Dependable Healthcare Services LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that the needs of patients admitted for treatment are met and that the patient’s individualized plan of care specifies that the care and services the s/he needs as identified in the comprehensive assessment, for 1 of 1 patient reviewed requiring social services, Patient ID #2. Findings are as follows: Review of the patient record revealed s/he was admitted to services with diagnoses including, but not limited to, other signs and symptoms involving the musculoskeletal system, cerebral infarction, bipolar disorder, and psychoactive substance abuse. Review of the OASIS Assessment documentation revealed his/her start of care date was 5/20/2025. Further review of the documentation revealed the patient needed community resource information for care, had an altered affect (depression, grief, body image change), and a social services referral was needed. Review of the plan of care lacked evidence of a social services referral for an evaluation of the patient to be completed. Review of the patient record lacked evidence that a referral for social services was implemented by the HHA. During a surveyor interview with the Director of Nursing, Staff A, and the Administrator, Staff B, on 8/21/2025 at 3:30 PM, they indicated that the HHA has not employed a social worker at the HHA for approximately 3-4 years however they are contracting out social services. They were unable to provide evidence that a referral for social services was provided for the patient to meet his/her needs identified in the comprehensive assessment.”

“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: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, evaluate and maintain an effective and ongoing Agency wide data driven Quality assessment/performance improvement (QAPI) program that is reviewed annually by a governing body as to ensure the program reflects the complexity of the Agency and involves all services including those under contract or arrangement and focuses on indicators related to improved outcomes. Findings are as follows: Review of QAPI documentation failed to reveal evidence of a QAPI program as indicated above and involves collection of data that is being monitored, evaluated and for which the Agency can demonstrate its operation. During a surveyor interview with the owners and sole members of the governing body, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide documented evidence of an Agency wide QAPI program as indicated above and required.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to assure that administrative and supervisory functions are not delegated to another Agency or organization and failed to monitor and control all services not furnished directly by the Agency. Findings are as follows: Review of an undated policy titled, “1.37 Services Under Contract”, states in part, “…to assure continuity and quality of services acquired through contract…a written contract is required for attaining services from other entities or individuals…contracts or agreements for services can only be initiated and approved by the Agency’s Administrator…the method of supervision of contracted personnel and the manner in which services will be controlled, coordinated, and valuated by the Agency…” Review of a document titled, “Agreement for Consulting Services” states in part, “…this agreement is made and entered into this 30th day of April, 2019, by and between [name redacted]…a Rhode Island professional service corporation (“Provider”), and Dependable Home Care, a Rhode Island licensed nursing home care provider (the “Agency”)…Provider agrees to all applicable Agency policies and procedures including, but not limited to, record keeping, reporting, supervision, personnel qualifications and other professional responsibilities…” During a surveyor interview with the Administrator and Director of Nursing Services on 8/19/2025 at 3:30 PM, they revealed the Agency provides skilled services which include rehabilitative therapy services that are contracted through another provider. Additionally, they revealed that contracted employees complete documentation as related to the treatments, evaluations and visits they provide to the Agency clients however, were unable to provide evidence that the Agency is monitoring the contracted services as to ensure that the services are being provided timely and in accordance with physician orders and that the clinical records contain all documentation for services rendered. Record review for Patient ID #7 revealed a start of care date of 8/7/2025 for which the patient was to receive skilled services including nursing, physical and occupational therapy. Further record review revealed a continuity of care from the post-acute facility the patient was discharged from revealed the patient is “unable to leave home without assistance and ambulation is severely limited due to pain, decreased strength and endurance.” Additional review of the above document revealed the patient required surgery for a right forearm and left femur injury resulting from the motor vehicle accident and has diagnoses including, but not limited to, below the knee amputation of left lower extremity, and anemia. Review of the physician orders for discharge state in part, “discharge to home with home health services from Dependable Home Care…skilled nursing care, PT, OT, Cardiopulmonary assessment, medication management…” Review of the services rendered to the patient as documented in the clinical record that was reviewed on 8/25/2025 revealed the patient received skilled nursing visits however, there was no documented evidence of physical therapy or occupational therapy services which were ordered by the patient’s physician. During a surveyor interview with the Director of Nursing on 8/25/2025 at 11:15 AM, she acknowledged upon record review there was no evidence of documentation indicating the patient has received physical or occupational therapy services as ordered by the physician. She further acknowledged that until brought to her attention by the surveyor, she was unaware of the services this patient had received since his/her start of care date. The Director of Nursing further revealed that the Agency receives documentation completed by the contracted employees/therapists “usually once a week” and revealed “it is sent electronically to a secured email which is then scanned into the patient’s clinical record.” In addition to the above, the Director of Nursing was unable to provide evidence that the contracted employees have the required health screenings, BCI, licensure, educational trainings, competencies and supervisory visits and revealed the Agency does not retain personnel files for the contracted employees and revealed “they (referring to the contracted Agency) take care of all that” and therefore, she was unable to provide evidence that the Agency’s administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled by the Agency, as required.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to establish and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach, that is reviewed and updated at least every two (2) years. Findings are as follows: Record of the emergency preparedness plan revealed it was last reviewed on 1/15/2024. Further review lacked evidence that the plan was reviewed prior to 2024. In addition, the documentation lacked evidence that the plan was comprehensive, utilized an all-hazards approach that was based on a risk assessment completed by the agency. Additionally, the plan lacked evidence that it was reviewed at minimum every two years. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the emergency preparedness plan included the above-mentioned criteria and was reviewed every two years.”

