H&m Care Inc.

“Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This Condition is not met as evidenced by: Based on review of clinical records, iQIES (Internet Quality Improvement and Evaluation System), and an interview with the Administrator, it was determined that the Home Health Agency (HHA) failed to report OASIS information. Findings include: This CONDITION is not met as evidenced under the following standards which did not result in immediate jeopardy: §484.45(a) Standard: Encoding and Transmitting OASIS §484.45(c)(2) Standard: Transmit Data Using Compliant Software”

“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 quality assessment performance improvement (QAPI) documents and an interview with the Compliance Director, it was determined that the Home Health Agency (HHA) failed to maintain an effective, ongoing, agency-wide, data-driven QAPI program. Findings include: This CONDITION is not met as evidenced under the following standards which did not result in immediate jeopardy: §484.65(a) Standard: Program Scope §484.65(b) Standard: Program Data §484.65(c) Standard: Program Activities §484.65(c)(2) Standard: Program Activities §484.65(d)(1)(2) Performance Improvement Project §484.65(e)(1)(2)(3) Executive Responsibilities for QAPI”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on review of personnel files and an interview with the Administrator, it was determined that the Home Health Agency (HHA) failed to ensure Home Health Aides were qualified to provide services. Findings include: This CONDITION is not met as evidenced under the following standards which did not result in immediate jeopardy: §484.80(a)(1)(i-iv) Standard: A Qualified HH Aide Successfully Completed §484.80(b)(1) Standard: Classroom and Supervised Practical Training §484.80(b)(4) Standard: HHA Maintains Documentation of Training”

“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 agency policy, emergency preparedness documentation, and interview with the Compliance Director, the Home Health Agency (HHA) failed to develop an emergency preparedness plan to include a facility-based and community-based risk assessment, utilizing an all-hazards approach that categorized the likelihood of events that may occur in the agency’s geographical area. Review of agency’s emergency preparedness documentation on 9/11/2025, at approximately 9:40AM revealed no evidence that the agency developed a categorized all-hazards risk assessment based on the agency’s geographical area. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above finding.”

“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 personnel files (PF), agency policies, and an interview with the Compliance Director, the Home Health Agency (HHA) failed to ensure staff emergency preparedness training was documented for four (4) of seven (7) personnel files (PF) reviewed, (PF1, PF2, PF6, and PF7). Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Emergency Preparedness Plan” states, “…6. Staff Training: Staff will be trained upon hire and at least annually…” Policy No. 5-15 titled “Emergency Response and Evacuation” states, “…Procedure: Training – 1. Personnel: All personnel will receive documented competency-based training at orientation and at least annually regarding emergency procedures and evacuation procedures…” A review of personnel files (PF) was conducted on 9/10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF1 – (Date of Hire): 10/14/2024 – File did not contain documentation of emergency preparedness training education at orientation. PF2 – (Date of Hire): 11/12/2020 – File did not contain documentation of emergency preparedness training education at orientation or annually for 2021, 2022, 2023, and 2024. PF6 – (Date of Hire): 9/3/2024 – File did not contain documentation of emergency preparedness training education at orientation. PF7 – (Date of Hire): 5/6/2025 – File did not contain documentation of emergency preparedness training education at orientation. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 HHA policy, emergency preparedness documentation, and an interview with the Compliance Director, the Home Health Agency (HHA) failed to conduct a full-scale community-based or facility-based functional exercise at least every two (2) years. Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy No. 5-15 titled “Emergency Response and Evacuation” states, “…Definitions: 3. Full-Scale Exercise. A real-life emergency situation is simulated as closely as possible. This exercise involves the organization’s response personnel, employees, the management, and community response organizations…11. Tabletop Exercise. Members of the emergency management group meet in a conference room setting to discuss their responsibilities and how they would react to emergency scenarios. This is a cost-effective and efficient way to identify areas of overlap and confusion before conducting more demanding training activities…” Review of the HHA emergency preparedness documentation on 9/11/2025 at approximately 9:50AM revealed no evidence that the HHA conducted a full-scale community-based or facility-based functional exercise, or tabletop exercises for 2024 or 2025. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above finding.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of clinical records (CR), agency policy, and interview with the Administrator via email, the Home Health Agency (HHA) failed to encode and electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments to the CMS (Centers for Medicare and Medicaid Services) system. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Initial RN Assessment Policy” states, “…7. Documentation Requirements: Complete the OASIS (Outcome and Assessment Information Set) as required for Medicare patients. Document findings in the clinical record on the same day as the assessment…” Review of OASIS transmissions in iQIES (Internet Quality Improvement and Evaluation System) on 9/19/25 at 11:30AM revealed there were no OASIS transmissions for 2023, 2024, and 2025. During an interview with the Compliance Director via email on 9/26/2025 at approximately 2:12PM, the Administrator stated that the HHA does not use OASIS; that the HHA uses an EMR (Electronic Medical Record) system called Alora. The administrator was asked if said electronic medical record system has the capability to transfer data to OASIS, and the Administrator stated that the HHA’s current EMR system (Alora) has the capability to transfer data to OASIS. However, OASIS was not added to the platform.”

