River Stone Home Health

“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 record review and interview, the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) was developed and implemented for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment was developed and implemented for the agency. On 07/30/25 at 2:00 p.m., Staff A stated the agency did not have AHRA as a part of its emergency preparedness program.”

“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 record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included current employee contact information for the agency for 10 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and #10) of 10 patients and five employees. Findings: A review of administrative records showed an Emergency Preparedness Communication Plan that had former employee contact information and showed no current employee telephone number contact information for the agency. On 07/30/25 at 2:00 p.m., Staff A stated the Emergency Preparedness Communication Plan was not updated and did not include current employees telephone contact information for the agency.”

“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 record review and interview, the agency failed to ensure an emergency preparedness testing and training program was reviewed and updated from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25 for all patients and employees. Findings: A review of administrative records showed no emergency preparedness plan testing and training program was reviewed and updated from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25. On 07/30/25 at 2:00 pm, Staff A stated the agency had no emergency preparedness plan testing and training program that showed it was reviewed and updated from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25.”

“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 record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25 for ten (Patients #1,2, 3, 4, 5, 6, 7, 8, 9 and #10) of 10 patients and five employees. Findings: A review of emergency preparedness records showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25. On 07/30/25 at 2:00 p.m., Staff A stated there were no table-top exercise, drill, community drill or plan activation event from 05/12/23 to 12/31/23, calendar year 2024 and 01/01/25 to 07/29/25.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of transfer/discharge summaries for two (Patients #8 and #9) of 10 patients. Findings: Patient #8 A review of the clinical record showed the patient was transferred to in-patient hospital services with discharge from the agency on 04/05/25. The clinical record showed no transfer with discharge summary was completed. On 07/30/25 1:25 p.m., Staff A stated patients #8 did not have a transfer summary completed. Patient #9 A review of the clinical record showed the patient was transferred to in-patient hospital services on 03/10/25. The clinical record showed no transfer summary was completed. On 07/30/25 1:35 p.m., Staff A stated patients #9 did not have a transfer summary completed.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure utilization of QAPI quality indicator data for 10/01/23 to 12/31/23, 01/01/24 to 06/30/24 and 11/01/24 to 12/31/24 for all patients and employees. Findings: A review of administrative QAPI records showed no quality indicator data collection sources utilized in the analysis and reporting of data in the agency’s QAPI Program for 10/01/23 to 12/31/23, 01/01/24 to 06/30/24 and 11/01/24 to 12/31/24. On 07/30/25 at 1:55 p.m., Staff A stated QAPI program documentation for 10/01/23 to 12/31/23, 01/01/24 to 06/30/24 and 11/01/24 to 12/31/24 did not show quality indicator data sources were used in the analysis and reporting of the data.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure performance improvement projects were identified, documented, followed and reported on by the agency in calendar years 2023, 2024 and 01/01/25 to 03/31/25 for all patients and three employees. Findings: A review of administrative QAPI Program records showed no performance improvement projects were identified, documented, followed and reported on by the agency in calendar years 2023, 2024 and 01/01/25 to 03/31/25. On 07/30/25 at 1:55 p.m., Staff A stated the QAPI program documentation did not show performance improvement projects were identified, documented, followed and reported on by the agency in calendar years 2023, 2024 and 01/01/25 to 03/31/25.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of a patient centered QAPI program in calendar years 2023, 2024 and 01/01/25 to 01/13/25 for all patients and employees. Findings: A review of administrative governing body meeting minute records showed no governing body oversite in the conduction of a patient centered QAPI program for calendar years 2023, 2024 and 01/01/25 to 01/13/25. On 07/30/25 at 2:05 p.m., Staff A stated the governing body committee meeting minutes for calendar years 2023, 2024 and 01/01/25 to 01/13/25 did not show review of QAPI program reporting for the agency.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Findings: A review of administrative governing body meeting records showed no governing body oversite of the agency’s program evaluation in calendar years 2023, 2024 and 01/01/25 through 07/28/25. On 07/30/25 at 2:00 p.m., Staff A stated governing body meeting minutes did not show governing body oversite of the agency’s program evaluation in calendar years 2023 and 2024 and 01/01/25 through 07/28/25.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure notification to the physician prior to a patient’s discharge from agency services for non-authorization of services by the payor source for one (Patient #6) of 10 patients. Findings: Patient #6 A review of the clinical records showed the patient was discharged from the agency on 07/17/25 for non-authorization of services by the payor source. The clinical record showed no communication or coordination of care attempts with the ordering medical provider to notify the patient was being discharged from home care services for non-authorization of services by the payor source. On 07/30/25 at 1:10 p.m., Staff A stated the SN did not communicate with the ordering medical provider that the patient was being discharged from the agency for non-authorization of services by the payor source, prior to the patient’s discharge from HHA services on 07/17/25.