Always A Step Beyond

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on review of agency policies/procedures, emergency preparedness program manual (EP) and an interview with the Administrator/Director of Nursing (PF#1), the agency failed to establish and maintain a comprehensive emergency preparedness program (Tag 004); failed to ensure the completion of an all-hazards risk assessment every two (2) years (Tag 006); failed to specify the population served (Tag 009); failed to maintain documentation of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers at least every two (2) years (Tag 0036): failed to ensure documentation to test the emergency plan annually (Tag 0037); failed to to test the emergency plan annually, which includes a full-scale exercise that is community-based every 2 years and an additional exercise at least every 2 years, opposite the year of the full-scale exercise for one (1) of one (1) EP reviewed EP #1. Findings include: Cross references: 484.102 (a) E-0004 Development of Emergency Preparedness Plan Review and Update Annually, the agency failed to review and update the emergency preparedness plan at least every two (2) years. 484.102(a)(1-2) E-0006 Program based on All Hazards Risk Assessment- the agency failed to complete an all-hazards risk assessment at least every two (2) years. 484.102(a)(3) E-0007 EP Program Patient Population- the agency failed to specify the population served by the agency one (1) of one (1) plan reviewed EP #1 484.102 (d) E-0036 EP Training and Testing-the agency failed to maintain documentation of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, and no documentation of emergency preparedness training conducted at least every two (2) years. 484.102(d)(1)E-0037 EP Training Program- the agency failed to document exercises to test the emergency plan annually, which includes a full-scale exercise that is community-based every 2 years and an additional exercise at least every 2 years, opposite the year of the full-scale exercise. 484.102(d)(2) E-0039 EP Testing Requirements the agency failed to document exercises to test the emergency plan annually, which includes a full-scale exercise that is community-based every 2 years and an additional exercise at least every 2 years, opposite the year of the full-scale exercise. The agency’s failure to develop, review and maintain a comprehensive emergency preparedness program led to it’s inability to provide effective and safe patient care.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on review of agency policies/procedures, clinical records (CR), agency documents and an interview with the agency Administrator/Director of Nursing (PF#1) it was determined that the agency failed to ensure a registered nurse conducted the initial evaluation, completed a comprehensive assessment that included the patient’s current health, psychosocial, functional, cognitive status, the patient’s strengths, goals, and care preferences, the patient’s continuing need for home care, the patient’s medical, nursing, rehabilitative, social, and discharge planning needs, failed to review all medications, and updated the comprehensive assessment the last 5 days of every 60 days. This CONDITION is not met as evidenced under the following standards: Cross Reference: 484.55.(a)(1) (Tag 514): Initial assessment visit -failed to ensure a registered nurse conducted the initial assessment visit within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date for six (6) out of six (6) clinical records reviewed (CR#1-6 484.55(c)(1) (Tag 528): Content of comprehensive assessment-failed to ensure a registered nurse assessed the patient’s current health, psychosocial, functional, and cognitive status for six (6) out of six (6) clinical record reviewed (CR#1-6) 484.55(c)(2) (Tag 530): The comprehensive assessment must accurately reflect the patient’s strengths, goals, and care preferences-failed to ensure a registered nurse assessed the patient’s strengths, goals, and care preferences for six (6) out of six (6) clinical record reviewed (CR#1-6) 484.55(c)(3) (Tag 532): The comprehensive assessment must include the patient’s continuing need for home care-failed to ensure a registered nurse assessed the patient’s continuing need for home care for six (6) out of six (6) clinical record reviewed (CR#1-6) 484.55(c)(4) (Tag 534): The comprehensive assessment must include the patient’s medical, nursing, rehabilitative, social, and discharge planning needs.