A&e Home Care LLC

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on a review of the Emergency Preparedness Program documents provided by the agency, and an interview with the administrator, the agency failed to provide evidence that the emergency preparedness plan was tested annually. Findings include: A review of the hospice emergency preparedness testing was conducted on 3/19/2026 at 1 pm and revealed the following: Agency fail to provide any evidence that exercises to test the emergency preparedness plan was conducted in 2024. A tabletop emergency preparedness exercise was conducted on 10/14/2025; however, there was no after-action analysis report regarding exercise. An interview conducted with the administrator on 3/19/2026 at approximately 2 pm confirmed the above findings.”

“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 observations, a review of agency policies, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for one (1) of one (1) clinical home visits conducted: CR#1. Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, “Policy No. 018R-Hand Hygiene” reads, “ (A) Indications for hand hygiene: ... ix. Before and after utilizing gloves... xi. When moving from a contaminated body site to a clean body site during client care... (F) Gloves Use: ... iii. Gloves should be changed when moving from a contaminated body site to a clean body site...” An off-site video call clinical home visit was conducted on 3/19/2026 from 6 pm to 6:25 pm at the home of CR#1. At around 6:15 pm, agency’s LPN (Licensed Practical Nurse) provided GJ (Gastrojejunostomy) tube site care. The nurse removed soiled dressing, cleaned the site, and placed nystatin cream and a new dressing. All took place with one pair of gloves. An interview with the administrator on 3/20/2026 at 12:16 pm confirmed the above findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on a review of clinical records (CR) and policies, and an interview with the administrator, the agency failed to complete a comprehensive assessment that accurately reflect the patient’s status including current health, psychosocial, functional, and cognitive status for one (1) of eight (8) CRs reviewed (CR# 5). Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, “Policy No. 002 – Development of Plan of Treatment” reads, “The plan of treatment will be developed in consultation with agency staff and shall cover pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. ... The therapist and other agency personnel shall participate in developing the plan of treatment...” A policy titled, “Policy No. 090– OASIS transmission” reads, “A&E Home Care will conduct comprehensive, patient-specific assessments that contain Outcomes and Assessment Information Set (OASIS) criteria that accurately reflect the patient’s current health status and include information that may be used to demonstrate the clients progress toward achievement of desired outcomes... Each new client will receive a client-specific comprehensive assessment that will identify the client’s continuing need for home care, will support eligibility for payor source criteria, and will facilitate care planning to meet the client’s needs...” A review of CRs was conducted on 3/17/2026 at 10 am, 3/18/2026 starting at 10:30 am and again on 3/19/2026 starting at 10:30 am. The Start of Care (SOC) and CMS-485 Home Health and Certification Period (CP) are shown below. CR#5, SOC: 3/6/2021, contains documentation that patient utilize trach tube/ventilator for breathing and gastrostomy tube for feeding. File contains a re-certification comprehensive assessment completed agency’s RN (registered nurse) on 2/7/2026 for CP 2/8/2026 - 4/8/2026. The comprehensive assessment revealed the following: Vital signs were not assessed. Respiratory assessment reads, “Requires suctioning through day, but remains on RA (room air). Tolerates weekly trach changes without difficulty.” This respiratory assessment did not include breath sounds, work of breathing, or secretion characteristics. Gastrointestinal/enteral feeding assessment reads, “12 Fr (French) 2.0 cm Mini Button in place for feedings – tolerates well.” This gastrointestinal assessment did not include gastrointestinal tube site assessment, no skin condition around stoma, no feeding tolerance details. Functional assessment reads, “Remains dependent on others for all care needs d/t (due to) Dx. (diagnosis)” This assessment did not include activity of daily living breakdown, mobility, transfer details. Psychological assessment reads, “CR#5 is a happy, social young boy.” This assessment did not include formal screening of relationships, living environment, or ability to participate in care. Cognitive status was not assessed. An interview with the administrator on 3/20/2026 at 1:33 pm confirmed the above 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 clinical records (CR) and policies, and an interview with the administrator, the agency failed to complete a comprehensive assessment including 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. for one (1) of eight (8) CRs reviewed (CR# 5). Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, “Policy No. 002 – Development of Plan of Treatment” reads, “The plan of treatment will be developed in consultation with agency staff and shall cover pertinent diagnoses, including... medications and treatments... The therapist and other agency personnel shall participate in developing the plan of treatment...” A policy titled, “Policy No. 090– OASIS transmission” reads, “A&E Home Care will conduct comprehensive, patient-specific assessments that contain Outcomes and Assessment Information Set (OASIS) criteria that accurately reflect the patient’s current health status and include information that may be used to demonstrate the clients progress toward achievement of desired outcomes... Each new client will receive a client-specific comprehensive assessment that will identify the client’s continuing need for home care, will support eligibility for payor source criteria, and will facilitate care planning to meet the client’s needs... III. Drug Regimen Review A. Each comprehensive assessment will include a review of all medications the client is currently using. B. The review is done to identify any potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. C. The nurse will notify the client’s physician of any potential adverse effects and drug interactions or ineffective drug therapy...” A review of CRs was conducted on 3/17/2026 at 10 am, 3/18/2026 starting at 10:30 am and again on 3/19/2026 starting at 10:30 am. The Start of Care (SOC) and CMS-485 Home Health and Certification Period (CP) are shown below. CR#5, SOC: 3/6/2021, contains documentation that patient utilize trach tube/ventilator for breathing and gastrostomy tube for feeding. File contains a re-certification comprehensive assessment completed agency’s RN (registered nurse) on 2/7/2026 for CP 2/8/2026 - 4/8/2026. The comprehensive assessment revealed the following: Medication review reads, “There have been no changes to CR#5’s medications.” The comprehensive assessment did not include a complete list of all current medications and a review for 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. An interview with the administrator on 3/20/2026 at 1:33 pm confirmed the above findings.”