“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 on record review and staff interview, it has been determined that the agency’s emergency preparedness plan failed to include 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 that is reviewed and updated at least every two (2) years. Findings are as follows: Review of the emergency preparedness plan documentation lacked evidence of procedure to notify emergency preparedness officials of patients in need in the event of an emergency evacuation. Additionally, the documentation lacked evidence that it was reviewed at minimum every two years. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the emergency preparedness plan included the above-mentioned criteria.”

“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 on record review and staff interview, it has been determined that the agency’s emergency preparedness plan failed to include policies and procedure for the use of volunteers in an emergency and is reviewed and updated at least every two (2) years. Findings are as follows: Review of the emergency preparedness plan documentation lacked evidence of processes for non-medical volunteers that includes the necessary privileging and training to be provided by the agency to perform tasks during an emergency. Additionally, the documentation lacked evidence that it was reviewed at minimum every two years. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the emergency preparedness plan included the above-mentioned criteria.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency’s emergency preparedness communication plan failed to include staff contact information regarding the entities providing services under arrangement, and volunteers, and is reviewed and updated at least every two (2) years. Findings are as follows: Review of the emergency preparedness communication plan documentation lacked evidence of staff contact info, information regarding the entities providing services under arrangement, and volunteers. Additionally, the communication plan lacked evidence that it was reviewed at minimum every two years. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the emergency preparedness plan included the above-mentioned criteria.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, the communication plan and that is reviewed and updated at least every two (2) years. Findings are as follows: Review of the emergency preparedness documentation lacked evidence of a training in-service education provided to staff and testing of the program from 2021 through 2023. Additionally, the program lacked evidence that it was reviewed at minimum every two years. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the emergency preparedness plan included the above-mentioned criteria.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to maintain documentation of initial and ongoing emergency preparedness training, that is to be provided to all staff, individuals providing services under arrangement, and volunteers upon hire ongoing every two (2) years. Findings are as follows: Review of the emergency preparedness documentation lacked evidence of initial and ongoing emergency preparedness training provided to staff, individuals providing services under arrangement, or volunteers. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the agency-maintained documentation of the above-mentioned information.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and staff interview, it has been determined that the agency failed to conduct exercises to test the emergency plan at least annually, participate in a full-scale exercise that is community based, and conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise. Findings are as follows: Review of the agency documentation lacked evidence that exercises to test the emergency plan were conducted from 2021 through 2023. During a surveyor interview with the Administrator, Staff B, on 8/25/2025 at 6:00 PM, he was unable to provide evidence that the agency-maintained documentation of the above-mentioned information.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to assist patients in realizing patent specific measurable outcomes and goals by not providing services outlined as such in the individualized plan of care for 2 patients reviewed, ID #s 5 and 6. Findings are as follows: 1. Review of the clinical record for Patient ID #5 revealed a start of care date of 11/18/2024 for services to include skilled nursing as ordered by his/her physician with frequency of 2 visits per week for a total of 9 weeks. Additional review of the clinical record revealed the patient was agreeable to the skilled nursing services and the schedule of services as indicated on the plan of care which was in accordance with physician orders. Review of the comprehensive assessment revealed the patient was motivated and agreeable to the established plan of care developed to have goals established by both the patient and professional staff. Review of a 9-week look back period from 11/18/2024 through 1/16/2025 revealed the patient did not receive skilled nursing services as ordered by his/her physician. Additionally, the clinical record failed to reveal documented evidence as to why the services were not rendered to the patient as ordered, nor was there documentation to support the Agency made effort to reschedule any missed visits or notify the patient’s physician of such. 2. Review of the clinical record for Patient ID #6 revealed a start of care date of 5/20/2025 for skilled services to include skilled nursing and home health aide services. Review of the frequency of services as ordered by the patient’s physician for the above-mentioned services were as follows: skilled nursing – 1 visit per week for a total of 2 weeks, and home health aide- 2 visits per week for a total of 8 weeks. Additional review of the clinical record revealed the patient was agreeable to the skilled services and the schedule as indicated on