“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 on review of quality assessment performance improvement (QAPI) documents and an interview with the Compliance Director, the Home Health Agency (HHA) failed to 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. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Scope of Care:…5. Ongoing – Continuous and periodic collection and assessment of data. Assessment of such data enables areas of potential problems to be identified and indicates data that should be collected and assess in order to identify whether a problem exists…Aggregation and Analysis: 1. The QAPI team will aggregate and analyze collected data, which may include detection of trends, patterns of behavior, and for an action plan to decrease occurrences…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program. There was no documentation to confirm the HHA utilized a focus and data-driven quality assessment and performance improvement plan to ensure safety and improved outcomes for patients. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on review of quality assessment performance improvement (QAPI) documents and an interview with the Compliance Director, the Home Health Agency (HHA) failed to utilize data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Data Collection:…4. Data collection includes developing QAPI indicators, criteria or performance levels for each major function or process determined to be improved. Data collection will be ongoing and frequency will be determined by the process improvement activity and the QAPI team…Aggregation and Analysis: 1. The QAPI team will aggregate and analyze collected data, which may include detection of trends, patterns of behavior, and for an action plan to decrease occurrences…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program. There was no evidence or documentation to confirm the HHA utilized data to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 on review of quality assessment performance improvement documents and an interview with the Compliance Director, the Home Health agency (HHA) failed to provide evidence that the QAPI program focused on high risk, high volume, or problem-prone areas, and considered the incidence, prevalence, and severity of problems in those areas. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Data Collection: 2. Data collection may include: High Risk Processes: Patients are placed at risk of serious consequences or deprived of care if care is not provided correctly, not provided when indicated or provided when not indicated. High Volume Processes: Care/service/process occurs frequently or affects large number of patients/staff. Problem Prone Processes: Care/service/process tends to produce problems for patients or staff…Aggregation and Analysis: 1. The QAPI team will aggregate and analyze collected data, which may include detection of trends, patterns of behavior, and for an action plan to decrease occurrences. The Agency will monitor at least one important aspect of the service/care provided by the Agency; at least one important administrative/operational aspect of function…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program. There was no evidence or documentation to confirm the HHA identified, selected or monitored high-risk, high-volume or problem-prone areas, nor considered the incidence, prevalence and severity of problems in those areas. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on review of quality assessment performance improvement documents and an interview with the Compliance Director, The Home Health Agency (HHA) failed to show evidence of tracking adverse patient events, analyzing their causes, and implementing preventive actions. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Data Collection: 4. Data collection includes developing QAPI indicators, criteria or performance levels for each major function or process determined to be improved…Aggregation and Analysis: 1. The QAPI team will aggregate and analyze collected data, which may include detection of trends, patterns of behavior, and for an action plan to decrease occurrences…2. Statistical techniques will be utilized, as appropriate, to analyze data. Such techniques help to focus the Agency’s attention and resources on those processes and outcomes for which more intensive analysis will be most beneficial…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program. There was no evidence or documentation to confirm the HHA’s QAPI program included measurable, objective and quantitative quality indicators to improve home health services. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 on review of quality assessment performance improvement (QAPI) documents and an interview with the Compliance Director, the Home Health Agency (HHA) failed to identify one performance improvement project either in development, on-going or completed in 2024 or 2025. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Responsibility/Accountability:…4. The QAPI team will meet on a regular basis and will share in reporting to the Administrator, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI team to staff, including contract staff. The QAPI team will meet at least quarterly to aggregate data and will prepare the action plans for improvement…Aggregation and Analysis: 1. The QAPI team will aggregate and analyze collected data, which may include detection of trends, patterns of behavior, and for an action plan to decrease occurrences. The Agency will monitor at least one important aspect of the service/care provided by the Agency; at least one important administrative/operational aspect of function…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program. There was no evidence or documentation to confirm the HHA identified and developed a performance improvement project. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on review of quality assessment performance improvement (QAPI) documents and an interview with the Compliance Director, the Home Health Agency (HHA) failed to ensure the Governing Body assumed overall responsibility for ensuring that the QAPI program reflected the complexity of the HHA and its services, involved all services (including those provided under contract or arrangement), focused on indicators related to improved outcomes, and took actions to address the HHA’s performance across the spectrum of care. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Quality Assessment Performance Improvement (QAPI) Plan” states, “Purpose: To continuously collect and analyze data to improve the Agency’s performance of patient care and other process…Responsibility/Accountability: 1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan. 2. Administrative responsibility for the QAPI plan is delegated to the Administrator, who, in turn, assigns certain QAPI activities to other staff members. The Administrator will be responsible for: ensuring adequate resources are available, assigning an adequate number of staff, allowing staff sufficient time to participate in QAPI activities and instituting appropriate information systems (manual and/or computer) for collecting and analyzing data…The QAPI team will be responsible for coordinating all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing QAPI design or improvement activities, planning actions, collecting data and analyzing the effectiveness of action and implementing effective actions…4. The QAPI team will meet on a regular basis and will share in reporting to the Administrator, who, in turn, will report to the Governing Body…” Reviewed HHA QAPI documentation on 9/8/2025 at approximately 1:55PM. There was no documentation of a QAPI program and there was no evidence or documentation to confirm the HHA conducted Governing Body meetings. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 review of personnel files (PF), agency policy, and an interview with the Compliance Director, the Home Health Agency (HHA) 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. Six (6) of seven (7) personnel files (PF) did not meet the requirement, (PF1, PF2, PF4, PF5, PF6, and PF7). Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Infection Control Policy” states, “…7. Education and Training – All staff shall receive initial and annual training on infection control procedures…” Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF1 – (Date of Hire): 10/14/2024 – File did not contain documentation of infection control education at orientation. PF2 – (Date of Hire): 11/12/2020 – File did not contain documentation of infection control education at orientation or annually for 2021, 2022, 2023, and 2024. PF4 – (Date of Hire): 4/1/2023 – File did not contain documentation of infection control education at orientation or annually for 2024. PF5 – (Date of Hire): 2/5/2025 – File did not contain documentation of infection control education at orientation. PF6 – (Date of Hire): 9/3/2024 – File did not contain documentation of infection control education at orientation. PF7 – (Date of Hire): 5/6/2025 – File did not contain documentation of infection control education at orientation. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on review of personnel files (PF), and interview with the Compliance Director, the Home Health Agency (HHA) failed to ensure personnel files contained initial and current certifications, for one (1) of seven (7) personnel files reviewed (PF6). Findings include: Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF6 – (Date of Hire): 9/3/2024 – File contained LPN licensure which expired on 6/30/2024. File did not contain current LPN licensure. File did not contain CPR certification on hire or current status. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above finding.”

