Angeles San Cristobal

“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 a Standard, Partial Extender and Extender Recertification, review of policies and interview with facility clinical manager (employee #3), on 11/07/2023 at 2:30 PM, it was determined that the agency failed to provide to the surveyor evidence of the development, implementation, evaluation, and maintenance of an effective, ongoing, Home Health Agency (HHA)-wide, data-driven Quality Assessment Performance Improvement- QAPI program, to evaluate compliance with this Condition of Participation: §484.65 Quality Assessment and Performance Improvement (QAPI) which makes this Condition Not Met. Findings include: On 11/08/203 at 11:10 AM during the survey process its was request to the clinical manager employee #3, all agency Manuals included the QAPI manual with minutes to evaluate compliance with the QAPI Condition of participation, at the end of the survey on 11/09/2023 at 3:37 PM, the facility did not provide evidence to evaluate this Condition.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to include a documented facility and community based all hazard approach risk assessment.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to 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. Findings include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to address the ability of providing services to patients during emergencies, continuity of operations, delegation of authorities and succession plans.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation Findings include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §418.113(a)(4) of the Emergency Preparedness.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish written policies and procedures. During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to stablish policies and procedures based on the emergency plan, risk assessment and communication plan as required under §418.113(b) of the Emergency Preparedness”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish individual plans for each patient must be included as part of the comprehensive patient assessment. Findings include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to include policies and procedures for ensuring all patients have an individualized plan in the event of an emergency.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and implement procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to have written procedures to notify State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency as required under §418.113(b)(2).”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have written procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to provide written procedures to follow up on-duty staff and patients during an emergency .”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to have written process for preserving patient information as required.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish policies and procedures for the use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to ensure policies and procedures to have in place a written communication plan of how the facility coordinates patient care and how the facility interacts and coordinate with emergency management systems to protect health and safety of patients as required under §418.113(c).”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include names and contact information for staff, entities providing services under arrangement, patients’ physicians and volunteers. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM, it was noted that the facility failed to ensure policies and procedures to provide contact information for the staff, entities providing services under arrangements, patients physicians and volunteers as required.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have primary and alternate means of communicating with staff, Federal, State, tribal, regional, and local emergency management agencies. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to develop primary / alternate means for communication with HHA’s staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have a method for sharing information and medical documentation for patients under facility’s care, as necessary, with other health providers to maintain the continuity of care. A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). A means of providing information about the general condition and location of patients under the facility’s care. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to provide a written method for sharing information and medical documentation for patients under the hospice’s care, as necessary, with other health care providers to maintain the continuity of care as required under §418.113(c)(4).”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM, it was noted that the facility failed to have written procedures of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM, it was noted that the facility failed to develop and maintain a emergency preparedness training and testing program based on the facilities risk assessment.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to 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. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 11/14/2023 at 8:30 AM through 10:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan annually. Findings Include: During the review of the facilities Emergency Preparedness Program with the HHA Supervisor ( employee #9) on 11/14/2023 at 8:30 AM, it was noted that the facility failed to conduct exercises to test facilities emergency plan.”

