Anchor Pulmonary Rehab and Home Healthcare Services LLC

“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: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 11/02/2020 and 08/23/2023 CITED AT E0004 Based on record review and interview, the agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every two years since 2020 (no reviews were done for 2023, 2024 and 2025) to evaluate its effectiveness and update the plan as needed. This failure placed agency patients at risk of harm in the event of an emergency or disaster if the agency’s emergency plan was not effective. Findings Included: Record review of the agency’s emergency preparedness plan binder [undated] did not include evidence the agency conducted a review of the emergency preparedness and response plan every two years since 2023. The Emergency Plan did not contain a review for 2023, 2024 and 2025. During an interview with Adm/PAS Sup on 08/12/2026 at 1:00 PM, the Surveyor asked why the agency did not complete an internal review of its emergency preparedness and response plan at least every two years since 2023 to evaluate its effectiveness and to update the plan as needed. The Adm/PAS Sup stated he did not know why it was not done, “I just didn’t get to it.” The Surveyor asked who was the Disaster Coordinator and the ADM stated, “I am.” During an interview with Adm/PAS Sup on 08/12/2026 at 1:15 PM, the Surveyor asked why the agency did not follow their plan of correction from the past two surveys dated 11/01/2020 and 08/23/2023 to correct the same deficiencies. Adm/PAS Sup stated there was no reason, but the agency would do it from now on. Agency policy titled, “EC.8 EMERGENCY PREPAREDNESS” with a revision date of 01/01/2009 read in part, “…PURPOSE… To establish a plan of action for providing continuous care in the event of an emergency…POLICY…The effectiveness of the emergency preparedness plan will be evaluated at least annually and after each actual emergency…PROCEDURE…J… 1. Agency will complete an internal review of the emergency response plan at least annually and after each actual emergency response to evaluate its effectiveness and update the plan as needed…3. After each actual disaster…a multi-disciplinary team including management and staff will evaluate effectiveness and update emergency plan as needed to improve processes…””

“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: THIS IS A CONTINUING DEFICIENCY FROM SURVEY DATED 08/23/2023 CITED AT E0039 Based on record review and interview, the agency failed to conduct exercises to test the emergency plan annually by conducting drills or after an actual emergency for three (2023, 2024 and 2025) of three years reviewed. This failure has the potential to place the agency patients at risk of harm in the event the agency lacked the organized preparation and planning for care and services in the event of a disaster. Findings include: Record review of the agency’s emergency preparedness binder did not include evidence of any drills for years 2023, 2024 and 2025. The emergency plan failed to reveal that the agency implemented their emergency plan after the widespread freeze in January 2024 and January 2025 which would have exempted them from conducting the drills. During an interview with Adm/PAS Sup on 08/09/2023 at 1:14 PM, the surveyor asked why the agency did not conduct any required drills for years 2023, 2024 and 2025. Adm/PAS Sup stated he was unaware that was required but he would start now. Agency policy titled, “EC.8 EMERGENCY PREPAREDNESS” with a revision date of 01/01/2009 read in part, “…PURPOSE… To establish a plan of action for providing continuous care in the event of an emergency…POLICY…The effectiveness of the emergency preparedness plan will be evaluated at least annually and after each actual emergency. The annual internal review will consist of testing the response phase of the emergency preparedness and response plan in a planned drill, it not tested during an actual emergency response…””

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to demonstrate that skilled nursing services and at least one other therapeutic service (physical therapy, speech therapy, occupation therapy, or Home Health Aide services) were made available either by direct hire or under arrangement. This failure meant the agency could not provide skilled services to patients in their service area. During an interview with the ADM on 08/11/2026 at 10AM the Surveyor asked what services the agency provided. The ADM reported that the agency has not had a Medicare patient in “5-years.” The surveyor requested access to the EMR (Electronic Medical Record) system to review the patient’s and the ADM stated, “I mean, we haven’t had a Medicare patient in 8 years.” During an interview with ADM on 08/11/2026 at 10:15AM the Surveyor asked if the agency has any contracts for therapeutic services and the ADM reported, “no, because we are not doing Medicare.” During an interview with the ADM on 08/11/2026 at 10:20PM the Surveyor asked why the agency wanted to keep the Medicare Certification if not servicing patients and the ADM reported that it was difficult to get and does not want to give up. The surveyor asked what had been done to attempt to get patients and the ADM stated, “I haven’t.” During an interview and concurrent record review on 08/12/2026 at 2pm the ADM brought the Home Health Agency Survey Report (Form-1572) to the surveyor [dated 08/12/2026]. The ADM reported in section 11. Titled, Services Provided, that the only service the agency can provide was skilled nursing. All other sections for physical therapy, occupational therapy…speech therapy…home health aide… were all “0” which indicated that those services are not provided. In addition, Section 12. Titled Staffing…time equivalents…had .1 for Registered Nurse and .1 for Licensed Practical Nurses and all other sections had a “0” for direct hire staff and staff under arrangement. The ADM reported that the agency did not have any direct care staff or staff under arrangement. The surveyor asked how the agency would have provided skilled services if they had received a referral and the ADM stated, “I am not sure.” The surveyor asked what 0.1 FTE meant the ADM reported the nurses have other jobs and work as needed. ADM reported it was more than “8-years since they worked.” Record review of agency policy, [undated] titled, Scope of Services, II. The Agency will primarily engage in providing skilled services and other therapeutic services as defined … of the act 484.105.”

“Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to review and update the agencies overall capital expenditure plan and operating budget at least annually for the following years – 2023, 2024, and 2025, for current 2026. This failure could place patients at risk of receiving inadequate care and services when the agency fails to prepare an operating budget and capital expenditure plan which considers the patients needs. During an interview with the ADM on 08/11/2026 at 12pm he reported that the governing body has not met for “several years” and that “we haven’t updated our budget and capital expenditure plan because we haven’t had any Medicare patients for eight years. I didn’t know we had to do it.” The surveyor asked if the agency updated an operating budget since 2016 and the ADM stated, “No, but I will do it now.” The Surveyor asked whose responsibility was it to ensure the operating budget and capital expenditure plan was completed and the ADM stated, “me.” The Surveyor asked who was on the governing board and the ADM reported that the agency doesn’t have one, it is only him because he thought he didn’t need to do it because he didn’t have Medicare patients. Record review of the agency’s manual [undated] titled, “Business Manual Profile” consisted of (8) pages that included a capital expenditure plan dated, July 22, 2010, (12) month Projected Budget dated 12/2016, and a proposed budget for December 2010 to November 2011. There was no documented evidence that the capital expenditure plan had been updated since 2010 and the operating budget was updated annually since 2016.”