Lady of Fatima Health Services, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on review of Emergency Preparedness documentation and an interview with the payroll specialist, staffing coordinator, and human resources, the agency failed to maintain documentation for review/update of the emergency preparedness plan with all required elements annually until 2019 and every two (2) years thereafter. Findings included: A review of agency policy titled, “Emergency Preparedness Plan” conducted on May 28, 2025, at approximately 10:00 AM states, “The Quality Assurance and Program Improvement (QAPI) department will conduct an annual review of the emergency plan and monitor the effectiveness of the Emergency Preparedness program as related to the following and will forward a written report to the Government Board...” A review of QAPI meeting minutes dated 10/1/2024 conducted on May 27, 2025, at approximately 12:30 PM, did not contain any documentation regarding the annual review of the Emergency Preparedness program. A review of Governing Body meeting minutes dated 9/8/2024 conducted on May 27, 2025, at approximately 12:35 PM, did not contain any documentation regarding the annual review of the Emergency Preparedness program. Agency did not provide any documentation for an Emergency Preparedness program. There was no documentation that the facility reviewed or updated the emergency preparedness plan with all required elements annually until 2019 and every two (2) years thereafter. An interview with the payroll specialist, staffing coordinator and the human resources manager on May 28, 2025, at approximately 11:00 am confirmed the above findings.”

“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 a review of agency policy, the agency’s emergency preparedness plan, and an interview with the payroll specialist, staffing coordinator, and the human resources manager, the agency failed to base the emergency preparedness plan on/or to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings: Agency did not have a policy specific to a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Agency did not provide any documentation of an Emergency Preparedness program that contained a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. An Interview with the payroll specialist, staffing coordinator, and the human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on a review of agency policy, emergency preparedness documentation, and interview with the agency payroll specialist, staffing coordinator and human resources manager, the agency failed to develop an emergency plan that addressed patient population, including, but not limited to, persons at-risk; the types of services the agency had the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans. Findings include: A review of agency policy titled “Emergency Preparedness Plan” conducted on May 28, 2025, at approximately 10:10 AM states, “All patients admitted to service will be classified according to level of acuity to determine the order in which visits should be made during an emergency situation...” Review of agency policy titled “Disaster and Priority Classification” conducted on May 28, 2025, at approximately 10:15 AM states, “Purpose: To ensure that patients receive scheduled and necessary home health care services. To provide replacement staff members for patients according to established priority-staffing criteria. To facilitate patient caregivers’ involvement for patient staffing needs, as necessary...” Agency did not provide any documentation of an Emergency Preparedness program that any evidence of an emergency plan that addressed patient/client population, including, but not limited to, persons at-risk; the types of services the facility had the ability to provide in an emergency; and continuity of operations, including delegation of authority and succession plans. An interview with the payroll specialist, staffing coordinator, and human resources manager on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“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 a review of agency policy, and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to demonstrate that the emergency preparedness communication plan included the Names and Contact Information for the following: Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers. Findings include: A review of agency policy titled, “Emergency Preparedness Plan” conducted on May 28, 2025, at approximately 10:20 AM states, “At the onset of an emergency situation the Director of Nursing (DON) or administrator will notify key agency staff to initiate the Emergency Preparedness plan by contacting the staff and patients who may be affected by the emergency...” Agency did not provide any documentation of an Emergency Preparedness Program that included the names and contact information for all agency staff and patients’ physicians. An interview conducted with the payroll specialist, staffing coordinator and the human resources manager on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on a review of agency policy, agency’s emergency preparedness plan, and an interview with the payroll specialist, staffing coordinator, and human resources manager, it was determined the agency failed to establish and maintain an emergency preparedness communication plan that included contact information for local/regional/state/federal emergency preparedness staff. Findings include: A review of the agency policy “Emergency Preparedness Plan” conducted on May 28, 2025, at approximately 10:10 AM states, “The agency will not be responsible to evacuation of patients, but will have a reasonable mechanism for triaging and identification of possible evacuation procedures through coordination with local law enforcement, Red Cross, or Civil Defense...” Agency did not provide any documentation of an Emergency Preparedness program that contained any documentation of a printed copy of the communication plan that included contact information for local/regional/state/federal emergency preparedness staff. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“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 a review of agency policy, emergency preparedness documentation, and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to develop and maintain an emergency preparedness plan training and testing program that was reviewed and updated at least every two (2) years, which includes the time period prior to the Covid-19 pandemic. Findings Include: Review of agency policy “Emergency Preparedness Plan” conducted on May 28, 2025, at approximately 10:10 AM states, “The agency will have a practice drill annually to help the Quality Assurance and Program Improvement (QAPI) department and administrator evaluate the adequacy of the emergency plan. Orientation and In-service: Personnel will attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency...” Agency did not provide any documentation of an Emergency Preparedness program that contained any documentation of an emergency preparedness plan training or testing program completed annually in accordance with agency policy. Interview with the payroll specialist, staffing coordinator, and human resources manager on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on a review of agency policy, a review of the clinical record (CR), and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to ensure visits or a treatment or service as required by the plan of care was conducted as ordered for one (1) of one (1) clinical records (CR) reviewed, (CR#3). Findings include: A review of agency policy/procedure titled “Medical Records & Documentation” conducted on May 28, 2025, at approximately 10:10 AM states, “Missed visits are documented on the Missed Visit form with reasons for missed visit and follow-up as required. The physician will be notified of the missed visit, and the date and time of notification will be documented on the form...” A review of CRs was conducted on May 27, 2025, at approximately 10:15 AM and on May 28, 2025, at approximately 9:30 AM revealed the following: CR #3, Start of Care: 12/16/2019. Discharge Date: 5/25/2020. Certification period reviewed: 4/13/2020 through 6/13/2020. File did not contain any documentation of a Plan of Care for this certification period. File did contain a Physician’s verbal order to modify the plan of care dated 5/12/2020 which contained an order for Physical Therapy (PT), Eval and Treatment. There is no documentation that PT completed an evaluation and there is no documentation of a missed visit/notification to the physician. An interview conducted with the payroll specialist, staffing coordinator, and human resources manager on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the payroll specialist, staffing coordinator and the human resources manager, the agency failed to demonstrate the presence of the following: Infection control education provided to staff at periodic intervals consistent with accepted standards of practice. Such education must be provided at orientation, annually, and as needed to meet the staff’s learning needs to provide adequate care; identify infection signs and symptoms; identify routes of infection transmission; appropriately disinfect/sanitize/ transport equipment and devices used for patient care; and use proper medical waste disposal techniques. Such education must include instructions on how to implement current infection prevention/treatment practices in the home setting. Three (3) of three (3) PFs did not meet the requirement, (PF# 1, 2, and 3). Findings include: A review of agency policy titled “Infection Control Management & Assessment” conducted on May 27, 2025, at approximately 12:30 PM states, “All staff are oriented to the infection control procedures upon hire...” A review of personnel files (PF) conducted on May 27, 2025, at approximately 1:00 PM revealed the following: PF #1, Date of Hire: Unknown. File did not contain evidence of annual infection control education for 2022, 2023 and 2024. PF #2, Date of Hire: 4/8/2024. File did not contain evidence of annual infection control education at orientation or for 2025. PF #3, Date of Hire: 2/1/19. File did not contain evidence of annual infection control education for 2023, 2024 and 2025. An interview conducted with the payroll specialist, staffing coordinator, and human resources manager on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on a review of agency policy, Governing Body documentation, and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to appoint an alternate administrator and alternate supervising nurse and failed to review and approve the agency’s policies and procedures annually in accordance with its policy. Findings include: A review of agency policy titled “The Governing Board” conducted on May 28, 2025, at approximately 10:40 AM states, “The Governing Body appoints an administrator and supervising nurse, adopts and periodically reviews written bylaws or an acceptable equivalent, and oversees business affairs of the agency...The Governing Body reviews, approves, and enforces the policies and procedures of the agency...” A review of the agency’s Governing Body meeting minutes dated 9/8/2024 conducted on May 27, 2025, at approximately 11:00 AM revealed no documentation of an appointment of an alternate administrator or alternate supervising nurse and no documentation that the agency’s policies and procedures were reviewed or approved. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on a review of agency policy/procedure, a review of patient clinical records (CR), and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to ensure that a reassessment occurred within the last five (5) days of every sixty (60) day recertification period for one (1) of three (3) CRs reviewed, (CR#1). Findings include: Agency was unable to provide a policy pertaining to the comprehensive patient assessment. A review of CRs was conducted on May 27, 2025, at approximately 10:15 AM revealed the following: CR #1, Start of Care: 5/31/17. Certification period reviewed 5/8/25 through 7/6/25, File did not contain any documentation of a comprehensive assessment by the RN in the last five (5) days of the current 60-day certification period. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to file clinical notes in accordance with its policy for three (3) of three (3) CRs reviewed, (CR #1, 2, and 3). Findings include: A review of agency policy titled “Medical Records and Documentation” conducted on May 28, 2025, at approximately 10:45 AM states, “Clinical and progress notes should be written the day service is rendered, submitted each week on Mondays by 4 PM, and filed into the medical record within seven (7) days. A review of CRs was conducted on May 27, 2025, starting at 10:15 AM and on May 28, 2025, starting at 9:30 AM revealed the following: CR #1, Start of Care: 5/31/17. Certification period reviewed: 5/8/25 through 7/6/25. File did not contain any skilled nursing (SN) notes dated after 2/5/2025. CR #2, Start of Care: 2/26/2021. Discharge Date: 3/10/2021. Certification period reviewed: 2/19/21 through 4/19/21. File did not contain any SN notes dated after 2/28/21. CR #3, Start of Care: 12/16/2019. Discharge Date: 5/25/2020. Certification period reviewed: 4/13/2020 through discharge. File did not contain any SN or Physical Therapy (PT) notes after 5/1/2020. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with the payroll specialist, staffing coordinator, and human resources manager, the agency failed to conduct Licensed Practical Nurse (LPN) supervisory visits in accordance with its policy for one (1) of three (3) CRs reviewed, (CR #1). Findings include: A review of agency policy titled, “Supervision of Clinical Staff” conducted on May 28, 2025, at approximately 10:35 AM states, “Licensed Practical Nurse: For all patients receiving care by a LPN, a Registered Nurse (RN) will make a visit to evaluate whether goals are met, and/or to revise the plan of care, no less often than every sixty (60) days...” A review of CRs was conducted on May 27, 2025, starting at 10:15 AM and on May 28, 2025, starting at 9:30 AM revealed the following: CR #1, Start of Care: 5/31/17. Certification period reviewed: 5/8/25 through 7/6/25. File did not contain any documentation of any LPN supervisory visits for this certification period or the certification period prior. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on review of agency policy, the Center for Disease Control Tuberculosis Guidelines; personnel files (PF), and an interview with payroll specialist, staffing coordinator, and human resources manager, the agency failed to follow its policies to provide documentation of the following: signed job descriptions for three (3) of three (3) PFs reviewed, (PF #1, 2, and 3); Federal Bureau of Investigations (FBI) background check for one (1) of three (3) PFs reviewed, (PF #2); current CPR certification for one (1) of three (3) PFs reviewed, (PF #1); orientation documentation for two (2) of three (3) PFs reviewed, (PF#1 and 2); initial competency evaluation for one (1) of three (3) PFs reviewed, (PF #2); annual competency evaluations for three (3) of three (3) PFs reviewed, (PF #1, 2, and 3); infection control training for three (3) of three(3) PFs reviewed, (PF #1, 2, and 3); annual performance evaluations for three (3) of three (3) PFs reviewed, (PF #1, 2, and 3); Hepatitis B vaccination documentation for one (1) of three (3) PFs reviewed, (PF #1); tuberculosis (TB) testing at hire for two (2) of three (3) PFs reviewed, (PF #1 and 2); and annual tuberculosis education for three (3) of three (3) PFs reviewed, (PF #1, 2, and 3). Findings Include: In May 2019, the CDC updated its recommendations for TB testing of health care personnel. The CDC guidelines state that all Health Care Workers (HCW) should: 1: receive baseline tuberculosis screening upon hire by using: a two-step tuberculin skin test (TST), a single blood assay for tuberculosis (TB), or a negative chest x-ray to test for infection with tuberculosis. 2. Completion of a tuberculosis symptom questionnaire. And 3. Completion of a tuberculosis risk assessment. After baseline testing for infection with tuberculosis, HCWs should receive TB education 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;(5-16-19) https://www.cdc.gov/tb/topic/testing/healthcareworkers.html. A review of agency policy titled “Employee File” conducted on May 28, 2025, at approximately 10:45 AM states, “The following information will be included in the personnel record: Signed Job Descriptions; CPR certification; Criminal History Check; Orientation form; Evaluations; Health Records...” A review of agency policy titled “Background Check” conducted on May 28, 2025, at approximately 10:50 AM states, “If an employee or applicant has not been a resident of Pennsylvania for the two prior years immediately preceding the employment application, a federal criminal history record must also be