Enhabit Home Health

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on review of agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, the agency failed to develop emergency preparedness policies and procedures based on the Hazard Risk Assessment for one (1) of one (1) year reviewed (2025). Findings included: Review of Agency Emergency Preparedness Plan on 3/2/26 at approximately 1:30pm revealed: “…Appendix-Response plans by disaster event Appendix E06.1…Quick Links 4.4.1 Active Shooter, 4.4.2 Bomb threat…4.4.3 Earthquake, 4.4.4 electrical Power Outage…4.4.8 Flood, 4.4.13 Wildfire” Hazard Risk Assessment tool failed to include the following hazards that policies were in place for: Active Shooter and bomb threat. Policies and procedures were not created for the following hazards identified as risks: Sever thunderstorms, snowfall, epidemic, pandemic, and communication outage. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of agency Emergency Preparedness policies and procedures the agency failed to develop policies for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency for one (1) of one (1) year reviewed (2025). Findings included: Review of Agency Emergency Preparedness Plan on 3/2/26 at approximately 1:30pm failed to include policies or procedures for the use of volunteers or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“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 the facility Emergency Preparedness Program, Personnel Files (PF), and employee interview, the facility failed to maintain documentation of training in emergency preparedness policies and procedures to all new and existing staff, consistent with their expected roles and demonstration of staff knowledge of emergency procedures initially and at least every 2 years for six (6) of six (6) PF reviewed (PF1-6). Findings included: Review of PF on 3/2/26, at approximately 3:00pm revealed: PF1, date of hire (DOH) 8/18/25, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. PF2, DOH 10/7/25, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. PF3, DOH 12/16/24, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. PF4, DOH 1/29/24, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. PF5, DOH 12/1/25, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. PF6, DOH 1/19/26, PF failed to include evidence of training in emergency preparedness policies and procedures and demonstration of staff knowledge of emergency procedures initially upon hire. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader 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 agency emergency preparedness program, and interview with staff (EMP), it was determined that the facility failed to participate in a full-scale exercise that is community-based every 2 years, failed to conduct an additional exercise opposite the year the full-scale or functional exercise that may include, but is not limited to a second full-scale exercise, a mock disaster drill, or 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. The facility also failed to 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 three (3) years reviewed (2023-2026). Findings included: Review of emergency preparedness plan conducted 3/2/26, at approximately 1:30pm revealed: no evidence of after-action reports evaluating a full scale, mock, or table-top disaster drill with analysis of the facilities response for years reviewed including 2023-2026. No evidence to confirm agency conducted/participated in drills. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader 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 review of Clinical Records (CR), home visit observations (HV), and interview with agency staff, the agency failed to ensure the Plan of Care (POC) included supplies and equipment required for three (3) of seventeen (17) CR reviewed (CR 11, 8, & 15), safety measures to protect against injury for four (4) of seventeen (17) CR reviewed (CR 7, 8, 10, 14), all medications the patient is currently using for one (1) of seventeen (17) CR reviewed (CR 8), and patient-specific interventions for two (2) of seventeen (17) CR reviewed (CR 8 & 11). Findings included: Review of CR on 3/4/26 between approximately 2:00pm and 3:30pm, and 3/5/26 between approximately 9:45am and 1:15pm revealed: CR7, start of services (SOS) 2/3/26, dates reviewed 2/3/26-3/4/36. Plan of Care (POC) included diagnosis of long term (current) use of anticoagulant and medication list included Aspirin 81mg and Eliquis 5mg for prevention of blood clots. Safety measures failed to include bleeding precautions. CR8, SOS 2/12/26, dates reviewed 2/12/26-3/4/26. POC included diagnosis of long term (current) use of anticoagulant and medication list included Aspirin 81mg and Eliquis 5mg for prevention of blood clots. Safety measures failed to include bleeding precautions. Skilled nurse clinical note documented at start of care on 2/12/26 included the narrative “…patient independent with straight catheter (procedure to insert a flexible catheter(tube) through the urethra to empty the bladder intermittently and removed afterwards) 4-5 times/day. POC failed to include orders for straight catheter procedure. POC also failed to include straight catheter supplies. CR included wound care order, “skilled nurse to perform wound care to bilateral feet diabetic ulcers, cleanse with normal saline solution, apply Santyl…) POC failed to include normal saline and Santyl on medication list. CR10, SOS 2/18/26, dates reviewed 2/18/26-3/5/26. POC included diagnosis of long term (current) use of anticoagulants and medication list included Eliquis 2.5mg for prevention of blood clots. Safety measures failed to include bleeding precautions. CR11, SOS 1/30/26, dates reviewed 1/30/26-3/5/26. HV#1 conducted 3/3/26 at approximately 9:00am revealed patient having left chest double lumen central catheter ( a long thin flexible tube inserted into a large vein, typically under the collarbone, with the tip resting near the heart). Interview with patient revealed patient/girlfriend was administering IV (intravenous) antibiotics every 48 hours until antibiotics had been discontinued on 2/26/26. Interview with nurse confirmed patient report. Observation and interview with nurse confirmed nurse flushed central line and performed dressing change for site since patient began services. POC failed to include IV supplies. POC failed to include orders to flush central line and change dressing until hospitalized on 2/3/26. CR14, SOS 2/24/26, dates reviewed 2/24/26-3/5/26. POC included diagnosis of long term (current) use of anticoagulants and medication list included Eliquis 5mg for prevention of blood clots. Safety measures failed to include bleeding precautions. CR15, SOS 2/10/26, dates reviewed 2/10/26-3/5/26. HV#7 conducted 3/4/26 at approximately 9:30am confirmed bedside commode frame used over bathroom toilet. POC failed to include bedside commode on DME (durable medical equipment)/supplies. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on review of Clinical Records (CR), home visit observations (HV), and interview with agency staff, the agency failed to ensure the Plan of Care (POC) included patient care orders for two (2) of seventeen (17) CR reviewed (CR 8 & 11). Findings included: Review of CR on 3/4/26 between approximately 2:00pm and 3:30pm, and 3/5/26 between approximately 9:45am and 1:15pm revealed: CR8, start of services (SOS) 2/12/26, dates reviewed 2/12/26-3/4/26. Skilled nurse clinical note documented at start of care on 2/12/26 included the narrative “…patient independent with straight catheter (procedure to insert a flexible catheter(tube) through the urethra to empty the bladder intermittently and removed afterwards) 4-5 times/day. POC failed to include orders for straight catheter procedure. CR11, SOS 1/30/26, dates reviewed 1/30/26-3/5/26. HV#1 conducted 3/3/26 at approximately 9:00am revealed patient having left chest double lumen central catheter (a long thin flexible tube inserted into a large vein, typically under the collarbone, with the tip resting near the heart). Observation and interview with nurse confirmed nurse flushed central line and performed dressing change for site since patient began services. POC failed to include orders to flush central line and change dressing until hospitalized on 2/3/26. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on home visit observations (HV) and interview with agency staff, the agency failed to ensure that drugs, services, and treatments were administered only as ordered by a physician or allowed practitioner for two (2) of seventeen (17) CR reviewed (CR11 & 12)/ one (1) of seven (7) HV conducted (HV3). Findings included: CR11, SOS 1/30/26, dates reviewed 1/30/26-3/5/26. Clinical note dated 2/3/26 included nursing narrative note documenting, “left upper chest PICC dressing changed…” CR failed to contain order to perform dressing change. Interview with administrator 3/4/26 at approximately 12:00pm confirmed no order for dressing change at start of care or, on POC, or obtained until patient services resumed post hospital stay on 2/9/26. CR12, SOS 2/9/26, dates reviewed 2/9/26-3/5/26. HV#2 conducted 3/3/26 at approximately 10:15am, surveyor observed nurse perform wound care to left and right lower leg wounds. Nurse removed old dressings and cleansed wounds with normal saline. Wound care order on plan of care instructed wounds to be cleansed with soap and water. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on home visit observations (HV) and interview with agency staff, the agency failed to ensure that each patient, and his or her caregiver(s) where applicable, received ongoing education and training provided by the home health agency (HHA), as appropriate, regarding the care and services identified in the plan of care for four (4) of seven (7) HV conducted (HV4-7). Findings included: HV4, conducted 3/3/26 at approximately 11:45am observing physical therapist with patient associated with CR13, start of service (SOS) 2/25/26. Interview at this time with the patient revealed home exercises that are being followed are from discharge from skilled nursing facility. Patient provided the discharge instructions with exercises for review. Interview with physical therapist at the visit confirms that exercise program developed by the HHA is to be left in the home with the patient. No evidence of home exercise program from HHA in home. Patient on services for 7 days at time of visit. HV5, conducted 3/3/26 at approximately 12:30pm observing occupational therapist with patient associated with CR14, start of service (SOS) 2/24/26. Interview with occupational therapist at the visit confirms that exercise program developed by the HHA is to be left in the home with the patient either by providing print outs or writing them in the patient booklet provided by the agency. Patient on services for 8 days at time of visit. HV6, conducted 3/4/26 at approximately 9:00am observing physical therapy assistant with patient associated with CR15, start of service (SOS) 2/10/26. No evidence of handouts in home that included physical therapy exercise program. No evidence of exercises written in patient booklet provided by the agency. Patient reported not receiving this information. Patient on services for 23 days at time of visit. HV7, conducted 3/4/26 at approximately 9:30am with occupational therapist with patient associated with CR15, start of service (SOS) 2/10/26. No evidence of handouts in home that included physical therapy exercise program. No evidence of exercises written in patient booklet provided by the agency. When therapist was conducting exercises with patient, the patient verbalized difficulty remembering or not knowing exercises the therapist was instructing to perform. Patient on services for 23 days at time of visit. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”

“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: Findings included: Review of CR on 3/4/26 between approximately 2:00pm and 3:30pm, and 3/5/26 between approximately 9:45am and 1:15pm revealed: CR10, start of services (SOS) 2/18/26, dates reviewed 2/18/26-3/5/36. CR contained a referral for home health services including skilled nursing, physical therapy, occupational therapy, and home health aide. No evidence that home health aide services were provided by the agency. No evidence of patient refusal of home health aide services. No evidence of communication to referring physician of services not provided. CR13, SOS 2/3/26, dates reviewed 2/25/26-3/5/36. HV#4 conducted 3/3/26 at approximately 11:45am revealed report by patient that the doctor ordered a home health aide and social worker. Patient confirms not having received these services to date. CR contained a referral for home health services including home health aide, social worker, occupational therapy, physical therapy, and speech therapy. No evidence that home health aide services or social worker were provided by the agency. No evidence of patient refusal of home health aide services. No evidence of communication to referring physician of services not provided. Exit interview on 3/6/26 at approximately 1:45pm with Vice President (VP) of regulatory affairs, OPS consultant, Infection/safety office, VP of operations, Administrator, and clinical team leader confirmed findings.”