“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 review of HHA documentation, and interview with the Compliance Director, it was determined that the Home Health Agency (HHA) failed to ensure meetings were held for the Governing Body. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Governing Body Policy” states, “…Policy Statement: The Governing Body shall assume full legal authority and responsibility for the management, operation, and performance of the Home Health Agency. This includes oversight of organizational planning, quality of services, financial management, and compliance with all applicable federal, state, and accrediting regulations…Procedures:…3. Meetings and Documentation – The Governing Body shall meet at least quarterly and additionally as needed…Written minutes of all meetings shall be maintained, signed by the chairperson, and retrained in the agency’s official records…” On 9/8/2025 at approximately 1:45PM, reviewed annual budget meeting minutes dated 1/1/2025. The documentation did not contain quarterly Governing Body meeting minutes. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above finding.”

“Transmit data using compliant software CFR(s): 484.45(c)(2) Transmit data using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the HHA or the HHA contractor to the CMS collection site. This Element is not met as evidenced by: Based on review of clinical records (CR), agency policy, and interview with the Administrator via email, the Home Health Agency (HHA) failed to transmit OASIS (Outcome and Assessment Information Set) data using electronic communications software that complies with the Federal Information Processing Standard from the HHA or the HHA contractor to the CMS collection. Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Initial RN Assessment Policy” states, “…7. Documentation Requirements: Complete the OASIS (Outcome and Assessment Information Set) as required for Medicare patients. Document findings in the clinical record on the same day as the assessment…” Review of OASIS transmissions in iQIES (Internet Quality Improvement and Evaluation System) on 9/19/25 at 11:30AM revealed there were no OASIS transmissions for 2023, 2024, and 2025. During an interview with the Compliance Director via email on 9/26/2025 at approximately 2:12PM, the Administrator stated that the HHA does not use OASIS; that the HHA uses an EMR (Electronic Medical Record) system called Alora. The administrator was asked if said electronic medical record system has the capability to transfer data to OASIS, and the Administrator stated that the HHA’s current EMR system (Alora) has the capability to transfer data to OASIS. However, OASIS was not added to their platform.”