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notices were provided to patients prior to discharge from agency services for two (Patients #6 and #7) of 10 patients. Findings: Patient #6 A review of the clinical record showed no advance notice of discharge was provided to the patient prior to discharge from the agency on 07/17/25 for non-authorization of services by the payor source. Patient #7 A review of the clinical record showed no advance notice of discharge was provided to the patient prior to discharge from the agency on 05/27/25 for non-authorization of services by the payor source. On 07/30/25 at 1:15 p.m., Staff A stated there were no ABN notices provided to patients #6 and #7 prior to being discharged from the agency.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POCs included medical provider pain reporting parameters for eight (Patients #1, 3, 4, 5, 6, 7, 9 and #10) of 10 patients. Findings: Patient #1 A review of the POC dated 05/29/25 to 07/27/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 06/03/25 showed a reported pain level of 3 of 10 · 06/11/25 showed a reported pain level of 5 of 10 · 06/20/25 showed a reported pain level of 4 of 10 · 06/27/25 showed a reported pain level of 6 of 10 · 07/03/25 showed a reported pain level of 5 of 10 · 07/18/25 showed a reported pain level of 6 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 12:50 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #3 A review of the POC dated 07/08/25 to 09/05/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 07/10/25 showed a reported pain level of 3 of 10 · 07/16/25 showed a reported pain level of 3 of 10 · 07/21/25 showed a reported pain level of 4 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:00 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #4 A review of the POC dated 07/18/25 to 09/15/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 07/23/25 showed a reported pain level of 6 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:02 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #5 A review of the POC dated 07/06/25 to 09/03/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 07/10/25 showed a reported pain level of 1 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:07 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #6 A review of the POC dated 06/26/25 to 08/24/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 07/03/25 showed a reported pain level of 3 of 10 · 07/10/25 showed a reported pain level of 2 of 10 · 0717/25 showed a reported pain level of 4 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:10 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #7 A review of the POC dated 03/30/25 to 04/18/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 04/22/25 showed a reported pain level of 7 of 10 · 05/06/25 showed a reported pain level of 8 of 10 · 05/13/25 showed a reported pain level of 7 of 10 · 05/23/25 showed a reported pain level of 8 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:22 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #9 A review of the POC dated 02/15/25 to 04/15/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 02/21/25 showed a reported pain level of 8 of 10 · 02/25/25 showed a reported pain level of 6 of 10 · 03/04/25 showed a reported pain level of 5 of 10 · 03/14/25 showed a reported pain level of 5 of 10 · 03/21/25 showed a reported pain level of 5 of 10 · 03/25/25 showed a reported pain level of 5 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:35 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification. Patient #10 A review of the POC dated 03/21/25 to 05/20/25 showed orders for SN to assess and instruct on pain management interventions every visit. SN visits dated: · 03/25/25 showed a reported pain level of 7 of 10 · 04/08/25 showed a reported pain level of 8 of 10 · 04/18/25 showed a reported pain level of 6 of 10 · 04/22/25 showed a reported pain level of 5 of 10 The clinical record showed no medical provider communications or change in orders. On 07/30/25 at 1:43 p.m., Staff A stated the POC did not include a pain reporting parameter for medical provider notification.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were included as a part of the patient’s plan of care for two (Patients #7 and #9) of ten patients. Findings: Patient #7 A review of the clinical record for certification period of 03/30/25 to 04/18/25 showed a patient discharge from agency services on 05/27/25. The clinical record showed no medical provider coordination of care or communication notes related to the patient’s discharge from agency services. On 07/30/25 at 1:22 p.m., Staff A stated: 1. The patient was seen by the RN on 05/27/25 for a recertification assessment for continuing services. 2. The medical provider returned the SN call and requested that the patient be discharged from agency services. 3. The order to discharge the patient from agency services was not entered into the patient’s clinical record. Patient #9 A review of the clinical record for certification period of 02/15/25 to 04/15/25 showed a medical provider order dated 03/24/25 for a PT assessment on 03/21/25. A PT evaluation dated 03/25/25 showed no physician notification of the proposed treatment plan and showed no order transcription for a PT visit frequency of one time a week for four weeks effective the week of 03/25/25. On 07/30/25 at 1:35 p.m., Staff A stated the medical provider PT order for patient #9 should have been transcribed and dated 03/21/25 and stated the PT assessment should have occurred during the week of 03/24/25.