“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 a Standard, Partial Extender and Extender Recertification, review of policies and with facility supervisor (employee #9), it was determined that the facility failed to ensure that for the Outcome Assessment Information Set -OASIS (comprehensive assessment) data collection and report there are available detailed procedures developed and implemented by facility, who include provisions to be taken to encode and transmit OASIS data within 30 days after completion the assessment to the beneficiary. Findings include: 1. Manual with policies and procedures who include provisions to be taken to encode and transmit OASIS data within 30 days after completion the assessment to each beneficiary was requested by the surveyor to the clinical manager during survey procedures on 11/09/23 at 10:30 AM. 2. Information provided consist in a group of paper title Table of contents Information Management with policies and procedures in English. This document reference is Home Health Care Manual 2000 MED-PASS and Joint Commission Standards (Revised February 2018). This document is not individualized by the facility, did not detailed provisions to be taken to encode and transmit OASIS data within 30 days after completion the assessment to each beneficiary. This Manual presented as the OASIS manual did not have evidence that is being reviewed and approved as the OASIS manual by the governing body.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, active and closed record (CR) records (RR) and interview with facility Clinical Manager (employee #3), it was determined that the facility failed to ensure that service and treatments are provided only as ordered by physician 2 out of 17 records reviewed (RR-CR #13 and HV #4) Findings Include: CCR #13 is a 71-year-old female patient admitted on 08/19/2023 with Cerebrovascular accident. During the review of this case, she received physical therapy services three visits per week according to Doctor of Physical Therapy. There was no visit from the physical therapist assistant in the week of September 3 to 9, 2023 and two visits in the week of September 17 to 23, 2023. No justification was found by the Physical therapist assistant or the physician. HV #4 is a 75-year-old female patient admitted on 9/11/2023 with Right Ankle ORIF. During the review of this case, she received physical therapy services three visits per week according to Doctor of Physical Therapy. There was no visit from the physical therapist assistant in the week of October 22 to 28, 2023. No justification was found by the Physical therapist assistant or the physician.”

“Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: This Standard is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, review of policies and interview with facility clinical manager (employee #3), on 11/07/2023 at 2:30 PM, it was determined that the agency failed to disclose the change of address to state survey agency at the time of the Home Health Agency move to other address. Findings include: On 11/07/2023 the Puerto Rico (PR) State Survey Agency programed a Recertification Survey for Angeles Visitantes Located at 3005, Ave. San Cristobal, Suite 500, Coto Laurel, PR. At the Arrived on 8:20 AM it was informed that the facility moved to the Center Diagnostic Treatment- CDT of Hormigueros, PR at 6 kilometers (KM) from prior location. When Arrive to the new address at 9:10 AM it was asked to the clinical manager employee #3 and to the agency Supervisor employee #7 when the agency change of address, and they do not remember and did not know if the CEO notified to the State Survey Agency. On 11/8/2023, the surveyor asks for evidence of the notification of change of address to the State Survey Agency, at 3:00 PM the agency supervisor employee #7 provide a letter dated 06/02/2023 notified to PR Health Department the physical address change, but no evidence of the notification to the State Survey Agency. On 11/09/2023 at 12:20 PM the agency supervisor employee #7 provide evidence of an email dated on 11/07/2023 at 10:59 AM from National Government Services, Inc send to the CEO notified the confirmation receipt of Medicare Enrollment Application and other email dated 11/8/2023 at 9:01 AM send by the National Government Service Inc to the agency CEO notified that the Medicare enrollment application was received on 11/07/2023 and currently being reviewed. With reference number PE0001178568.”

“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 an unannounced recertification Standard and Extended survey, review of the State Law Licensing of Medical Director (MD), Registered Nurse (RN) and Physical Therapist (PT), it was determined that the agency failed to vaccine with Influenza vaccine accordance to Health Department Administrative Order #244, Criminal Record, Health Certificate, Cardiopulmonary Resuscitation (CPR), Law 300, and Hepatitis B for 9 out of 23. (MD#1, RN#5, RN# 7, RN#9, RN#10, RN# 12, PT#13, PT#14, PT#16, and PT#18) Findings Include: 1. During the review of Medical Director (MD), Registered Nurse (RN) and Physical Therapy (PT) credential file on 11/09/2023 at 9:30 AM with the Clinical Manager (employee# 3) the following was determinate: a. MD#1 no evidence was found in the credentials of Hepatitis B vaccine and Law 300. b. RN#5 no evidence was found in the credentials of Health Certificate, Law 300, CPR, Hepatitis B, and Influenza vaccine. No evidence of an exemption letter for the influenza vaccine was found. c. RN#7 no evidence was found in the credentials of Hepatitis B vaccine and Influenza Vaccine. No evidence of an exemption letter for the influenza vaccine was found. d. RN#9 no evidence was found in the credentials of Law 300 and Influenza vaccine. No evidence of an exemption letter for the influenza vaccine was found. e. RN#10 no evidence was found in the credentials of Influenza vaccine. No evidence of an exemption letter for the influenza vaccine was found. f. RN#12 no evidence was found in the credentials of Criminal Record. g. PT#13 no evidence was found in the credentials of Hepatitis B vaccine. h. PT#14 no evidence was found in the credentials of Hepatitis B vaccine. i. PT#16 no evidence was found in the credentials of Law 300. j. PT#18 no evidence was found in the credentials of Health Certificate.”