“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 on review of clinical records (CR), agency policy, and interview with the Compliance Director, the Home Health Agency (HHA) failed to ensure the RN conducted the initial comprehensive assessment for one (1) of seven (7) clinical records reviewed (CR5). Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Initial RN Assessment Policy” states, “Policy Statement: The Home Health Agency shall require that all patients admitted to home health services receive a comprehensive initial assessment performed by a qualified Registered Nurse (RN). This assessment must determine the immediate care needs of the patient, establish eligibility, and initiate the development of the patient’s Plan of Care…” Review of clinical records (CR) on 9/8/2025 from approximately 10:43AM until approximately 1:25PM, and 9/9/2025 from approximately 9:50AM until approximately 10:45AM revealed: CR5 – SOC 11/17/2022: Diagnosis (Diabetes, Hypertension). The CR did not contain documentation of the initial RN comprehensive assessment. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 review of clinical records, and an interview with the Compliance Director, the Home Health Agency (HHA) failed to follow its policy and failed to ensure the individual plan of care (POC) contained 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, for one (1) of seven (7) clinical records reviewed (CR5). Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Plan of Care Policy” states, “…Policy Statement: The Home Health Agency shall develop and maintain a written Plan of Care for each patient…Procedures: 2. Content of the Plan of Care – The POC shall include, but is not limited to:…Types of services and disciplines involved, frequency and duration of services, orders for medications, treatments, and equipment, nutritional, safety, and emergency preparedness needs, patient/caregiver education and participation…3. Physician Involvement – The POC must be reviewed, approved, and signed by the ordering physician…” Review of clinical records (CR) on 9/8/2025 from approximately 10:43AM until approximately 1:25PM, and 9/9/2025 from approximately 9:50AM until approximately 10:45AM revealed: CR5 – SOC 11/17/2022: Diagnosis (Diabetes, Hypertension). The CR contained a plan of care (POC)/physician’s orders dated 1/1/2019 for SN services for two (2) hours per day for three (3) days per week to assess resident and monitor efficacy of all medications. The POC is signed and dated by the Administrator (RN) on 6/13/2024. The POC did not 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. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 review of agency policy, clinical records, and an interview with the Compliance Director, the Home Health Agency (HHA) failed to ensure the physician or approved personnel reviewed and revised the plan of treatment at least every 60 days or as the patient’s condition changed, for one (1) of seven (7) clinical records (CR) reviewed (CR5). Findings include: Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy No. 11-47, titled “Person-Centered Treatment Plan” states, “…Procedure - Timeframes for Review and Modification:…7. Treatment plans will be reviewed periodically with the consumer to reflect current issues; maintain relevance; modify goals, objectives, and interventions when necessary. 8. A formal documented review of the treatment plan will be conducted at least once per month…” Policy titled “Plan of Care Policy” states, “…Policy State:…The Plan of Care (POC) is mandatory before the initiation of services and shall be reviewed and updated as required by federal, state, and payer regulations…Procedures:…4. Review and Update of Plan of Care – The POC must be reviewed at least every 60 days (or more frequently if required by payer regulations or patient needs)…” Review of clinical records (CR) on 9/8/2025 from approximately 10:43AM until approximately 1:25PM, and 9/9/2025 from approximately 9:50AM until approximately 10:45AM revealed: CR5 SOC 11/17/2022: Diagnosis (Diabetes, Hypertension). The CR contained a plan of care (POC)/physician’s orders dated 1/1/2019 for SN services for two (2) hours per day for three (3) days per week to assess resident and monitor efficacy of all medications. The POC is signed and dated by the Administrator (RN) on 6/13/2024. The POC did not contain a current certification period (last certification period was 6/2/2025 through 8/1/2025), a physician signature, duration of SN services, or documentation of services to be provided by the SN. The CR did not contain evidence that the POC was reviewed every 60 days. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on review of personnel files (PF), and an interview with the Compliance Director, the Home Health Agency (HHA) failed to demonstrate the presence of the following: a Home Health Aide successfully completed a training and competency evaluation program. Two (2) of two (2) personnel files (PF) did not meet the requirement, (PF4 and PF5). Findings include: Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF4 – (Date of Hire): 4/1/2023 – File did not contain evidence that the Home Health Aide completed a home health aide training and competency program PF5 – (Date of Hire): 2/5/2025 – File did not contain evidence that the Home Health Aide completed a home health aide training and competency program. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This Element is not met as evidenced by: Based on review of personnel files (PF), and an interview with the Compliance Director, the Home Health Agency (HHA) failed to demonstrate the presence of the following: Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services, for two (2) of two (2) personnel files (PF) reviewed (PF4 and PF5). Findings include: Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF4 – (Date of Hire): 4/1/2023 – File did not contain evidence of a minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. PF5 – (Date of Hire): 2/5/2025 – File did not contain evidence of a minimum of 75 hours of classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM confirmed the above findings.”

“HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This Element is not met as evidenced by: Based on review of personnel files (PF), and an interview with the Compliance Director, the Home Health Agency (HHA) failed to provide evidence of documentation of home health aide competency and supervised practical training. Two (2) of two (2) personnel files (PF) did not meet the requirement, (PF4 and PF5). Findings include: Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF4 – (Date of Hire): 4/1/2023 – File did not contain documentation of home health aide competency and supervised practical training. PF5 – (Date of Hire): 2/5/2025 – File did not contain documentation of home health aide competency and supervised practical training. Interview with the Compliance Director on 9/11/2025 at approximately 2:30PM 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 personnel files (PF), CDC (Centers for Disease Control) and OSHA Guidelines, and interview with the Compliance Director, the administrator failed to ensure personnel files contained initial and annual skills evaluations, annual performance evaluations, and initial health examinations with annual education, for four (4) of seven (7) personnel files reviewed (PF1, PF2, PF6, and PF7). Findings include: “Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 - Historically, U.S. health care personnel were at increased risk for latent TB infection (LTBI) and TB disease from occupational exposures, but recent data suggest that this is no longer the case. CDC and the National Tuberculosis Controllers Association have updated the 2005 CDC recommendations for testing health care personnel. The update includes 1) TB risk assessment, symptom screening, and TB testing upon hire with a TB blood test (e.g., interferon-gamma release assay) or tuberculin skin test for those without documented prior TB or LTBI; 2) no annual TB testing for most health care personnel without a known exposure or ongoing transmission; 3) for health care personnel with LTBI treatment is strongly encouraged; 4) annual symptom screening for health care personnel with untreated LTBI; and 5) annual TB education for all health care personnel. These recommendations apply to health care personnel and volunteers in all health care settings. However, state and local TB screening and testing regulations may have different requirements.” “United States Department of Labor – Occupational Safety and Health Administration (OSHA) – OSHA Fact Sheet: Hepatitis B Vaccination Protection as defined in the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030…In addition, employers must make Hepatitis B vaccination available to these workers. Hepatitis B vaccination is recognized as an effective defense against HBV infection…Declining the Vaccination: Employers must ensure that workers who decline vaccination sign a declination form”. Reviewed HHA policies and procedures on 9/11/2025 from approximately 11:27AM until approximately 12:05PM. Policy titled “Performance Evaluation Policy” states, “…Policy Statement: The Home Care Agency shall conduct performance evaluations for all personnel at regular intervals and as needed. Evaluations will assess competency, professionalism, adherence to agency polices, and contribution to quality care…Procedures: 1. Frequency of Evaluations – Initial Evaluation: Conducted at the end of the employee’s probationary period (typically 90 days). Annual Evaluation: Conducted at least once every twelve (12) months. Special Evaluations: May be conducted in response to performance concerns, disciplinary actions, or significant changes in job responsibilities…” Review of personnel files (PF) was conducted on 9//10/2025, at approximately 11:37AM until approximately 12:35PM revealed the following: PF1 – (Date of Hire): 10/14/2024 – File did not contain a TB symptom screen and TB risk assessment on hire. File did not contain documentation of Hepatitis B immunity or declination. PF2 – (Date of Hire): 11/12/2020 – File did not contain documentation of annual skills and performance evaluations for 2021, 2022, 2023, and 2024. File did not contain a TB symptom screen and TB risk assessment on hire or TB annual education for 2021, 2022, 2023, and 2024. File did not contain documentation of Hepatitis B immunity or declination. PF6 – (Date of Hire): 9/3/2024 – File did not contain documentation of Hepatitis B immunity or declination. PF7 – (Date of Hire): 5/6/2025 – File did not contain a TB symptom screen and TB risk assessment on hire. File did not contain documentation of Hepatitis B immunity or declination. Interview with the Compliance Director, on 9/11/2025 at approximately 2:30PM confirmed the above findings.”