the patient’s plan of care which was in accordance with physician orders. Review of the comprehensive assessment revealed the patient was motivated and agreeable to the established plan of care developed to have goals established by both the patient and professional staff. Review of a 9-week look back period from 5/20/2025 through 7/19/2025 revealed the patient did not receive the skilled services as ordered by his/her physician. Additionally, the clinical record failed to reveal documented evidence as to why the services were not rendered to the patient as ordered, nor was there documentation to support the Agency made effort to reschedule any missed visits or notify the patient’s physician of such. During a surveyor interview with the Director of Nursing on 8/21/2025 at 4:30 PM, she acknowledged the above-mentioned patients did not receive services in accordance with physician orders and their individualized plan of care and schedule and was unable to provide evidence the Agency attempted to reschedule missed visits as to assist the patients with realizing the desired goals outlined in the comprehensive assessment and plan of care, as required.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain a Quality assessment/performance improvement (QAPI) program that demonstrates measurable improvement in indicators related to infectious and communicable diseases for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. Findings are as follows: Review of QAPI documentation failed to reveal evidence of a QAPI program in which the Agency is measuring, analyzing, and tracking quality indicators which include adverse patient events and other aspects of performance that enable the Agency to assess processes of care, services, and operations. During a surveyor interview with the owners and sole members of the governing body, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence the Agency has maintained a coordinated based QAPI program that is agency wide for the surveillance, investigation, identification, prevention, control and investigation of infectious and communicable diseases as an integral part of the QAPI program, as required”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to develop a Quality assessment/performance improvement (QAPI) program which includes data collection from quality indicator data derived from Oasis that is used to monitor the effectiveness and safety of services and quality of care and identifies opportunities for improvement and for which the frequency and detail of the data collection has been approved by the governing body. Findings are as follows: Review of QAPI documentation failed to reveal evidence of an active QAPI program in which the Agency is collecting data as determined by the frequency approved by the governing body. Review of the minutes of a governing body meeting conducted on May 1, 2024, lacked evidence of QAPI information or that the governing body has approved frequency and detail of data collection. During a surveyor interview with the owners and sole members of the governing body, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of a QAPI program that is collecting data and for which the governing body has approved the frequency of such collection, as required.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain performance improvement activities that focus on high risk, high volume, or problem-prone areas that directly or potentially threaten the health and safety of patients served by the Agency. Findings are as follows: Review of the documentation provided to the surveyors failed to reveal evidence of performance improvement activities as identified above. During a surveyor interview with the owners and sole members of the governing body, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of performance improvement activities identified for concerns related to services and associated with high risk, high volume and problem-prone areas, as required.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to track unexpected and/or adverse events that have, or potentially could impact a patient’s plan of care, and have the potential to cause a decline in a patient’s condition. Findings are as follows: Review of the documentation provided to the surveyors failed to reveal evidence the Agency is tracking events or encounters which have caused or could cause a negative outcome to a patient as to allow subsequent analysis to identify the root cause of the event and to reduce the likelihood of such events in the future. During a surveyor interview with the owners, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide documentary evidence of the Agency’s tracking of unexpected and/or adverse events, as required.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the governing body failed to ensure the Agency has developed, implemented, and maintained an ongoing Quality assessment/performance improvement (QAPI) program which prioritizes patient care and safety and for which all improvement actions are evaluated for effectiveness. Findings are as follows: Review of documentation related to governing body that was provided to the surveyors for review lacked evidence that the governing body has reviewed QAPI or ensured that the Agency has developed a QAPI program as indicated above. Further review of the governing body meetings conducted in 2024 revealed a meeting was held on May 1, 2024, and review of the minutes lacked evidence of there being information related to a QAPI program. During a surveyor interview with the owners and sole members of the governing body, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of a QAPI program as highlighted above and for which the governing body is reviewing as part of their executive responsibilities, as required.