- failed to ensure a registered nurse assessed the patient’s medical, nursing, rehabilitative, social, and discharge planning needs for six (6) out of six (6) clinical record reviewed (CR#1-6) 484.55(c)(5) (Tag 536): Review of all medications the patient is currently using 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- failed to 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 six (6) of the six (6) CRs reviewed. (CR#1-6) 484.55(d)(1) (Tag 546) Update of the comprehensive assessment the last 5 days of every 60 days beginning with the start-of-care date-failed to ensure a registered nurse updated the comprehensive assessment the last 5 days of every 60 days beginning with the star-of-care date for four (4) out of six (6) clinical record reviewed (CR#1, 2, 4, and 5) The cumulative effect of these systematic problems resulted in the agency’s inability to ensure the provision of quality healthcare to the patients.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on review of agency policies/procedures, clinical records (CR), and an interview with the agency’s Administrator/Director of Nursing(PF#1), it was determined that the agency failed to ensure individualized care plans were developed (Tag 572);individualized to meet the patient’s needs and cover all the required elements (tag 574); ordered and signed by a physician (Tag 580); reviewed and revised at least every sixty 60 days (Tag 592) for six (6) of six (6) records reviewed CR #1-6; This CONDITION is not met as evidenced under the following standards: Cross Reference: 484.60(a)(1) (Tag 572): Plan of care- failed to ensure a Home Health Certification and Plan of Care/Treatment was created for six (6) out of six (6) clinical record reviewed (CR#1-6) 484.60(a)(2) (Tag 574): Content of the plan of care- failed to ensure an individualized plan of care was developed that covered all required elements per agency policy for six (6) of six (6) clinical records (CR) reviewed. (CR #1-6) 484.60(b) (Tag 580) Conformance with the physician orders- failed to obtain a physician order for services, and treatments and/or medications for six (6) of the six (6) CRs reviewed. (CR#1-6) 484.60(d) (Tag 588) Review and revision of the plan of care- failed to ensure an individualized plan of care was reviewed and revised no less frequently than every 60 days for six (6) of six (6) clinical records (CR) reviewed. (CR #1-6) 484.60(c)(2) (Tag 592) Revised plan of care reflects information in updated comprehensive assessment- failed to ensure a revised plan of care reflecting current information from the updated comprehensive assessment contained information regarding the patient’s progress toward measurable outcomes and goals for six (6) of six (CR) reviewed. (CR #1-6) The cumulative effect of these systematic problems resulted in the agency’s inability to ensure the provision of quality healthcare to the patients.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on review of agency policies/procedures, clinical records (CR), and an interview with the agency Administrator/Director of Nursing (PF#1), the agency failed to ensure development of a Quality Assessment and Performance Improvement (QAPI) program that showed measurable outcomes indicators that would improve health outcomes, patient safety and quality of care by measuring, analyzing, and tracking quality indicators (Tag 642); failed to ensure performance activities focused on high risk, high volume, and problem prone areas (Tag 656); failed to conduct performance improvement projects (Tag 658) for one (1) of one (1) year received. 2025. This CONDITION is not met as evidenced under the following standards: Cross Reference: 484.65(a) (Tag 642): Program scope-failed to develop a Quality Assessment and Performance Improvement (QAPI) program that showed measurable improvement in indicators that would improve health outcomes, patient safety and quality of care by measuring, analyzing, and tracking quality of indicators for one (1) of one (1) QAPI requested. 484.65(c) (Tag 646): Program activities- agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested. 484.65(c)(3) (Tag 656) Implementation- failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested. 484.66(d) (Tag 658) Performance improvement projects- failed to conduct performance improvement projects as part of the Quality Improvement Performance Improvement (QAPI) program for one (1) of one (1) QAPI requested. The cumulative effect of these systematic problems resulted in the agency’s inability to ensure the provision of quality healthcare to the patients.”

“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 policies/procedures, agency emergency preparedness documentation and interview with agency staff, the agency failed to review and update the emergency preparedness plan at least every two (2) years. Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed a policy titled “Emergency Preparedness Plan Orientation/In-Service Training” dated 7/2017. There was no documentation that the plan was reviewed and/or updated every two (2) years. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm 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 review of policies/procedures, agency emergency preparedness documentation and interview with agency staff, the agency failed to complete an all-hazards risk assessment at least every two (2) years. Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed a “Hazard Risk Analysis” form for 2017. There was no documentation that an all-hazards risk assessment was completed every two (2) years. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm 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 review of agency emergency preparedness documentation and interview with agency staff, the agency failed to specify the population served by the agency one (1) of one (1) plan reviewed EP #1 Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed no documentation of a plan that is specific to the population served by the agency. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm 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 review of agency emergency preparedness documentation and interview with agency staff, the agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency preparedness plan, the risk assessment, policies and procedures, and the communication plan, which must be reviewed and updated at least every two (2) years. Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed an “Emergency Preparedness In-Service Quiz”. There was no documentation that the training and testing program was reviewed and updated at least every two (2) years. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above 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 agency emergency preparedness documentation and interview with agency staff, the agency failed to maintain documentation of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, and no documentation of emergency preparedness training conducted at least every two (2) years. Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed no documentation of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers. There was no documentation that emergency preparedness training was conducted at least every two (2) years. The agency did not maintain documentation of all emergency preparedness training and demonstration of staff knowledge of emergency procedures. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above 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 documentation and interview with agency staff, the agency failed to document exercises to test the emergency plan annually, which includes a full-scale exercise that is community-based every 2 years and an additional exercise at least every 2 years, opposite the year of the full-scale exercise. Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed no documentation of emergency preparedness exercises conducted annually. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm 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 upon agency policy review, clinical record(CR) review, and an interview with the Administrator/Director of Nursing, it was determined the agency failed to ensure a Home Health Certification and Plan of Care/Treatment was created for six (6) out of six (6) clinical record reviewed (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 11:30 AM and revealed the following: Agency policy titled “Plan of Care (POC)” stated, “ Policy: Each patient will receive home health services that are written in an individual plan of care that identifies patient-specific measurable outcomes and goals, which is established, periodically reviewed and signed by a physician...2. POC development: The POC is: b. Developed within 5 days of the SOC/ROC or Follow UP Assessment...g. Must be signed by the attending...p Administrator/Clinical Manager or Nursing Supervisor shall review the plan of care for completeness prior to it being submitted to MD for signature...r. A copy of the POC shall be maintained in the patient’s clinical record...3. POC UPDATES/REVISIONS: A revised POC must reflect current information from the patients updated comprehensive assessment...a. The POC is updated/revised: i. At least every 60 days beginning with the SOC date. ii. Upon initial assessment and development of the 485. iii. As new orders are received. vi. At Follow Up Recertification periods...b. Update process: At time of recertification, a written summary of the patient’s status and the services being provided, is submitted with the POC for physician review... 4. POC INCLUDES …a. All pertinent diagnosis b. Patients mental, Psychosocial, and cognitive status c. Types of services, supplies, and equipment needs. d. Frequency & duration of visits of be made e. Prognosis, f. Rehab Potential g. Functional Limitations h. Activities permitted i. Nutritional requirements j. All medications and treatments k. Safety measures to protect against injury...” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:00 A.M to 1:00 PM, and again on February 10, 2026, at approximately 1PM which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 12/7/2023, admission diagnosis Autistic disorder, primary diagnosis Autistic disorder, secondary diagnosis pervasive developmental disorder unspecified. The Calendar revealed HHA visits Monday - Friday from 7 am -4 pm, then 8:30 pm -4:30 am. Saturday and Sunday 7 am -2 pm, then 8:30 pm-4:30 am. CR#2 SOC 6/29/2023: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 6/29/2023, admission diagnosis Cerebral Palsy, unspecified, primary diagnosis oth generalized epilepsy, not intractable, w stat epi, secondary diagnosis cortical blindness, right side of brain. The Calendar revealed LPN visits started on June 30, 2023. From September 5, 2025, to February 7, 2026, 1-5 times a week from 8pm to 7am. CR#3 SOC 1/27/2026: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 1/20/2026, admission diagnosis Down syndrome, unspecified. The Calendar revealed HHA visit started on 2/3/26, from 9am to 12pm. CR#4 SOC 2/4/2026: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 1/26/2026, admission diagnosis Unspecified convulsions, secondary diagnosis Epileptic spasms, intractable, with status epilepticus. The Calendar revealed HHA visit started on 2/8/26 from 12pm-8pm, Monday to Friday from 3pm-11pm, and Sunday from 12pm to 8pm. CR#5 SOC 11/24/2025: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 11/24/2025, admission diagnosis Congenital hypotonia, primary diagnosis, Congenital hypotonia, secondary diagnosis Congenital hypotonia, and services required Home Health Aide. The Calendar revealed HHA visit started on November 25, 2025. Monday to Sunday from 2pm to 10pm, then 10:00 pm to 6am. CR#6 SOC 4/23/2025: Contained no documentation of a “Home Health Certification and Plan of Care” and therefore did not contain the following: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies, and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, and other appropriate items. File contained no documentation of any physician orders enabling agency to conduct services. A document titled “Client Profile” revealed a SOC of 4/23/2025, admission diagnosis Autistic disorder, Primary diagnosis Autistic disorder, secondary diagnosis Mixed receptive-expressive language disorder, and services required Home Health Aide. The Calendar revealed HHA visit started on 8/1/2025 from 9:30 am-3:30 pm. Visits times documented as follows: Monday, Tuesday Saturday and Sunday from 9:30 AM to 3:30 PM, Wednesday, Thursday and Friday 9:30 am to 3:30 pm and 5:30 pm to 9:30 pm. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based upon agency policy/procedures review and an interview with the Director of Nursing/Administrator (PF#1), it was determined the agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that showed measurable improvement in indicators that would improve health outcomes, patient safety and quality of care by measuring, analyzing, and tracking quality of indicators for one (1) of one (1) QAPI requested. Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “A: 24 Quality Assessment Performance Improvement (QAPI) IC Committee” states, “POLICY: Our Agency believes in fostering ongoing improvement of the organization’s performance and quality of services & programs through its Quality Assessment Performance Improvement (QAPI) program. See QAPI Policy Binder for complete QA program policies and procedures…” Agency policy titled “QA: 1 QAPI Policy” states, “POLICY: It is the policy of our Agency to have in place, an ongoing quality assurance and performance improvement (QAPI) program that is agency-wide, data-driven, across all aspects of Agency services and programs…” The QAPI program documentation was requested on February 9, 2026, at approximately 11:30 AM. The agency Administrator/Director of Nursing could not provide any documentation pertaining to the QAPI program. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based upon agency policy/procedure review and an interview with the Administrator/Director of Nursing (PF#1), it was determined the agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested. Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “QA: 4 QA Performance Improvement Projects (PIPs)” states, “PROCEDURE: A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements. The agency conducts PIPs to examine and improve care/services in areas that the agency identifies as needing attention. Areas that need attention will vary depending on the agency and the unique scope of services the agency provides. Our Agency will prioritize PIPs as follows: Areas that affect patients first, High risk areas for opportunities and improvement… Our agency will document: All QA projects undertaken, The reasons for conducting these projects, The measurable progress achieved on the projects.” The QAPI program documentation was requested on February 9, 2026, at approximately 11:30 AM. The agency Administrator/Director of Nursing could not provide any documentation pertaining to the QAPI program. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based upon agency policy/procedure review and an interview with the Administrator/Director of Nursing (PF#1), it was determined the agency failed to conduct performance improvement projects as part of the Quality Improvement Performance Improvement (QAPI) program for one (1) of one (1) QAPI requested. Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “QA: 4 QA Performance Improvement Projects (PIPs)” states, “PROCEDURE: A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements. The agency conducts PIPs to examine and improve care/services in areas that the agency identifies as needing attention. Areas that need attention will vary depending on the agency and the unique scope of services the agency provides. Our Agency will prioritize PIPs as follows: Areas that affect patients first, High risk areas for opportunities and improvement… Our agency will document: All QA projects undertaken, The reasons for conducting these projects, The measurable progress achieved on the projects.” The QAPI program documentation was requested on February 9, 2026, at approximately 11:30 AM. The agency Administrator/Director of Nursing could not provide any documentation pertaining to the QAPI program. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm 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 and procedure, agency documentation, and interview with the Administrator/Director of Nursing (PF#1), it was determined the Governing body (GB) and the agency failed to follow its own policy and conduct a two (2) person governing body meeting and ensure documentation in regards to the reviewing and approval the the annual program evaluation and the agency policies for one (1) of one (1) GB reviewed. (GB#1) Findings include: Review of agency policy was conducted on February 11, 2026, at approximately 11:30 AM and revealed the following: Policy titled, “Governing Body” stated “Procedure: 1. General: a. MEMBERS of the GB: The GB will be no less than 2 individuals, at least 21 years of age. ...these rules be reviewed and approved annually as part of the Agency annual evaluation...” Policy titled, “Agency Evaluation Policy” stated, “ 3. ANNUAL EVALUATION RESULTS PROCESSING a. Once the team has completed review of all the evaluation areas, the Annual Evaluation document will be completed, signed/dated & presented to the Governing Body for review & final approval.” GB#1-Review of agency documentation on February 10, 2026, at approximately 11:25 AM revealed documentation of Governing Body meetings held on January 31, 2026. There was no documentation contained in this meeting minutes about annual budget or the review and approval of the annual program evaluation or agency policies. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based upon reviews of agency policy/procedures, clinical records (CR) and an interview with the Administrator/Director of Nursing, it was determined the agency failed to ensure a registered nurse conducted the initial assessment visit within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date for six (6) out of six (6) clinical records reviewed (CR#1-6) Based upon clinical record review, agency policy review, and an interview with the Director of Nursing/Administrator and staff, it was determined the agency failed to ensure a registered nurse conducted the initial assessment visit within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date for six (6) out of six (6) clinical record reviewed (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “Admission Policy/Approved Treatments” stated, “ 1. ADMISSIONS: Referrals are accepted by the Nursing Supervisor/designee on the Referral Form. C. ADMITTED TO CARE PROCESS: i. Once the determination is made that the patient is suitable for admission, an initial assessment is scheduled within 48 hours of the referral...” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. CR#2 SOC 6/29/2023: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. CR#3 SOC 1/20/2026: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. CR#4 SOC 2/4/2026: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. CR#5 SOC 11/24/2025: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. CR#6 SOC 4/23/2025: Contained no documentation of a referral form, a Plan of Care (POC), a certification period, or an initial or comprehensive assessment. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based upon agency policy review, clinical record review(CR), and an interview with the Administrator/ Director of Nursing (PF#1), it was determined the agency failed to ensure a registered nurse assessed the patient’s medical, nursing, rehabilitative, social, and discharge planning needs for six (6) out of six (6) clinical record reviewed (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “Assessments” stated, “a. THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFELCTE THE PATIENT’S STATUS AND MUST INCLUDE: 9. Patient medical, nursing, rehab, social & discharge planning needs.” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CR#2 SOC 6/29/2023: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CR#3 SOC 1/20/2026: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CR#4 SOC 2/4/2026: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CR#5 SOC 11/24/2025: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CR#6 SOC 4/23/2025: Contained no documentation of a comprehensive assessment that included the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator/Director of Nursing (PF#1), the agency failed to ensure an individualized plan of care was developed that covered all required elements per agency policy for six (6) of six (6) clinical records (CR) reviewed. (CR #1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy #C: 48 titled “Plan of care (POC) stated, “4. POC INCLUDES: The POC is developed in consultation with staff, patient, physician and other providers involved in the patient’s care and includes: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status, c. Types of services, supplies and equipment needs, d. Frequency & duration of visits of be made, e. Prognosis, f. Rehab Potential, g. Functional Limitations, h. Activities permitted, i. Nutritional requirements, j. All medications and treatments, k. Safety measures to protect against injury, l. Plans for the patient during a natural or man-made disaster, m. 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, n. Patient & caregiver education/training to facilitate timely discharge, o. Patient specific interventions & education, p. Measurable outcomes & goals identified by the patient & Agency, q. Information related to any Advance Directives, r. Homebound status, s. Any additional items the Agency or physician may choose to include.” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a Plan of Care (POC) or orders on file. CR#2 SOC 6/29/2023: Contained no documentation of a Plan of Care (POC) or orders on file. CR#3 SOC 1/20/2026: Contained no documentation of a Plan of Care (POC) or orders on file. CR#4 SOC 2/4/2026: Contained no documentation of a Plan of Care (POC) or orders on file. CR#5 SOC 11/24/2025: Contained no documentation of a Plan of Care (POC) or orders on file. CR#6 SOC 4/23/2025: Contained no documentation of a Plan of Care (POC) or orders on file. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above 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 upon agency policy review, clinical record (CR) review, and an interview with the Administrator/Director of Nursing (PF#1), it was determined the agency failed to obtain a physician order for services, and treatments and/or medications for six (6) of the six (6) CRs reviewed. (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “ Physician Services” stated, “POLICY: Drugs, services and treatments are administered by Agency staff only as ordered by a physician…” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: A document titled “Client Profile” revealed a SOC of 12/7/2023, admission diagnosis Autistic disorder, primary diagnosis Autistic disorder, secondary diagnosis pervasive developmental disorder unspecified. The Calendar revealed HHA visits Monday - Friday from 7 am -4 pm, then 8:30 pm -4:30 am. Saturday and Sunday 7 am -2 pm, then 8:30 pm-4:30 am. Contained no evidence of a physician order. CR#2 SOC 6/29/2023: A document titled “Client Profile” revealed a SOC of 6/29/2023, admission diagnosis Cerebral Palsy, unspecified, primary diagnosis oth generalized epilepsy, not intractable, w stat epi, secondary diagnosis cortical blindness, right side of brain, and services required Skilled Nurse. The Calendar revealed LPN visits 1-5 times a week from September 5, 2025, to February 7, 2026. Nurses note dated 1/10/2026, the LPN documented administering “all medication, feedings, and fluids “ via G-tube. LPN documented on 1/11/26 “formula Compleat Pediatric @55ml/hr for a total volume of 450ml.” LPN note dated 1/18/26, the LPN documented, “All medications, feedings, and fluids administered as ordered, well tolerated.” Nurses note dated 1/24/2026, the LPN documented “saline drops administered to nostrils, rub chest ointment applied to the patient’s chest per Dad request.” Contained no evidence of a physician order. Contained no medication list or record. CR#3 SOC 1/20/2026: A document titled “Client Profile” revealed a SOC of 1/20/2026, admission diagnosis Down syndrome, unspecified, and services required Home Health Aide. The Calendar revealed HHA visit started on 2/3/26 from 9am to 12pm. Contained no evidence of a physician order. CR#4 SOC 2/4/2026: A document titled “Client Profile” revealed a SOC of 1/26/2026, admission diagnosis Unspecified convulsions, secondary diagnosis Epileptic spasms, intractable, with status epilepticus, and services required Home Health Aide. The Calendar revealed HHA visit started on 2/8/26 from 12pm-8pm. Contained no evidence of a physician order. CR#5 SOC 11/24/2025: A document titled “Client