“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 Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), with the Clinical Manager employee #3, it was determined that the agency failed to ensure that governing body assume full legal responsibility providing its quality assessment and performance improvement program. Findings include: During the Partial Extender and Extender survey, it was requested on multiple occasions on 11/08/2023 and 11/09/2023 the facility quality assessment and performance improvement (QAPI) program manual and minute of the QAPI program. On 11/08/2023 at 2:00 PM the clinical Manager employee #3 stated that the QAPI program oversaw by the Chief Executive Officer (CEO) employee #1. During the survey process from 11/07/2023 through 11/09/2023 from 8:00 AM till 4:00 PM the CEO was not present in the survey. On 11/08/2023 at 11:10 AM during the survey process its was requested to the clinical manager employee #3, all agency Manuals included the QAPI manual with minutes to evaluate compliance with the QAPI Condition of participation, at the end of the survey on 11/09/2023 at 3:37 PM, the facility did not provide evidence to evaluate QAPI program to evaluate compliance with this standard.”

“Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This Standard is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), with the Clinical Manager employee #3, it was determined that the agency failed to ensure that medical records contain and reflect past and current information of patient’s status for 4 out of 17 records reviewed (R.R-H.V #1, #3, R.R #11, and #12). Findings include: 1. R.R-H.V #1 is a 66-year-old female patient admitted on 05/09/2023 with a diagnosis of Stage II Sacral Pressure Ulcer. During the review of the case on 11/08/2023 at 9:00 AM, it was found the following that the patient plan of care (485) establishes RN services 3 visit per week for 9 weeks: a. During the week from 10/15/2023 through 10/21/2023 the RN did not document the sacral ulcer measure and the Right Buttock Ulcer measure. b. During the week from 10/22/2023 through 10/28/2023 the RN did not document the sacral ulcer measure and the Right Buttock Ulcer measure. c. During the week of 10/22/2023 through 10/28/2023 the RN visits the patient on 10/25/2023 and on 10/27/2023. However, no evidence was found of the third visit of the week and no evidence that facility personnel documented if the physician was notified related to the visit not performed. d. During the week of 10/29/2023 through 11/04/2023 the RN visits the patient on 10/30/2023. However, no evidence was found of two visits of the week not performed and no evidence that facility personnel documented if the physician was notified related to the visit not performed. 2. R.R-H.V # 3 is a 60-year-old female patient admitted on 10/24/2023 with a diagnosis of Muscle Atonia. During the review of the case on 11/08/2023 at 1:41 PM, it was found the following: a. The Outcome Assessment Information Set -OASIS (Initial Comprehensive Assessment) performed by the physical therapist, the M030 Start of Care (SOC) date was on 10/26/2023 and the M0090 Date Assessment Completed and the M0104 Date of Referral was left in blank. 3. R.R #11 is a 62-year-old male patient admitted on 09/07/2023 with a diagnosis of Urinary Incontinence and Ulcer. During the review of the case on 11/08/2023 at 3:14 PM, it was found the following that the patient plan of care (485) establishes RN Services 2 visit per week for 7 weeks: a. During the week from 09/24/2023 through 09/30/2023 the RN did not perform a visit to provide care to the skin lesion in the right arm and measure the lesion. 4. R.R #12 is an 89-year-old male patient admitted on 09/11/2023 with a diagnosis of Cerebrovascular Accident (CVA). During the review of the case on 11/09/2023 at 10:33 AM, it was found that the patient plan of care (485) establishes Speech Therapist (ST) Services 2 visit per week for 6 weeks: a. OASIS (Initial Comprehensive Assessment) performed by the Speech therapist; the M030 Start of Care (SOC) date was left in blank. b. During the week from 09/17/2023 through 09/23/2023, the week from 10/08/2023 through 10/14/2023 and the week from 10/15/2023 through 10/21/2023 the ST did not perform the two-visit established in the Plan of care (485).”

“Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient’s clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This Standard is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), with the Clinical Manager employee #3, it was determined that the agency failed to ensure that patient medical record be available to the patient free of charge upon request at next home visit or within 4 business days. Findings include: 1. During the Extender survey process it was asked to the clinical manager employee #3 related to the policy if patient request copy of their medical record on 11/09/2023 at 2:30 PM and the employee #3 state that the facility have a form that the patient fill out to request the medical record with a cost, but do not have any policy about this.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), Review of policy and procedure with the Clinical Manager (employee #3), it was determined that the agency failed to ensure provide to all patients written notice of the right and responsibilities related to discharge and transfer. Findings include: During the review of the information provided to patient at the admission on 11/07/2023 at 10:00 AM, it was found that patient was provided with Patient Rights and Responsibilities, one of the patients right related to Discharge and transfer indicate that patient have the right to be inform and receive a copy of the agency policy for transfer and discharge. When ask to the clinical manager employee #3 on 11/07/2023 at 10:15 AM about the policy and procedure for transfer and discharge, she do not know about this policy. The agency failed to develop and implement the policy and procedure of the Home Health agency transfer and discharge.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, review of the admission package, it was determinate that the facility failed to promote patients right to receive contact information for the Home Health Agency (HHA) Administrator (employee# 2), including the name, business address and phone number to receive complaints. Findings Include: 1. During review of admission package on 11/07/2023 at 9:45AM, the following was found: Home Health Agency Administrator (employee# 2) contact information, including the Administrator’s name, business address, and complaint telephone number, was not included as part of the information given to the patient/caregiver when admitted receive Home Health Agency services.”

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, review of the packet, it was determined that the facility failed to promote patient rights by not receiving privacy education sheets for patients for whom Outcome Assessment Information Set-OASIS data collected. Findings Include: 1. During review of admission package on 11/08/2023 at 11:00AM, the following was found: Information related to the comprehensive OASIS assessment and privacy notices in cases of collecting OASIS data information were not included as part of the information included in the intake package provided to patients and caregivers.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), Review of training program with the Clinical Manager (employee #3), it was determined that the agency failed to ensure that personnel be train related to 45 CFR parts 160 and 164 pertain to requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Findings include: During the review of the agency Training Program on 11/07/2023 at 11:15 AM with the Clinical Manager (employee #3), it was found that no evidence that the agency provides to all personnel the HIPAA training.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, review of the document agency admission of the patient right with the Clinical Manager (employee #3), it as determined that the facility failed to ensure to document the correct telephone numbers for the State Licensing (Law 101) and the Medicare State Agency established for the purpose of receiving any complaints. Findings Include: 1. During the review of patient admission documentation provide by the Clinical Manager (employee #5) on 11/07/2023 at 11:02 AM, it was found that the State Agency Medicare and State Licensing (Law 101) phone numbers were not updated in case a patient had a complaint.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R) with the Clinical Manager (employee #3), it was determined that the agency failed to ensure that transfer or discharge is necessary for the patient’s welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity for 4 out of 17 records reviewed (R.R-H.V. #3, R.R #8, #9, and #10). Findings include: 1. During the entrance conference on 11/07/2023 at 9:10 AM, the clinical manager employee #3 refer to the surveyor that have two Physical Therapist (PT) to cover the services since 10/12/2023, and performed the patient different assessment with tele consult or tele conference, the previous PT was resign on September 29, 2023, that patient is admitted with need of PT services, they notified to patient that do not have the services and patient accepted wait until they have the services and notified to their physician about patient decision. However, no evidence was found in patient record review related to the patient decision and physician notification as evidence: a. R.R-H.V. # 3 is a 60-year-old female patient admitted on 10/24/2023 with a diagnosis of Muscle Atonia. During the review of the case on 11/08/2023 at 1:41 PM, it was found that on 09/28/2023 the agency receive physician referred for PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/24/2023. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. b. R.R. #8 is a 79-year-old female patient admitted on 10/02/2023 with a diagnosis of Essential Hypertension and Muscle Weakness. During the review of the case on 11/09/2023 at 11:15 AM, it was found that on 09/27/2023 the agency receives physician referral for Registered Nurse (RN) Services and PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/02/2023 and RN performed the initial assessment. PT service entrance on 11/03/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. c. R.R. #9 is a 65-year-old male patient admitted on 10/04/2023 with a diagnosis of Total Knee Replacement. During the review of the case on 11/09/2023 at 1:10 PM, it was found that on 09/26/2023 the agency receives physician referral for Registered Nurse (RN) Services and PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/04/2023 and RN performed the initial assessment. PT service entrance on 10/24/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. d. R.R. #10 is an 81-year-old male patient admitted on 10/10/2023 with a diagnosis of Retention of Urine, Acute Kidney Failure, Hypertensive Heart Disease, and Muscle Weakness. During the review of the case on 11/09/2023 at 09:40 AM, it was found that on 09/18/2023 the agency receives physician referral for PT Services and on 10/06/2024 another referral for RN services and PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/10/2023 and RN performed the initial assessment. PT service entrance on 10/16/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care.”

“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 a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), Review of policy and procedure with the Clinical Manager employee #3, it was determined that the agency failed to ensure that the Initial Assessment was performed withing 48 hour of receiving the patient referred for 11 out of 17 Records Reviewed (R.R-H.V #1, #2, #3, R.R. #8, #9, #10, #11, #12, Closed R.R #14, #16, and #17). Findings include: 1. R.R-H.V #1 is a 66-year-old female patient admitted on 05/09/2023 with a diagnosis of Stage II Sacral Pressure Ulcer. During the review of the case on 11/08/2023 at 9:00 AM, it was found that patient was referred to the facility on 05/05/2023 for Registered Nurse (RN) services for wound Care. Evidence was found that the initial comprehensive assessment was performed by RN on 05/09/2023, four (4) days later. No evidence was found in the medical record that justified why the facility did not enter after 4 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/08/2023 at 9:10 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 2. R.R.-H.V #2 is an 81-year-old female patient admitted on 10/21/2023 with a diagnosis of Left (Lt) Buttock Pressure Ulcer. During the review of the case on 11/08/2023 at 11:20 AM, it was found that patient was referred to the facility on 10/19/2023 for RN services, Physical Therapist (PT) Services, Home Health Aid (HHA) Services. Evidence was found that the initial comprehensive assessment was performed by RN on 10/21/2023, three (3) days later. No evidence was found in the medical record that justified why the facility did not enter after 3 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/08/2023 at 11:25 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 3. R.R-H.V #3 is a 60-year-old female patient admitted on 10/24/2023 with a diagnosis of Muscle Atonia, Post Operate Lt Toal Knee Replacement (TKR). During the review of the case on 11/08/2023 at 1:41 PM, it was found that patient was referred to the facility on 09/28/2023 for PT Services. Evidence was found that the initial comprehensive assessment was performed by PT on 10/24/2023, twenty-seven (27) days later. No evidence was found in the medical record that justified why the facility did not enter after 27 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/08/2023 at 1:50 PM, related to the delay in entrance to perform the Initial comprehensive assessment and stated that this was the period that do not have PT services from 09/28/2023 through 10/17/2023. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 4. R.R #8 is a 79-year-old female patient admitted on 10/02/2023 with a diagnosis of Muscle Weakness. During the review of the case on 11/09/2023 at 11:15 AM, it was found that patient was referred to the facility on 09/27/2023 for RN Services and PT Services. Evidence was found that the initial comprehensive assessment was performed by RN on 10/02/2023, five (5) days later and the PT Services entrance on 11/3/2023. No evidence was found in the medical record that justified why the facility did not enter after 5 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 11:30 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 5. R.R #9 is a 65-year-old male patient admitted on 10/04/2023 with a diagnosis of Right (Rt) TKR. During the review of the case on 11/09/2023 at 1:10 PM, it was found that patient was referred to the facility on 09/26/2023 for RN Services and PT Services. Evidence was found that the initial comprehensive assessment was performed by RN on 10/04/2023, eight (8) days later and the PT Services entrance on 10/24/2023. No evidence was found in the medical record that justified why the facility did not enter after 8 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 1:20 PM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 6. R.R #10 is an 81-year-old male patient admitted on 10/10/2023 with a diagnosis of Urinary Incontinence. During the review of the case on 11/09/2023 at 9:40 AM, it was found that patient was referred to the facility on 10/06/2023 for RN Services and PT Services. Evidence was found that the initial comprehensive assessment was performed by RN on 10/10/2023, four (4) days later and the PT Services entrance on 10/16/2023. No evidence was found in the medical record that justified why the facility did not enter after 4 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 9:45 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 7. R.R #11 is a 62-year-old male patient admitted on 09/07/2023 with a diagnosis of Urinary Incontinence and Ulcer. During the review of the case on 11/08/2023 at 3:14 PM, it was found that patient was referred to the facility on 09/01/2023 for RN Services and PT Services. Evidence was found that the initial comprehensive assessment was performed by RN on 09/07/2023, five (5) days later and the PT Services entrance on 09/08/2023. No evidence was found in the medical record that justified why the facility did not enter after 5 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/08/2023 at 3:25 PM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 8. R.R #12 is an 89-year-old male patient admitted on 09/11/2023 with a diagnosis of Cerebrovascular Accident (CVA). During the review of the case on 11/09/2023 at 10:33 AM, it was found that patient was referred to the facility on 09/05/2023 for Speech Therapist (ST) Services and PT Services. Evidence was found that the initial comprehensive assessment was performed by ST on 09/11/2023, six (6) days later and the PT Services entrance on 11/03/2023. No evidence was found in the medical record that justified why the facility did not enter after 6 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 10:45 Am, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 9. R.R #14 is an 86-year-old female patient admitted on 08/14/2023 with a diagnosis of CVA. During the review of the case on 11/09/2023 at 9:15 AM, it was found that patient was referred to the facility on 08/09/2023 for PT Services. Evidence was found that the initial comprehensive assessment was performed by RN on 08/14/2023, five (5) days later and the PT Services entrance on 08/24/2023. No evidence was found in the medical record that justified why the facility did not enter after 5 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 9:25 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 10. R.R #16 is a 71-year-old female patient admitted on 07/31/2023 with a diagnosis of Parkinson Disease. During the review of the case on 11/09/2023 at 10:55 AM, it was found that patient was referred to the facility on 07/18/2023 for PT Services to increase balance and mobility. Evidence was found that the initial comprehensive assessment was performed by PT on 07/31/2023, thirteen (13) days later. No evidence was found in the medical record that justified why the facility did not enter after 13 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 11:00 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral. 11. R.R #17 is a 69-year-old male patient admitted on 08/10/2023 with a diagnosis of Other Specific Disorder of Muscle. During the review of the case on 11/09/2023 at 10:15 AM, it was found that patient was referred to the facility on 07/14/2023 for PT Services. Evidence was found that the initial comprehensive assessment was performed by PT on 08/10/2023, twenty-eight (28) days later. No evidence was found in the medical record that justified why the facility did not enter after 28 days of receiving the physician referral. Interview with the clinical manager employee #3 on 11/09/2023 at 10:15 AM, related to the delay in entrance to perform the Initial comprehensive assessment and did not explain why. The facility failed to perform the initial comprehensive assessment Start of Care (SOC) within 48 hours of receiving the patient referral.