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Agency’s Quality assessment/performance improvement (QAPI) program and that includes a method for identifying infections and communicable disease problems. Findings are as follows: Review of the documentation related to QAPI failed to reveal evidence that infectious and communicable diseases were an integral part. Review of a document titled, “Client Infection Control Log” revealed documentation for two patients’, ID #s 8 and 9. Further review revealed the onset date of a UTI (urinary tract infection) for Patient ID #8 was 11/29/2010 however the documentation lacked evidence of ongoing tracking and data collection of the antibiotic prescribed to treat the infection, documentation of any symptoms the Patient may have been experiencing or potential medication adverse effects. In addition, s/he also had a pneumonia infection, however the documentation lacked information regarding the onset date, test results for the infection, or identification of the antibiotic used to treat the infection. Review of the documentation for Patient ID #9 revealed s/he had an UTI with an onset date of 8/1/2025. Further review revealed the documentation for C&S results (laboratory procedure used to identify specific bacteria or fungi responsible for an infection and to determine which antibiotics or antifungal medications are effective against them) stated, “…Frequent UTI…”. Additional review of the agency documentation lacked evidence of ongoing, systematic collection and tracking of patient infections data. During a surveyor interview with the Director of Nursing on 8/25/2025 at 4:00 PM, she acknowledged that the above-mentioned documentation was not complete. In addition, she was unable to provide evidence that the agency is maintaining a coordinated agency-wide program that includes ongoing tracking, and the methodology used to identify patient’s infections. In addition to the above, during a surveyor interview with the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of an agency wide QAPI program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases, as required.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA (Home Health Agency) failed to provide infection control education to Registered Nurse (RN), Staff E and Patient ID #1. Findings are as follows: 1. Review of the patient record revealed his/her start of care date was 7/21/2025, and s/he was admitted to the agency with diagnoses, including but not limited to, stage 2 pressure ulcer to the right heel (damage to the skin that results in the loss of the outermost layer (epidermis) and exposure of the dermis, which is the middle layer of skin. This type of ulcer typically appears as a shallow, open wound with a pink or red wound bed), infection of amputation stump to right lower extremity, acquired absence of left leg below the knee, peripheral vascular disease, and prediabetes. Review of the plan of care revealed s/he is at risk for falls, pressure ulcer, and hospitalization. Further review of the plan of care revealed physician orders for the skilled nurse to instruct the patient on infection control and prevention for open wounds. Review of the skilled nursing notes revealed upon admission to the agency s/he has incision wounds to his/her big and little toes on the right foot and a stage 2 pressure ulcer to the right heel. Further review of the skilled nursing notes, authored by RN, Staff E, lacked evidence that infection control and prevention education was provided to the patient relative to his/her wounds. In addition, review of a skilled nursing note, dated 8/18/2025 and authored by Staff E, revealed in part, “…Pt [patient] went to the wound center last Friday. [S/he] is very disappointed as the MD stated that the wounds are bigger and there is no improvement to [his/her] wounds…” During a surveyor interview with the Director of Nursing (DON), Staff A, on 8/21/2025 at approximately 4:00 PM, she indicated that her expectation would be that the nurse would have followed the physician’s order to provide infection control education to the patient and document doing so it in the patient’s record. 2. On 8/25/2025 this surveyor requested agency documentation of initial and ongoing infection control in-service educations provided to Registered Nurse, Staff E. During a surveyor interview with the DON and the Administrator, Staff B, on 8/25/2025 at 4:00 PM, they were unable to provide documented evidence of infection control education that was provided to Staff E and indicated that the teaching provided to her was verbal.”

“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: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to maintain responsibility for rehabilitative services rendered to patients and that are provided under contract and conduct onsite supervisory visits on behalf of Physical and Occupational Therapy Assistants. Findings are as follows: Review of an undated policy titled, “1.37 Services Under Contract”, states in part, “…to assure continuity and quality of services acquired through contract…a written contract is required for attaining services from other entities or individuals…contracts or agreements for services can only be initiated and approved by the Agency’s Administrator…the method of supervision of contracted personnel and the manner in which services will be controlled, coordinated, and valuated by the Agency…” Review of a document titled, “Agreement for Consulting Services” states in part, “…this agreement is made and entered into this 30th day of April, 2019, by and between [name redacted]…a Rhode Island professional service corporation (“Provider”), and Dependable Home Care, a Rhode Island licensed nursing home care provider (the “Agency”)…Provider agrees to all applicable Agency policies and procedures including, but not limited to, record keeping, reporting, supervision, personnel qualifications and other professional responsibilities…” Record review for skilled Patient ID #7 revealed a start of care date of 8/7/2025. Review of physician orders as outlined on the patient’s plan of care revealed an order for skilled nursing, PT