Profile” revealed a SOC of 11/24/2025, admission diagnosis Congenital hypotonia, primary diagnosis, Congenital hypotonia, secondary diagnosis Congenital hypotonia, and services required Home Health Aide. The Calendar revealed HHA visit started on 11/25/2025 from 2pm to 10pm, then 10om to 6am. Contained no evidence of a physician order. CR#6 SOC 4/23/2025: A document titled “Client Profile” revealed, SOC of 4/23/2025, admission diagnosis Autistic disorder, Primary diagnosis Autistic disorder, secondary diagnosis Mixed receptive-expressive language disorder, and services required Home Health Aide. The Calendar revealed HHA visit started on 8/1/2025 from 9:30 am-3:30 pm. Visits times documented as follows: Monday, Tuesday Saturday and Sunday from 9:30 AM to 3:30 PM, Wednesday, Thursday and Friday 9:30 am to 3:30 pm and 5:30 pm to 9:30 pm. Contained no evidence of a physician order. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator/Director of Nursing (PF#1), the agency failed to ensure an individualized plan of care was reviewed and revised no less frequently than every 60 days for six (6) of six (6) clinical records (CR) reviewed. (CR #1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy #C: 48 titled “Plan of care (POC) stated, “3. POC UPDATES/REVISIONS: A revised POC must reflect current information from the patient’s updated comprehensive assessment and contain info from the patient’s progress towards measurable outcomes & goals identified by the Agency & patient in the POC. a. The POC is updated/revised: i. At least every 60 days beginning with the SOC date.” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a Plan of Care (POC) or orders on file. CR#2 SOC 6/29/2023: Contained no documentation of a Plan of Care (POC) or orders on file. CR#3 SOC 1/20/2026: Contained no documentation of a Plan of Care (POC) or orders on file. CR#4 SOC 2/4/2026: Contained no documentation of a Plan of Care (POC) or orders on file. CR#5 SOC 11/24/2025: Contained no documentation of a Plan of Care (POC) or orders on file. CR#6 SOC 4/23/2025: Contained no documentation of a Plan of Care (POC) or orders on file. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Administrator/Director of Nursing (PF#1), the agency failed to ensure a revised plan of care reflecting current information from the updated comprehensive assessment contained information regarding the patient’s progress toward measurable outcomes and goals for six (6) of six (CR) reviewed. (CR #1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy #C: 48 titled “Plan of care (POC) stated, “3. POC UPDATES/REVISIONS: A revised POC must reflect current information from the patient’s updated comprehensive assessment and contain info from the patient’s progress towards measurable outcomes & goals identified by the Agency & patient in the POC.” A review of Clinical records (CR) conducted on February 9, 2026, at approximately 11:30 AM to 1:00 PM, on February 10, 2026, at approximately 1PM and on February 11, 2026, at approximately 12 PM, which revealed the following: CR#1 Start of Care (SOC) 12/7/2023: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. CR#2 SOC 6/29/2023: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. CR#3 SOC 1/20/2026: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. CR#4 SOC 2/4/2026: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. CR#5 SOC 11/24/2025: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. CR#6 SOC 4/23/2025: Contained no documentation of a comprehensive assessment or a Plan of Care (POC) containing information regarding the patient’s progress toward measurable outcomes and goals. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based upon agency policy/procedure review and an interview with the Administrator/Director of Nursing (PFF#1), it was determined the agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested. Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:00 PM and revealed the following: Agency policy titled “QA: 4 QA Performance Improvement Projects (PIPs)” states, “PROCEDURE: A Performance Improvement Project (PIP) is a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements. The agency conducts PIPs to examine and improve care/services in areas that the agency identifies as needing attention. Areas that need attention will vary depending on the agency and the unique scope of services the agency provides. Our Agency will prioritize PIPs as follows: Areas that affect patients first, High risk areas for opportunities and improvement… Our agency will document: All QA projects undertaken, The reasons for conducting these projects, The measurable progress achieved on the projects.” The QAPI program documentation was requested on February 9, 2026, at approximately 11:30 AM. The agency Administrator/Director of Nursing could not provide any documentation pertaining to the QAPI program. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on a review of agency policies/procedures, review of personnel files (PF), and an interview with the Administrator/Nursing Director (PF#1), the agency failed to ensure documentation of competency evaluation for clinical staff for ten (10) of the ten (10) PFs requested. (PF#1-10) Findings include: A review of agency’s policy conducted on February 17, 2026, at approximately 9am revealed the following: Agency policy titled “Competency Skills Testing: Clinical Staff” stated, “POLICY: It is the policy of Guaranteed Home Health Services, Inc. d/b/a Always A Step Beyond to provide skills competency evaluations at the time of hire and annually thereafter, and as needed based on performance, for clinical professional and paraprofessional staff to ensure the highest quality of consumer care. Skills competencies are performed on hire and at least annually...” A review of personnel files conducted on February 10, 2026, between approximately 10:30 am to 11:30 am, and again on February 17, 2026, at approximately 10am, revealed the following: PF#1 Date of hire (DOH) 6/20/25: Contained no documentation verifying skills competency evaluation on hire. (Administrator/Director of Nursing) PF#2 DOH 9/28/23: Contained no documentation verifying skills competency evaluation on hire. No documentation of skill competency evaluation for year 2024 and 2025. Licensed Practical Nurse providing services to CF#2. PF#3 DOH 11/24/25: Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#5 PF#4 DOH 8/25/25: Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#4 PF#5 DOH 8/23/25: Contained no documentation verifying skills competency evaluation on hire.) Home Health Aide providing services for CF#6 PF#6 DOH 7/8/25: Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#6 PF#7 DOH 1/15/25: Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#3 PF#8 No DOH documented. Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#1 PF#9 No DOH documented. Contained no documentation verifying skills competency evaluation on hire. Home Health Aide providing services for CF#1 PF#10 No DOH documented. Contained no documentation verifying skills competency as the Alternate Administrator. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on a review of agency policy/procedure, personnel files (PF), agency documentation, and an interview with the Administrator/Director of Nursing (PF#1), it was revealed that the Governing body (GB) failed to appoint a qualified professional to act as the Agency Administrator in writing for one (1) of one (1) GB reviewed. (GB#1) . Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 2:15 PM and revealed the following: Agency policy titled “ Administrator/Alternate Administrator stated, “POLICY: It is the policy of the Agency for the Governing Body to designate in writing, a qualified professional to act as the Agency Administrator and for the Governing Body/Administrator, to select a pre-designated Alternate Administrator to act in the absence of the Agency Administrator. Both will be available during all operating hours. Based on a review of agency policy/procedure, personnel files (PF), agency documentation, and an interview with the Administrator/Director of Nursing (PF#1), it was revealed that the Governing body (GB) failed to appoint a qualified professional to act as the Agency Administrator in writing for one (1) of one (1) GB reviewed. (GB#1) . Personnel review conducted on February 9, 2026, at approximately 11:50 am revealed the following: PF#1 Date of hire 6/20/2026: Did not contain a signed job description for the role of administrator. Contained no documentation of competency, skill assessments, or performance evaluation. On February 10, 2026, at approximately 2:30 PM, during an interview with the administrator, he reported not being familiar with Home Health surveys. He reported only knowing the survey process of nursing homes. When I asked him for the orders for the skilled case, he informed me the doctor’s orders were in the patient’s home. On February 9, 2026, at approximately 2:25pm, PF#1 reported that he had to go pick up a child in New Jersey where he lives. There was no other administrator available for oversight or in the event of an emergency. GB#1- Reviewed Governing body minutes conducted on February 9, 2026, at approximately 3 PM revealed, The Governing body minutes dated 1/31/2026, approved PF#1 as the administrator and the owner as the alternate. On February 10, 2026, surveyor requested the personnel files of the alternate and the previous administrator. The agency failed to provide termination date and personnel file for the previous administrator. The agency failed to provide the personnel file for the alternate administrator/owner, who resides in Boston. An interview with the Administrator/Director of Nursing on February 10, 2026, at approximately 2:30 PM, then again by phone on February 27, 2026, at approximately 12pm confirmed the above findings.”