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), Review of policy and procedure with the Clinical Manager employee #3, it was determined that the agency failed to ensure that the comprehensive assessment must be updated the last 5 days of every 60 days beginning the stat of Care date for 4 out of 17 records reviewed (H.V. #1, #5, R.R #11, and #12). Findings include: 1. R.R-H.V #1 is a 66-year-old female patient admitted on 05/09/2023 with a diagnosis of Stage II Sacral Pressure Ulcer. During the review of the case on 11/08/2023 at 9:00 AM, it was found the following: a. The Certification period from 05/09/2023 through 07/07/2023. On 06/23/2023, the registered nurse (RN) performed the Recertification OASIS, 15 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. b. The Certification period from 09/06/2023 through 11/04/2023. On 10/23/2023, the RN performed the Recertification OASIS 13 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. 2. R.R.- H.V #5 is an 89-year-old female patient admitted on 09/21/2023 with a diagnosis of Total Incontinence, and Controlled Diabetes Mellitus. During the review of the case on 11/08/2023 at 10:00 AM, it was found the following: a. The Certification period from 03/31/2023 through 05/29/2023. On 05/22/2023, the RN performed the Recertification OASIS 8 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. b. The Certification period from 07/29/2023 through 09/26/2023. On 09/13/2023, the RN performed the Recertification OASIS 14 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. 3. R.R #11 is a 62-year-old male patient admitted on 09/07/2023 with a diagnosis of Ulcer and Incontinence. During the review of the case on 11/08/2023 at 3:14 PM, it was found the following: a. The Certification period from 09/07/2023 through 11/05/2023. On 10/27/2023, the RN performed the Recertification OASIS 10 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. 4. R.R #12 is an 89-year-old male patient admitted on 09/11/2023 with a diagnosis of Cerebrovascular Accident (CVA). During the review of the case on 11/09/2023 at 10:33 AM, it was found the following: a. The Certification period from 09/11/2023 through 11/9/2023. On 10/30/2023, the RN performed the Recertification OASIS 10 days before finishing the certification period not according to Medicare regulation to update at least 5 days of every 60 days of the beginning the start of care. 5. Interview with the clinical manager employee #1 on 11/08/2023 at 11:00 AM, related to the reason to perform the recertification more than 5 days of every 60 days to finish the certification period and stated than the Medical Insurance Plan demand to perform the Recertification OASIS 2 week before finishing the period of certification.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, seven Home Visit (H.V) and ten Records Reviewed (R.R), Review of policy and procedure with the Clinical Manager employee #3, it was determined that the agency failed to ensure patient physician be promptly alert that agency lack of Physical Therapist- PT from 09/29/2023 through 10/11/2023 for 4 out of 17 records reviewed (R.R-H.V #3, R.R. #8, #9 and #10). Findings include: 1. During the entrance conference on 11/07/2023 at 9:10 AM, the clinical manager employee #3 refer to the surveyor that they have 2 Physical Therapist (PT) to cover the services since 10/12/2023, and performed the patient different assessment with tele consult or tele conference, the previous PT resign on September 29, 2023, that patient admitted with need of PT services, they notified to patient that they do not have the services and patient accepted wait until have the services and notified to their physician about patient decision. However, no evidence was found in patient record review related to the patient decision and physician notification as evidence: a. R.R-H.V # 3 is a 60-year-old female patient admitted on 10/24/2023 with a diagnosis of Muscle Atonia. During the review of the case on 11/08/2023 at 1:41 PM, it was found that on 09/28/2023 the agency receive physician referred for PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/24/2023. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. b. R.R. #8 is a 79-year-old female patient admitted on 10/02/2023 with a diagnosis of Essential Hypertension and Muscle Weakness. During the review of the case on 11/09/2023 at 11:15 AM, it was found that on 09/27/2023 the agency receive physician referred for Registered Nurse (RN) Services and PT Services. At this moment agency lack of PT Services. The Star of Care (SOC) was performed on 10/02/2023 and RN performed the initial assessment. PT service entrance on 11/03/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. c. R.R. #9 is a 65-year-old male patient admitted on 10/04/2023 with a diagnosis of Total Knee Replacement. During the review of the case on 11/09/2023 at 1:10 PM, it was found that on 09/26/2023 the agency receive physician referred for Registered Nurse (RN) Services and PT Services. At this moment the agency lacks PT services. The Star of Care (SOC) was performed on 10/04/2023 and RN performed the initial assessment. PT service entrance on 