and OT evaluation and treatment. Further review of the record lacked evidence that the Agency provided services to the patient in accordance with physician orders. Record review revealed the patient was seen by nursing on 8/7/2025 and 8/14/2025 however, there was no documentation related to a PT or OT evaluation or treatments. Additionally, the physician order for skilled nursing was for a skilled nursing visit once a week for 9 weeks. During a surveyor interview with the Director of Nursing on 8/25/2025 at 11:15 AM she acknowledged the record did not reveal evidence of a PT or OT evaluation or documentation related to treatments as ordered by the patient’s physician. In addition, she was unable to provide evidence that the patient had nursing visits within physician orders as evidenced by the record lacking evidence of documentation related to a nursing visit that was completed during the week of 8/17/2025 through 8/23/2025. During a surveyor interview with the Administrator and Director of Nursing Services on 8/19/2025 at 3:30 PM, they were unable to provide evidence that the rehabilitative therapy services were provided in a timely manner and in accordance with physician orders. Additionally, when questioned about documentation related to on-site supervisory visits for therapy staff, they revealed that they are not conducting supervisory visits for the therapy staff and revealed the contracted agency does that and therefore, were unable to provide evidence that the Agency’s administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled by the Agency, as required.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure all entries are appropriately authenticated by signature of the primary author, or entry identifier who has reviewed and approved the entry, and dated, for 1 record reviewed, Patient ID #7. Findings are as follows: Review of the clinical record revealed the above-mentioned patient was admitted to skilled services on 8/7/2025. Further record review revealed the comprehensive and OASIS assessment lacks evidence of authentication as evidenced by there being no signature and of the assessor and date in which the assessment was done. During a surveyor interview with the Director of Nursing on 8/25/2025 at 11:15 AM, she acknowledged that the comprehensive assessment in the clinical record lacked evidence of a signature and date and then placed a call to the nurse as to inform her of the above and asked her to sign and date the comprehensive assessment. Therefore, based on the above, the Director of Nursing was unable to provide evidence that the Agency ensures all entries in clinical records are authenticated, as required.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to develop, implement, and maintain policies and procedures specific to the way in which patient records are protected for loss, theft, or unauthorized use. Findings are as follows: During a surveyor interview with the Administrator and Director of Nursing on 8/19/2025 at 2:00 PM, it was revealed that the Agency is under arrangement with a rehabilitation provider and professional staff of that provider do not have access to the electronic medical records database or patient records. The Director of Nursing revealed that the professional staff under arrangement document assessments, visits, and individualized care plans on paper which “usually is emailed to a secured email once a week.” and indicated the contents of the secured email is then scanned into the patient’s clinical record. In addition, the Director of Nursing revealed that she does not know of the schedules of those professional staff working under arrangement and therefore, it is possible that the documents they have completed on paper for the Agency patients serviced are transported to and from patient homes. Review of Agency policies failed to reveal evidence of a policy related to the safeguarding of patient records or contents of patient records that are not entered directly into the patient’s medical record by use of the electronic database. During a subsequent interview with the Director of Nursing while in the presence of the Administrator on 8/19/2025 at 4:30 PM, she acknowledged that the Agency does not have personnel files for professional staff under arrangement. Based on the above findings, the Agency was unable to provide evidence of the contracted staff’s participation in educational trainings related to HIPPA or demonstrate policies and systemic procedures as to ensure the Agency secures and protects clinical records of patients and the privacy of information contained within such records to prevent theft, loss, or unauthorized use in the patients home, in transit, or any other location, as required.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to protect and promote patient rights to receive services outlined in their plan of care for 2 patients reviewed, ID #s 2 and 7. Findings are as follows: 1. Record review for Patient ID #2 revealed a start of care date of 5/20/2025. Review of the plan of care revealed physician orders inclusive of HHA (home health aide) services with frequency for 2 visits per week for a total of 9 weeks. Further review of the clinical record failed to reveal documented evidence that the patient received HHA services in accordance with physician orders. 2. Record review for Patient ID #7 revealed a start of care date of 8/7/2025. Review of the plan of care revealed physician orders inclusive of skilled nursing, PT (physical therapy) and OT (occupational therapy) evaluations and treatment. Further review of the clinical record failed to reveal documented evidence that the patient received PT and OT services in accordance with physician orders. During a surveyor interview with the Administrator and Director of Nursing on 8/25/2025 at 6:00 PM, they were unable to provide evidence that the Agency provided services as outlined in the above-mentioned patients individual plan of care, as required.”

“Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure comprehensive assessments accurately reflect the patient’s status and must include incorporation of the current version of the Outcome and Assessment Information Set (OASIS) information and must include information related to patient history for one patient reviewed, ID #7. Findings are as follows: Review of the clinical record for Patient ID #7 revealed a comprehensive assessment and OASIS assessment was initiated by Registered Nurse, Staff H, on 8/7/2025 however, the assessment is incomplete as evidence by section D0150 Patient Mood Interview (PHQ-2 to 9) having unanswered questions. The questions in this section require the assessor to ask the patient specific questions related to the patient’s mood and are utilized as a professional tool to screen individuals for Depression. Additionally, the assessment is not authenticated or dated by the nurse rather lists the name of the nurse under the assessor. During a surveyor interview with the Director of Nursing on 8/25/2025 at 11:15 AM, she acknowledged that the comprehensive assessment was incomplete as evidenced by section D0150 being incomplete. In addition, she further acknowledged that the assessment was not signed nor dated by the assessor and revealed it should have been completed, signed and dated by the assessor. Therefore, based on the above, the Director of Nursing was unable to provide evidence that the comprehensive assessment in the clinical record for Patient ID #7 accurately reflects his/her status due to the questions in the patient mood interview being unanswered and therefore, revealing no evidence they were asked to the patient as to accurately reflect his/her mood status, as required.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to take actions aimed at performance improvement and failed to implement those actions and therefore, were unable to provide evidence related to the measuring and tracking of the performance as to ensure that improvements are sustained. Findings are as follows: Review of documentation related to Quality assessment/performance improvement (QAPI) revealed a written policy however, no evidence of an established program with actions aimed at performance improvement as highlighted above. During a surveyor interview with the owners, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of Agency actions related to performance improvement, as required.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to provide services that are ordered by a physician for 2 patients reviewed, ID #s 2 and 7. Findings are as follows: 1. Record review for Patient ID #2 revealed a start of care date of 5/20/2025. Review of physician orders revealed an order for HHA (home health aide) services with frequency for 2 visits per week for a total of 9 weeks. Further review of the clinical record failed to reveal evidence the Agency provided HHA services to the patient in accordance with physician orders. 2. Record review for Patient ID #7 revealed a start of care date of 8/7/2025. Review of physician orders revealed orders for skilled nursing, PT (physical therapy) and OT (occupational therapy) evaluations and treatment. Further review of the clinical record failed to reveal evidence the Agency provided PT services to the patient in accordance with physician orders as evidenced by the record failing to reveal documentation as related to a PT evaluation or treatments. During a surveyor interview with the Administrator and Director of Nursing on 8/25/2025 at 6:00 PM, they were unable to provide evidence that the Agency provided services as ordered by the physicians for the above-mentioned patients, as required.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the Agency failed to ensure that education was provided for 1 of 1 caregiver and patient who had wounds, Patient ID #1. Findings are as follows: Review of the patient record revealed s/he was admitted to the agency on 7/21/2025 with diagnoses including, but not limited to, stage 2 pressure ulcer to the right heel (damage to the skin that results in the loss of the outermost layer (epidermis) and exposure of the dermis, which typically appears as a shallow, open wound with a pink or red wound bed), infection of amputation stump to right lower extremity, acquired absence of left leg below the knee, peripheral vascular disease, and prediabetes. Additional review revealed s/he has wounds to the incisions on his/her “big toe” and “little toe” on the right foot and a stage 2 pressure ulcer to the right heel. Further review of the record lacked evidence of education provided to the patient and caregiver regarding mitigation strategies to prevent the worsening of his/her stage 2 pressure ulcer and wounds, or smoking cessation counseling was offered to the patient. During a surveyor interview with the Director of Nursing, Staff A, on 8/21/2025 at approximately 4:00 PM, she revealed that her expectation would be that education should have been provided to the patient and caregiver relative to his/her smoking and any potential behaviors that may result in poor wound healing or that increase his/her risk for rehospitalization.”

“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: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency lacked evidence of having developed and maintained a Quality Assessment and Improvement (QAPI) program in which all skilled professional staff (direct employees and contractor employees) have provided input into the development and have participated in all phases of implementation of the QAPI program. Findings are as follows: Review of QAPI documentation lacked evidence of there being a QAPI program in which all professional staff are involved in and have participated. During a surveyor interview with the owners, the Administrator and Director of Nursing, on 8/25/2025 at 6:15 PM, they were unable to provide evidence of a QAPI program for which all members of the professional staff have been included and involved in the development of the program and participated in all phases, as required.”

