. Orders were received to provided HHA visits nine hours per week. Interview with Staff B revealed Patient #4 requested all nine hours to be completed on Mondays due to the families request. No HHA visits were completed for the week of 04/11/22 and 04/18/22, with the last HHA visit documented on 04/25/22. Interview with Staff A and Staff B on 01/10/24 at 4:15 PM verified no documentation was found regarding missed visits being reported to the physician for modification of the POC.”