Abby Health Care Inc.

“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 facility documentation, and staff (EMP) interviews, the facility failed to develop and maintain an emergency preparedness plan based on a community-based risk assessment, utilizing an all-hazards approach. Findings included: Review of the agency Emergency Plan on March 25, 2025, at approximately 3:30pm failed to reveal a community-based risk assessment, utilizing an all-hazards approach. Interview with Owner on March 25, at approximately 3:45pm confirmed the Emergency Preparedness Plan provided to this surveyor failed to include a community-based risk assessment. Owner reports being unable to locate this document.”

“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 facility documentation, and staff (EMP) interviews, the facility failed to develop and maintain an emergency preparedness communication plan that included names and contact information for the Staff and Entities providing services under arrangement. Findings included: Review of the agency Emergency Plan on March 25, 2025, at approximately 3:30pm revealed a phone tree that failed to be updated with names and contact information for the current Staff and Entities providing services. Interview with Owner on March 25, at approximately 3:45pm confirmed the Emergency Preparedness Plan phone tree included employees that were no longer employed at the agency and was not updated to reflect current Staff and Entities providing services under arrangement names and contact information.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of facility documentation, personnel files (PF), and staff (EMP) interviews, the facility failed to develop and maintain an emergency preparedness training and testing program based on the risk assessment, policies and procedures, and communication plan that is reviewed and updated at least every 2 years. Findings included: Review of the agency Emergency Plan on March 25, 2025, at approximately 3:30pm revealed a failure of the plan to include emergency preparedness training and testing program based on the risk assessment, policies and procedures, and communication plan. Interview with Owner on March 25, at approximately 3:45pm confirmed the Emergency Preparedness Plan failed to include emergency preparedness training and testing program based on the risk assessment, policies and procedures, and communication plan. Owner reports being unable to locate these documents.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of facility documentation, personnel files (PF), and staff (EMP) interviews, the facility failed to maintain documentation that staff demonstrated knowledge of emergency procedures initially for three (3) of four (4) PF reviewed (PF1-3) and at least every 2 years for two (2) of two (2) PF that had 2 years of more of employment (PF 1 & 4). Findings included: Review of PF on March 26, 2025, at approximately 2:30pm revealed: PF1, date of hire (DOH) 6/2/21, PF failed to include evidence of demonstrated knowledge of emergency procedures initially upon hire and biennially, in 2023. PF2, DOH 8/15/23, PF failed to include evidence of demonstrated knowledge of emergency procedures initially upon hire. PF3, DOH 6/2/23, PF failed to include evidence of demonstrated knowledge of emergency procedures initially upon hire. PF4, DOH 4/22/11, PF failed to include evidence of demonstrated knowledge of emergency in 2023. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on review of facility documentation and staff (EMP) interviews, the facility failed to test the emergency plan at least annually for two (2) of three (3) years reviewed. (2023 & 2024). Findings included: Review of the agency Emergency Plan on March 25, 2025, at approximately 3:30pm revealed no documentation that the agency participated in a full-scale exercise, a facility-based exercise, a mock disaster drill, or a table top exercise for 2023 or 2024. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“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 a review of clinical records (CR), home health agency (HHA) policy, and employee interview, the agency failed to provide evidence that a discharge/transfer summaries was sent to the physician/receiving facility for two (2) of two (2) CR’s reviewed (CR 1 & 2). Findings included: Review of agency policy on March 25, 2025, at approximately 1:45pm reveled: “Medica Record Content...PROCEDUE...4. Each medical record will contain the following: ...Notification to the prescribing physician/practitioner of patient discharge. A completed discharge summary when patient is discharged from the Agency. Relevant transfer information when patient is transferred to another organization...” Interview with Clinical director on March 31, 2025, at approximately 2:50pm: When surveyor inquired if transfer or discharge summaries go the physician or receiving facility, the Clinical Director responded, “Sometimes, if they wish...” CR review on March 31, 2025, at approximately 2;45pm revealed: CR1, start of service (SOS) 12/11/24, CR revealed patient discharged from home health services on 1/6/25 to the community with no formal support services due to patient request. No evidence available to reflect that discharge a summary was sent to the plan of care physician. CR2, SOS 12/14/24, CR revealed patient discharged from home health services upon being transferred to the hospital emergency room with hospital admission on 1/20/25. No evidence available to reflect that discharge a summary was sent to the plan of care physician. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“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 a review of documentation and employee interview, the agency governing body failed to ensure that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained for one (1) of one (1)observation. Findings included: Interview with agency Owner on March 25, 2025, at approximately 3:00pm revealed inability to produce documentation of agency Quality Assessment and Performance Improvement (QAPI) program or meeting minutes for 2022, 2023, or 2024. Owner reports inability to locate these documents.”