10/24/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care. d. R.R. #10 is an 81-year-old male patient admitted on 10/10/2023 with a diagnosis of Retention of Urine, Acute Kidney Failure, Hypertensive Heart Disease, and Muscle Weakness. During the review of the case on 11/09/2023 at 09:40 AM, it was found that on 09/18/2023 the agency receives physician referral for PT Services and on 10/06/2024 another referral to RN services and PT services. At this moment the agency lack of PT Services. The Star of Care (SOC) was performed on 10/10/2023 and RN performed the initial assessment. PT service entrance on 10/16/2023 that perform the initial evaluation. No evidence was found related to the efforts made to notify the patient and physician of the unavailability of PT Services at the start of care.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, review of the admission package, it was determinate that the facility failed to promote patients right to receive contact information for the Home Health Agency (HHA) Clinical Manager (employee #3), including the name, business address and phone number to receive complaints. Findings Include: 1. During review of admission package on 11/07/2023 at 9:45AM, the following was found: The Home Health Agency Clinical Manager (employee# 3) contact information, including the Clinical Manager name, business address, and complaint telephone number, was not included as part of the information given to the patient/caregiver when admitted receiving Home Health Agency services.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a Standard, Partial Extender and Extender Recertification, review of policies and interview with facility clinical manager (employee #3), on 11/07/2023 at 2:30 PM, it was determined that the agency failed demonstrate that skilled professional services participate in the implementation of the HHA’s Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. No evidence was provided related to the participation of the Skill Professional Services, Include Nursing Services, Physical therapist, Speech-language pathology services and Occupational services participate in the QAPI program.”

“Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, The employee Education Manual was reviewed with the Clinical Manager (employee #3), it was determined that the agency failed to include education for physical therapy and speech therapy personnel. Findings Include: 1. During the interview with the Clinical Manager (employee# 3) on 11/07/2023 at 10:55AM the following was found: a. Only guidelines for nursing staff were included as observed in the education manual. b. The clinical manager did not include education for the physical therapy and speech therapy staff who are part of the facility staff.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on an unannounced recertification Standard and Extended survey, performed on 11/07/2023 seven Home Visit (HV) and fifth Records Reviewed (RR) with the Clinical Manager (employee #3), it was determined that the facility failed to ensure that all Home Health Agency (HHA) services must be provided in accordance with current clinical practice guidelines for infection control accepted hand washing professional standards of practice and urinary catheter insertion standard practice for 2 out of 7 home visits (HV # 1 and #5). 2. H.V #1 is a 66-year-old female patient visit on 11/07/2023 at 2:50 PM at the patient home to evaluate the urinary catheter insertion care procedure accompanied by the Registered Nurse (RN) (employee #4). a. The RN # did not wash her hands two of five opportunities to wash her hand. b. The RN #4 does not clean genital area with soap and water first. c. The RN #4 does not perform aseptic hand wash before putting on the sterile gloves. d. The RN #4 cleans the genital area with Betadine from top to bottom but releases the labia minora to reposition the fingers and visualize the meatus. e. The RN #4 failed to follow accepted standard of practice to prevent the transmission of infectious diseases during the practice procedure urinary catheter insertion, according with the Center for Disease Control Prevention (CDC). Findings Include: 1. HV #5 is an 89-year-old female patient visit on 11/07/2023 at 1:31 PM at the patient home to evaluate the urinary catheter insertion care procedure accompanied by the Registered Nurse (RN) (employee #5) and Clinical Manager (employee #5). The RN #5 did not wash her hands on several occasions. She only washed his hands with soap and water first before inserting the urinary catheter and after inserting it. The RN #5 does not clean genital area with soap and water first then does not Perform hand hygiene. The RN #5 does not perform aseptic hand wash and don sterile gloves. The RN #5 cleans the genital area with betadine from bottom to top. The RN #5 failed to follow accepted standard of practice to prevent the transmission of infections diseases during the practice procedure urinary catheter insertion, according with the Center for Disease Control Prevention (CDC).”