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for three (Patients #2, 4 and #9) of ten patients. Findings: Patient #2 A review of the POC dated 06/23/25 to 08/21/25 showed orders for a PT assessment. The clinical record showed a PT assessment dated 07/16/25 and showed no coordination of care with the ordering medical provider for the recommended treatment plan and visit frequency. A review of the clinical record showed PT visits were conducted on 07/18/25 and on 07/21/25. On 07/30/25 at 12:52 p.m., Staff A stated the PT should have notified the medical provider after the assessment to show coordination of care for treatment plan recommendations and orders for the visit frequency. Patient #4 A review of the POC dated 07/18/25 to 09/15/25 showed orders for a PT assessment. The clinical record showed a PT assessment dated 07/21/25 and showed no coordination of care with the ordering medical provider for the recommended treatment plan and visit frequency. A review of the clinical record showed PT visits were conducted on 07/23/25, 07/26/25 and on 07/29/25. On 07/30/25 at 12:52 p.m., Staff A stated the PT should have notified the medical provider after the assessment to show coordination of care for treatment plan recommendations and orders for the visit frequency. Patient #9 A review of the POC dated 02/15/25 to 04/15/25 showed orders for a PT assessment. The clinical record showed a PT assessment dated 03/25/25 and showed no coordination of care with the ordering medical provider for the recommended treatment plan and visit frequency. A review of the clinical record showed the patient was discharged from agency services for unexpected death in the home on 03/29/25. On 07/30/25 at 1:43 p.m., Staff A stated the PT should have notified the medical provider after the assessment to show coordination of care for treatment plan recommendations and orders for the visit frequency.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN visits were conducted as ordered on the POC for two (Patients #2 and #6) of 10 patients. 2. PT visits were conducted as ordered on the POC for one (Patient #2) of 10 patients. Findings: Patient #2 A review of the POC dated 06/23/25 to 08/21/25 showed orders for a SN visit frequency of one time a week for one week, then two times a week for six weeks and a PT assessment week of 07/11/25 after a resumption of care from in-patient hospital services. A review of the clinical record showed during the week of 07/14/25 to 07/20/25 SN missed visits occurred on 07/14/25 and 07/17/25 (two visits ordered, no visits conducted). The clinical record showed no other SN visits were attempted during that week and showed no patient refusal of SN revisit attempts, no medical provider notification and no change in orders. A review of the clinical record showed that during the week of 07/11/25 to 07/14/25 no PT assessment was attempted (one visit ordered, no visit conducted) until the following week on 07/16/25 and showed no patient refusal of PT assessment, no medical provider notification and no change in orders. On 07/30/25 at 12:52 p.m., Staff A stated: 1. The SN should have attempted to make up the missed SN visits until the Friday of that week. 2. The PT assessment should have occurred in the week of the post hospital resumption of care as ordered. 3. Any changes in the orders for the SN and PT visits should have been documented in the clinical record. Patient #6 A review of the POC dated 06/26/25 to 08/24/25 showed orders for a SN visit frequency of one time a week for eight weeks. A review of the clinical record showed during the week of 06/30/25 to 07/06/25 SN missed visit occurred on 07/03/25 (one visit ordered, no visits conducted). The clinical record showed no other SN visits were attempted during that week and showed no patient refusal of SN revisit attempts, no medical provider notification and no change in orders. On 07/30/25 at 12:52 p.m., Staff A stated: 1. The SN should have attempted to make up the missed SN visits until the Friday of that week. 2. Any changes in the orders for the SN visits should have been documented in the clinical record.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative QAPI program records for calendar years 2023, 2024 and 01/01/25 to 03/31/25 showed no multi-disciplined skilled professional staff participation. On 07/30/25 at 2:00 p.m., Staff A stated there were no QAPI program meeting minutes or documented activities for calendar years 2023 and 2024 and 01/01/25 to 03/31/25 that showed multi-disciplined skilled professional staff participation.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment or designation of the current administrator for the agency for all patients and staff. Findings: A review of governing body meeting minutes showed no appointment or designation of the current administrator for the agency. On 07/30/25 at 2:00 p.m., Staff A stated governing body meeting minutes did not show appointment or designation of the current administrator for the agency.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure completed transfer/discharge summaries were provided for three (Patients #2, 8 and #9) of 10 patients. Findings: Patient #2 A review of the clinical record showed an in-patient hospital transfer date of 07/04/25. The clinical record showed no transfer summary was provided to the in-patient hospital service provider. On 07/30/25 at 12:52 p.m., Staff A stated the agency had no evidence which showed the transfer summary was sent to the receiving service provider for patient #2. Patient #8 A review of the clinical record showed a discharge date from agency services on 07/17/25. The clinical record showed no discharge summary was provided to the ordering medical provider. On 07/30/25 at 1:25 p.m., Staff A stated the agency had no evidence which showed the discharge summary was sent to the ordering medical provider for patient #8. Patient #9 A review of the clinical record showed an in-patient hospital transfer with discharge date of 03/29/25. The clinical record showed no transfer summary was provided to the in-patient hospital service provider or the ordering medical provider. On 07/30/25 at 1:35 p.m., Staff A stated the agency had no evidence which showed the transfer with discharge summary was sent to the receiving service provider or the ordering medical provider for patient #9.”