Consolidated First Choice Home Health Inc.

“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 interview, the agency failed to complete an internal review of its emergency preparedness and response plan every two years to evaluate its effectiveness and to update the plan as needed for 1 of 3 calendar years. (2024 or 2025) The agency did not review the EPP within two years during 2024 or 2025. This failure could potentially lead to unidentified issues with the emergency plan and place patients at risk of harm or not having their needs met if the agency was not prepared for an actual emergency event. Findings included: Record review of the Emergency Management Plan dated 1/9/26 indicated the annual review date was 1/9/26. The binder gave no indication that the plan was reviewed in 2025 or 2024. Record review of the Emergency Preparedness Plan Review dated 1/9/26 indicated the disaster manual was reviewed and was current on 1/9/26. The binder gave no indication that the plan was reviewed in 2025 or 2024. During an interview and record review on 8/12/26 at 2:00 pm, the Alternate Administrator/ Supervising Nurse said the CEO was over EPP. The Alternate Administrator/ Supervising Nurse said EPP should be reviewed annually. The Alternate Administrator/ Supervising Nurse reviewed the EPP binder and confirmed the EPP was not reviewed in 2024 or 2025. The Alternate Administrator/ Supervising Nurse said she was not sure why the plan was not reviewed in 2024 or 2025. The Alternate Administrator/ Supervising Nurse said if the agency did not review their EPP they would not be able to enact plans for the patients using updated data. During a telephone interview on 8/12/26 at 2:25 pm, the Administrator/ Alternate Supervising Nurse said the CEO was over EPP. The Administrator/ Alternate Supervising Nurse said she was not sure how often the EPP should be reviewed. The Administrator/ Alternate Supervising Nurse said she thought it was every 6 months. During an interview and record review on 8/12/26 at 2:42 pm, the CEO said the EPP plan was reviewed every year. The CEO reviewed the EPP binder and said the annual review for 2024 and 2025 may have been misfiled by the Administrator since she was out on leave because the agency reviews it every year. Record review of an “Emergency Preparedness Planning and Implementation” policy dated 11/15/17 indicated, “… The agency shall prepare and maintain a comprehensive Emergency Preparedness and Response Plan … The plan shall be updated annually … The administrator, supervising nurse (if applicable), and other individuals designated by the administrator shall complete an internal review of the plan at least annually …””