Prudential Health Care Services Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to develop, maintain, and update an emergency preparedness plan for 3 (2023, 2024, 2025) of 3 years utilizing a community based all-hazards approach which included strategies for addressing emergency events identified by the risk assessment within the required two-year period. The last documented risk assessment was completed in 2013. The 2013 risk assessment failed to include the risk of pandemics. This failure meant the agency patients were subjected to unsafe care by an agency that lacked the preparation for emergencies. The surveyor requested the agency’s Emergency Preparedness Manual during the entrance conference on 04.27.2026 at 11AM. Record review pf the Emergency Preparedness Manual, dated 02.01.2019, found no current, up to date risk assessment using an all-hazards approach. The last identified risk assessment was dated 2013. An interview was conducted on 4.29.2026 at 12:30pm with the Agency Administrator who stated he is also the agency Disaster Coordinator. The Administrator/ Disaster Coordinator stated that the agency’s safety plan was discussed during the agency’s annual Quality Assurance and Performance Improvement meetings, which include himself, the Alternate Administrator, Director of Nursing, and Alternate Director of Nursing as part of the disaster team. The Administrator/ Disaster Coordinator stated that he was not aware that the agency was required to update the emergency plan every two years utilizing an all-hazards approach. The Administrator/Disaster Coordinator stated the plan had not been updated since 2013 and did not include strategies for addressing emergency events identified by risk assessment for the pandemic caused by (SARS-COV-2.) The Administrator stated that he was unaware that he was required to review, update, and maintain the emergency preparedness plan utilizing an community based all-hazards approach which included strategies for addressing emergency events identified by the risk assessment within the required two-year period. Agency Policy Emergency Preparedness and Response Plan EC.40 last reviewed 02.06.2026, read in part: “… Policy I. The Agency will establish and maintain an emergency preparedness program that must include but not be limited to, an emergency plan, policies and procedures, communication plan, and the testing and training program. II. The Agency will have a written Emergency Preparedness and Response Plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The plan will: A. Be based on and include a documented all hazards risk assessment (facility-based and community based) that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area and/or facility. B. Establish a strategy/plan of action addressing emergency events identified by the risk assessment in order to meet the health, safety, and security needs of the Agency, the staff, the patient/client population, and the community prior to, during, and after an emergency or disaster… E. Be reviewed and updated, including related policies and procedures, at least every two years…””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to conduct Performance improvement projects for 3 (2023, 2024, and 2025) of three years of the survey review period. The HHA failed to document the performance improvement projects undertaken for 2023, 2024, and 2025 and the reasons for conducting projects, and the measurable progress achieved on projects. This failure meant patients were potentially subjected to poor quality of care, poor health outcomes, and inadequate care. Record Review of the agency’s Quality Assurance and Performance Improvement Manual dated 05.01.2024, revealed that the agency had not performed and documented any performance improvement projects for the years 2023, 2024, and 2025. An interview was conducted on 4.27.2026 at 3pm with the Agency Administrator stated the Quality Assurance / Performance Improvement committee met once a year in this survey period, 2023, 2024, and 2025. The Administrator stated, “we discussed some process improvements, we just didn’t document them.” The Agency Administrator stated, he was not aware Performance Improvement projects were required to be completed annually since they are not currently serving any Medicare patients. The surveyor asked about the agency policy and procedures for performance improvement projects and the Agency Administrator stated he was responsible for ensuring the agency was following their own policies, as well as the regulations. Record review of the agency’s policy manual, titled, “Quality Assessment Performance Improvement Program QAPI.5” Section II, dated 05.01.2024, states, “The Agency will maintain documentary evidence of its Quality Assessment Performance Improvement and be able to demonstrate its operations to CMS [Center for Medicare and Medicaid Services].” Section III, E titled, “Performance Improvement Projects,” 1. And 2., state, “The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…””

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patients resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization for 1 (#1) of 1 patients who completed home visits with the surveyor and had a home folder. The agency did not follow policy to ensure the patients had the required numbers as required by regulation, placing clients at risk of receiving inadequate care, and including the information to request an expedited review of changes in services provided by the agency. This failure meant the patients’ rights were violated to ensure access to services as needed. The surveyor requested a sample admission packet with all documents provided to the agency patients during the entrance conference on 04.27.2026 at 11am. Record review of the sample admission packet provided by the Administrator revealed a resource list dated January 2011 which failed to include the required Federally funded and state-funded entities. The list did not include the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. Interview and record review on 4.29.26 at 10am during home visit of Patient #1 revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization In the home folder provided by the agency during admission. The surveyor asked if the patient had removed any items from the home folder and he stated they had not removed anything and had not been provided with a list of resources other than what was in the home folder. An interview was conducted on 4.29.26 at 12pm with the agency Administrator. The agency Administrator reported that the administrative office clerk was responsible for printing and putting the home admission packets together. The agency Administrator reported that he didn’t believe he needed to add the resource numbers due to not having any current Medicare patients. He reported that he was responsible for giving the correct forms to the office staff to make packets and that he did not do this because he wasn’t aware that it was a requirement. In addition, the agency Administrator reported that he was responsible for ensuring all the policies of the agency were implemented and followed. Record review of the agency’s policy manual [dated 05.04.2024], titled, “Patient/Client Rights and Responsibilities, RI.5” Section K, states, …Be advised of the names, addresses, and telephone numbers of the following Federally-funded and State-funded entities that serve the area where the patient / client resides: 1. Agency on Aging, 2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center, 5. Quality Improvement Organization.”