“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: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure that all professional staff participate in educational in-service trainings sponsored by the Agency. Findings are as follows: During a surveyor interview with the Administrator and Director of Nursing during the entrance conference on 8/19/2025 at 2:15 PM, it was revealed that the Agency does not retain personnel files on behalf of any of the professional rehabilitative staff who are not employed by the Agency directly, rather, employed with a provider that the Agency has a contractual agreement. Upon receipt of this information, the surveyors questioned how the Agency monitors for compliance as related to the regulatory provisions specific to personnel including, but not limited to, evidence of completed educational and in-service trainings on behalf of the contracted staff, the Administrator and Director of Nursing revealed “they take care of that” referring to the contracting provider. Therefore, they were unable to provide evidence that the contracted professional staff have participated in educational in-service trainings and acknowledged they have not done so for any sponsored by the Agency. In addition to the above, a sample of 5 personnel files were reviewed on behalf of direct care professional staff employed by the Agency and 4 of the 5 files reviewed lacked evidence of employee participation in in-service trainings. The employee files reviewed were as follows: -Staff A, Director of Nursing who was hired on 1/6/2011. -Staff C, Homemaker who was hired on 11/10/2023. -Staff D, Certified Nursing Assistant who was hired on 9/14/2024. -Staff E, Registered Nurse who was hired on 9/8/2022. During a subsequent surveyor interview with the Administrator and Director of Nursing on 8/25/2025 at 6:00 PM, thy were unable to provide evidence of the professional staff employed directly by the Agency, or under contract, as having participated in in-service trainings, as required.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to provide supervisory visits every 14 days for 1 patient receiving home health aide (HHA) services and skilled nursing services, ID #6. Findings are as follows: Record review for Patient ID #6 revealed the patient was admitted to skilled services on 5/20/2025. Further review of the clinical record revealed the physician orders for skilled services were inclusive of skilled nursing, HHA, Physical and Occupational therapy. Additional review of the clinical record failed to reveal documented evidence that supervisory visits were conducted or a supervisory assessment(s) of the aide services provided to the patient was completed no less frequently than every 14 days. During a surveyor interview with the Director of Nursing on 8/21/2025 at 4:30 PM, she acknowledged that the clinical record for Patient ID #6 lacked documented evidence of supervisory visits or assessments of aide services provided to the skilled patient were completed no less than every 14 days, as required.”

“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: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined that the HHA (Home Health Agency) failed to ensure that skilled nursing services are provided in accordance with current clinical practice guidelines and accepted professional standards of practice for 1 of 1 patient with wounds, Patient ID #1. Findings are as follows: Review of a Home Health Care Now article from issue dated September/October 2022 and titled, “Back to the Basics: Wound Assessment, Management, and Documentation”, states in part, “…Documentation of Wounds. Documentation is critical in the home health setting…Current clinical information should be in the clinical record…this includes weekly measurements…” Review of the patient record revealed s/he was admitted to the agency on 7/21/2025 with diagnoses, including but not limited to, stage 2 pressure ulcer to the right heel (damage to the skin that results in the loss of the outermost layer (epidermis) and exposure of the dermis, which typically appears as a shallow, open wound with a pink or red wound bed), infection of amputation stump to right lower extremity, acquired absence of left leg below the knee, peripheral vascular disease, and prediabetes. Additional review revealed wounds to the incisions of the patient’s “big toe” and “little toe” on the right foot and a stage 2 pressure ulcer to the right heel. Review of the skilled nursing documentation authored by Registered Nurse, Staff E, lacked documented evidence of wound measurements for the wounds on the little toe and the pressure ulcer to the right heel for the week of 8/10/2025 through 8/16/2025. During a surveyor interview with the Director of Nursing, Staff A, on 8/25/2025 at 6:00 PM, she was unable to provide evidence that wound measurements were completed.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: This Element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to ensure that clinical records of discharged patients contain evidence of a discharge summary for 1 patient reviewed for a planned discharge, ID #5. Findings are as follows: Record review revealed the patient was admitted for skilled services on 11/18/2024. Further record review revealed the patient was discharged from the Agency on 1/16/2025. Additional review of the record failed to reveal evidence a discharge summary was completed nor was there evidence the Agency notified the physician of the patient’s discharge. During a surveyor interview with the Director of Nursing on 8/21/2025 at 4:30 PM, she acknowledged that the clinical record for Patient ID #5 lacked evidence of a discharge summary, as required.”