obtained...” A review of agency policy titled “Employee Development Program” conducted on May 28, 2025, at approximately 10:00 AM states, “The agency will follow all local, state and federal regulations in conducting in-service and educational programs...” A review of agency policy titled, “Employee Evaluations” conducted on May 28, 2025, at approximately 10:05 AM states, “Evaluations will be conducted: At the time of the employee’s first year end...annually...” A review of agency policy titled “Employee Initial Two-Step Tuberculosis (TB) & Annual TB Testing” conducted on May 28, 2025, at approximately 10:10 AM states, “Lady of Fatima Health Services, Inc. will administer the two-step TB skin test to all new employees...” A review of PF’s conducted on May 28, 2025, from approximately 9:20 AM to 10:00 AM revealed the following: PF #1, Date of Hire: unknown, did not contain any documentation of the following: signed job description for Registered Nurse (RN) or Supervising Nurse; current CPR certification; orientation documentation; annual competency for 2022, 2023, or 2024; infection control training for 2022, 2023, or 2024; performance evaluations for 2022, 2023, or 2024; Hepatitis B vaccination documentation; TB testing at hire; and annual TB education for 2022, 2023, or 2024. PF #2, Date of Hire: 4/8/2024, did not contain any documentation of the following: signed job descriptions for Licensed Practical Nurse (LPN); Alternate Administrator, or Alternate Supervising Nurse; FBI background history (file contained Virginia driver’s license issued on 10/7/2022); orientation documentation; initial competency; annual competency for 2025; infection control education at hire and for 2025; performance evaluation for 2025; TB testing, symptom screening and risk assessment at hire; and annual TB education for 2025. PF #3, Date of Hire: 2/1/19, did not contain any documentation of the following: signed job description for LPN; annual competency for 2023, 2024, or 2025; infection control training for 2023, 2024, or 2025; and annual TB education for 2023, 2024, or 2025. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation during survey periods and an interview with the payroll specialist, staffing coordinator and human resources manager, the supervising nurse and/or alternate supervising nurse were not available during operational hours Findings include: Upon arrival to agency on May 27, 2025, at approximately 9:15 AM, this surveyor announced that she was there to conduct the Medicare recertification survey and asked if the administrator/alternate administrator and/or supervising nurse/alternate supervising nurse were available. Payroll specialist stated neither were available at that time nor were they available during the survey period on May 27, 2025, from approximately 9:15 AM through 2:30 PM. During survey period on May 28, 2025, from approximately 9:15 AM to 11:15 AM, the administrator/alternate administrator and/or supervising nurse/alternate supervising nurse were not available. Payroll specialist stated neither were available during the survey period. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This Element is not met as evidenced by: Based on observation during survey periods and an interview with the payroll specialist, staffing coordinator and human resources manager, the supervising nurse and/or alternate supervising nurse were not available during operational hours. Findings include: Upon arrival to agency on May 27, 2025, at approximately 9:15 AM, this surveyor announced that she was there to conduct the Medicare recertification survey and asked if the administrator/alternate administrator and/or supervising nurse/alternate supervising nurse were available. Payroll specialist stated neither were available at that time nor were they available during the survey period on May 27, 2025, from approximately 9:15 AM through 2:30 PM. During survey period on May 28, 2025, from approximately 9:15 AM to 11:15 AM, the administrator/alternate administrator and/or supervising nurse/alternate supervising nurse were not available. Payroll specialist stated neither were available during the survey period. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on a review of agency policies, clinical records (CR), and interview with the payroll specialist, staffing coordinator, and human resources manager, it was determined that the agency failed to complete and/or submit to the physician a discharge summary for two (2) of two (2) discharged CRs, (CR #2 and 3). Findings include: A review of agency policy titled “Patient Discharge” conducted on May 28, 2025, did not contain any documentation regarding completing and/or submitting to the physician a discharge summary. A review of CRs conducted on May 27, 2025, from approximately 10:20 AM to 1:00 PM and May 28, 2025, from approximately 9:30 AM to 10:00 AM revealed the following: CR #2, Start of Care: 2/26/21. Discharge Date: 3/10/21. Certification period reviewed: 2/19/21 through 4/19/21 File contained documentation of a discharge summary dated 3/10/21. There is no documentation that the physician was notified of discharge or that the discharge summary was sent to the physician. CR #3, Start of Care: 12/16/19. Discharge Date: 5/25/20. Certification period reviewed: 4/13/20 through 6/13/20. File did not contain any documentation of a discharge summary and there is no documentation that the physician was notified of discharge or that a discharge summary was sent to the physician. An interview with the payroll specialist, staffing coordinator, and human resources manager conducted on May 28, 2025, at approximately 11:00 AM confirmed the above findings.”