“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 clinical home visit (HV) observations, a review of agency policies, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for two (2) of two (2) clinical home visits conducted, (HV 1 & 3). Based on clinical home visit (HV) observations, a review of agency policies, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for two (2) of two (2) clinical home visits conducted, (HV 1 & 3). Findings included: Review of agency policy on March31, 2025, at approximately 12:45pm revealed: “Exposure Control Plan: OSHA Regulations...PROCEDURE...Hand Hygiene, Hand hygiene is the most important procedure in the prevention of infections. Handwashing will be performed by all staff according to established Hand Hygiene Policy...Methods of Disinfection...5. Thermometers will be wiped with alcohol pad after each use...6. Stethoscopes and blood pressure cuffs will be cleaned with Agency approved disinfectant after each use...Nursing Bag Technique...2. Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area if indicated. Open the bag near the care area and, if possible, near the water supply. Wash hands thoroughly with bacteriostatic foam/liquid/gel., Remove all items which will be needed for the visit. -Place items on one of the paper towels. Close the bag and give the patient care., -If additional items are needed after care has started, wash hands before re-entering bag., -Clean any visibly soiled items which will be returned to the bag., - Wash hands and return equipment to the bag; close bag., -Tidy up the work area disposing of wastes.” “Hand Hygiene Policy and Compliance Program...POLICY Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent growth of microorganisms on the nails, hands, and forearms...PROCEDURE, 1. Indications for staff performing hand hygiene are: Before and after direct patient care...Before and after collecting specimen., After any contact with contaminated materials, before re-entering nursing bag or patient’s clean supplies...7. The Agency will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: ... I. Indications for handwashing and hand antisepsis...B. ...Before direct patient contact, after removing gloves, ...IV. Use of gloves...D. Change or remove gloves if moving from contaminated to clean patient site to the environment...” HV1 conducted March 26, 2025, at approximately 10:30am with Clinical Director. The nurse did not have a clinical bag. The nurse was utilizing a small belt bag secured around the waist with a zipper pocket. The nurse removed a thermometer from the bag without performing hang hygiene and used it to take the patients temperature. The nurse then removed a blood pressure cuff, stethoscope, and pulse oximeter and use them to take the patient’s blood pressure, pulse and oxygen saturation. All items used were them returned to the belt bag without being disinfected. The bag was very small, and did not have a designated clean or dirty area. the nurse failed to utilize a barrier such as paper towels or a plastic bag. HV3 conducted March 31, 2025, at approximately 11:00am with Clinical Director. The nurse had a small clinical bag that was stuffed with supplies. No clearly designated clean or dirty areas. No hand hygiene performed prior to removing supplies from bag. Prior to performing wound vac dressing change, nurse donned 2 pairs of gloves layered on top of one another without performing hang hygiene. The nurse removed the dirty dressing, removed a pair of gloves, wiped the wound with gauze pads then removed second pair of gloves. the nurse donned a clean pair of gloves without performing hand hygiene and completed the application of the new wound vac dressing. the nurse then removed the gloves and did not perform hang hygiene. The nurse then confirmed with the patient that the dressing at the insertion site of the peripherally inserted central catheter (PICC) would be changed. The nurse donned clean gloves without performing hang hygiene first. With the clean gloves, the nurse cleaned the bedside table for positioning of the patient’s arm. The nurse removed these gloves and donned sterile gloves without performing hang hygiene, removed the dirty site dressing and removed gloves. New gloves donned without performing hand hygiene dressing applied, gloves removed. No hand hygiene. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on a review of personnel files (PF) and an interview with the owner, the agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases for one (1) of one (1) observation. Findings included: Review of agency policy on March 26, 2025, at approximately 3:30pm revealed: “Occupational Exposure to Tuberculosis/Prevention ... PROCEDURE...2. The Director of Clinical Services will perform annual risk assessment surveillance for the Agency to determine the need, type, and frequency of testing/assessment for direct care staff... of Transmission of TB Plan... On March 26, 2025, at approximately 2:50pm, surveyor requested Infection control program and Tuberculosis annual risk assessment surveillance and infection control committee documentation. At this time owner repots inability to locate this documentation. No documentation available for review. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“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 a review of agency policy, clinical records (CR), home visit (HV) observation, and interview with the agency Owner, the agency failed to ensure the nurse clarified indications for as needed medications for four (4) of seven (7) clinical records (CR) reviewed (CR3, 4, 6, & 7). Findings included: Agency policy reviewed on March 25, 2025, at approximately 1:15p.m. revealed: “Medication Orders…PROCEDURE…4. “Indication for use” must be included in PRN medication orders or if the medication is ordered for a condition not usually treated with that medication. “Medication Reconciliation, POLICY The Agency will reconcile the patient’s medication at time of admission and on an ongoing basis…PROCEDURE, 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that the patient is taking at home, including dose, strength, route, and frequency…Any concerns or discrepancies will be reconciled by an RN with the patient’s physician/practitioner., Discrepancies include duplications, omissions, changes, contraindications and/or unclear information… CR3, reviewed on March 31, 2025, at approximately 1:25pm revealed a start of service (SOS) 2/7/25, dates reviewed 2/7/25-3/10/25. Plan of care included Meclizine HCl 25mg tab by mouth every 8 hours PRN (pro re nata-as needed). No indicator to identify when medication is needed. CR4, reviewed on March 25, 2025, at approximately 12:15pm revealed a SOS 3/5/25, dates reviewed 3/13/25-3/31/25. Plan of care included Lidocaine HCL-Menthol 4% cream topically PRN to affected areas. No indicator to identify when or where medication is needed. Plan of care included TUMS oral-1 PRN. No indicator to identify when medication is needed. CR6, reviewed on March 26, 2025, at approximately 12:30pm revealed a SOS 1/6/25, dates reviewed 1/6/25-3/26/25. Plan of care included Oxygen 50% aerosol trach mask PRN, Diphenhydramine HCL 25mg as needed every 6 hours gastric tube, Albuterol Sulfate 2.5mg/3ml (0.083%) vial nebulizer 3 times a day PRN and Acetaminophens 325mg/actuation spray non-aerosol PRN. No indicators to identify when medications needed. CR7, reviewed on March 31, 2025, at approximately 12:00pm revealed a SOS 2/10/25, dates reviewed 2/10/25-3/31/25. Plan of care included Neomycin-Bacitracin-Polymyxin 3.5mg-400unit-10,000 unit/gram ointment PRN Opthalmic. No indicator to identify when medication needed. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“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 a review of agency policy, clinical records (CR), and an interview with the agency Owner, the agency failed to ensure the patient’s plan of care included All medications and treatments for two (2) of seven (7) clinical records (CR) reviewed (CR3 &5). Findings included: Agency policy reviewed on March 25, 2025, at approximately 1:30 p.m. revealed: “Plan of Care-CMS #485 and Physician/Practitioners Orders...PROCEDURE...4. The individualized plan of care must include the following: ...All medications and treatments...Patient-specific interventions and education...5. All patient care orders, including verbal orders, must be recorded in the plan of care...” CR review conducted March 31, 2025, between approximately 10:00am and 2:00pm revealed: CR3, start of service (SOS)2/7/25, dates reviewed 2/7/25-3/10/25. Plan of care included supplies for straight catheterization procedure, interventions include to monitor for straight catheter use, and goal of “no events of urinary retention exhibited by need to self cath…”. No order included in plan of care for straight catheterization procedure. Supplies on the plan of care also include diabetic testing strips and a Freestyle Libre Device. Plan of care failed to include orders to monitor blood glucose and orders to apply/change freestyle Libre monitoring device. CR5, SOS 3/13/25, dates reviewed 3/13/25-3/31/25. Plan of care includes “CBC, BMP, ESR, CRP, every Monday” and “weekly IV dressing change as ordered.” No orders that specify how to obtain blood work, venipuncture or via Peripherally Inserted Central Catheter (PICC) line. Documentation reveals both methods have been utilized. No orders for IV dressing change as referenced on plan of care. PICC line is a double lumen (has 2 ports), plan of care failed to include orders for maintenance of lines. Order to flush is included with antibiotic administration, however, does not specify which lumen to use. Plan of care includes intervention to change wound vac three times a week, no orders included to clean wound when changing. Observation of HV3 revealed nurse cleansed with saline wet gauze and patted dry before applying wound vac. Interview with patient during HV revealed patient is to be taking Humulin R- 10 units with meals. Plan of care failed to include this medication. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on a review of personnel files (PF) and an interview with the owner, the agency failed to demonstrate the presence of baseline screening for mycobacterium tuberculosis (TB) for three (3) of four (4) PF reviewed (PF1, 3 & 4), annual TB education for four (4) of four (4) PF reviewed (PF1-4), and Clinical Practice License for three (3) of four (4) PF reviewed (PF2-4). Findings included: The CDC guidelines state that all Health Care Workers (HCW) should receive baseline tuberculosis screening upon hire, using a two-step tuberculin skin test (TST) or a single blood assay for tuberculosis (TB) to test for infection with tuberculosis. After baseline testing for infection with tuberculosis, HCWs should receive TB screen annually. HCWs with a baseline positive test for tuberculosis infections should receive one chest radiograph result to exclude tuberculosis disease. CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care settings, 2005. Morbidity and Mortality World Report 2005;(RR-17) http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf. *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). Review of PF on March 26, 2025, at approximately 2:30pm revealed: PF1, date of hire (DOH) 6/2/21, PF failed to include evidence of baseline TB screening and annual TB education for 2022, 2023, & 2024. PF2, DOH 8/15/23, PF failed to include evidence of annual TB education for 2024 of 2025. Employee identified to be a physical therapist; PF failed to include evidence of current physical therapy license. PF3, DOH 6/2/23, PF failed to include evidence of baseline TB screening and annual TB education for 2024. Employee identified to be a registered nurse; PF failed to include evidence of nursing license. PF4, DOH 4/22/11, PF failed to include evidence of baseline TB screening and annual TB education for 2022, 2023, & 2024. Employee identified to be a registered nurse; PF failed to include evidence current of nursing license. Nursing license in PF expired 4/30/2023. Interview with Owner and Clinical Director on March 31, 2025, at approximately 3:00pm confirmed findings.”