“Basis and Scope CFR(s): §484.1 Basis and Scope (a) Basis. This part is based on: (1) Sections 1861(o) and 1891 of the Act, which establish the conditions that an HHA must meet in order to participate in the Medicare program and which, along with the additional requirements set forth in this part, are considered necessary to ensure the health and safety of patients; and (2) Section 1861(z) of the Act, which specifies the institutional planning standards that HHAs must meet. (b) Scope. The provisions of this part serve as the basis for survey activities for the purpose of determining whether an agency meets the requirements for participation in the Medicare program. This Condition is not met as evidenced by: Based on record review and staff interview, it has been determined the HHA failed to meet the regulatory provisions of the Condition of Participation (CoP) requirements and remain in substantial compliance with all conditions of participation. Findings are as follows: Review of a letter dated July 3, 2025, originated by Community Health Accreditation Partner (CHAP), addressed to the Administrator of Dependable Healthcare Services LLC. and sent to the Department revealed the HHA has been terminated from CHAP, effective July 1, 2025, due to the HHA’s failure to meet Accreditation requirements, specific to “aborted visit(s)”. Further review of the letter which states in part, “…DEPENDABLE HOME CARE is no longer CHAP accredited and your contract for accreditation services is now officially terminated. Termination of accreditation also includes the termination of deemed status, which may result in the revocation of the Medicare provider agreement…DEPENDABLE HEALTHCARE SERVICES LLC dba DEPENDABLE HOME CARE may not publicize themselves as a CHAP accredited organization and must remove all CHAP logos and identifiers from all company websites and business materials. Additionally, CHAP will notify the Centers for Medicare and Medicaid Services (CMS) and other appropriate regulatory bodies of the termination of accreditation...” Due to the HHA losing their deemed and Accreditation status, the Department had scheduled a recertification survey which was initiated on 7/14/2025 at 9:30 AM. Upon entry of the HHA, it was observed by the surveyors that a certificate from CHAP was displayed on a wall indicating the HHA had Accreditation and deemed status. Additionally, upon entry to the HHA it was observed by the surveyors that only one employee was noted to be in the office who revealed she was an office coordinator who will be identified as Staff A. Introductions were made and the surveyors provided an explanation of the survey process to Staff A which included a request for someone from the HHA to be present to conduct the entrance conference which identifies specific information requested and required for review. Additionally, Staff A revealed that there was no one in the office who could assist with the survey and indicated that she did not have access to Agency records due to records being stored in the Administrator’s office which was locked and precluded her ability to access. Staff A revealed that she would need to call the Administrator who was out of the country. Staff A further revealed that the hours of operation as indicated on the entrance door were Monday-Friday 8:30 AM to 5:00 PM. A telephone call was immediately made by the office coordinator to the agency Administrator, while in the presence of the surveyors. During a surveyor telephone interview with the Administrator at approximately 10:00 AM, he revealed that he was unable to participate in the entrance conference due to being out of the Country and suggested that Staff A call the Director of Nursing (DON). During a surveyor telephone interview with the DON in the presence of Staff A, on 7/14/2025 at approximately 10:15 AM, she acknowledged that she was in Pennsylvania and therefore, unable to participate in the entrance conference due to her not being onsite at the HHA. She revealed that she was trying to schedule a flight to RI or if unable to do so would plan to drive. The DON indicated to Staff A the other office coordinator identified as Staff B, who was not in the office at this time however, scheduled to work on this date could perhaps be of assistance with conducting the entrance conference and getting access to the requested information. Staff A revealed that she received a text message from Staff B who revealed she had a family emergency which may preclude her ability to come into work. While on the telephone with the DON, Staff A further revealed that she was scheduled to leave work for the day at 12:00 PM and therefore, based on the above, the HHA failed to provide surveyors access to pertinent documentation and information required for the purpose of conducting a survey, and was unable to provide evidence of their ability to adhere to the regulatory requirements of the Conditions of Participation (CoP), as required.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on surveyor observation and staff interview, it has been determined the HHA failed to ensure that when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator is available to provide continuity of services. Findings are as follows: Upon entrance to the Agency on 7/14/2025 at approximately 9:30 AM, an interview was conducted with the Office Coordinator, Staff A, in which she revealed that the Administrator was out of the country and the Agency documentation was in the Administrator’s locked office, which she does not have access to retrieve the information needed to conduct a survey. Surveyor observation of a sign outside of the Agency door revealed the hours of operation are 8:30 AM to 5:00 PM and Staff A confirmed this when questioned by the surveyor. During a telephone interview with the Administrator on 7/14/2025 at approximately 10:00 AM, it was revealed that he is not available to come into the office to assist the survey team with facilitating the complaint and recertification surveys because he is out of the country and that Staff A should contact the Director of Nursing (DON) to assist the surveyors with facilitating the survey. During a surveyor interview with the DON, in the presence of Staff A on 7/14/2025 at approximately 10:15 AM, it was revealed that she is currently in Pennsylvania and will need to either drive, or book a flight, to return to Rhode Island and will assist the surveyors with the survey sometime later. It was further indicated that the DON questioned Staff A regarding another Office Coordinator, Staff B, who may be available to assist the surveyors. Staff A indicated that Staff B is unavailable to come into the office due to a personal matter. During a surveyor interview with the Administrator on 7/14/2025 at approximately 10:30 AM, he was unable to provide evidence that when the administrator is not available, a qualified, pre-designated person, is available to assume the same responsibilities and obligations as the Administrator.”