Amazing Angels Home Health

“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 at least bi-annual to evaluate its effectiveness and to update the plan as needed for 1 of 1 agency’s Emergency Plan. The agency did not review the Emergency Preparedness Plan in 2023 or 2024. 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 is not prepared for an actual emergency event. Findings included: Record review of the agency’s Emergency Preparedness Plan indicated the plan was last reviewed on 07/13/22. The Emergency Preparedness Plan gave no indication the agency conducted an annual a bi-annual review of the emergency preparedness plan from 7/13/22 to 3/26/25. During an interview on 03/25/25 at 2:08 p.m., the Administrator/ Supervising Nurse said she was the Emergency Preparedness coordinator for the agency. During an interview on 03/25/25 at 2:40 p.m., the Administrator/ Supervising Nurse said she could not find where the Emergency Preparedness Plan was reviewed in 2023 or 2024. The Administrator/ Supervising Nurse said the Emergency Preparedness Plan should be reviewed every year. The Administrator/ Supervising Nurse said she was responsible for reviewing the Emergency Preparedness Plan. The Administrator/ Supervising Nurse said the Emergency Preparedness Plan was not reviewed because the agency did not have any active patients. Attempted a telephone interview on 03/25/25 at 3:05 p.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Attempted a telephone interview on 03/26/25 at 11:15 a.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Record review of an Emergency Preparedness and Response Plan policy dated 01/01/13 indicated “… The agency will complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed. …””

“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 interview, the agency failed to conduct an exercise to test the emergency preparedness and response plan at least once a year or after an actual emergency response to decide if the plan worked and to update any needed changes for 3 of 3 years reviewed. (2022, 2023 and 2024) This failure could lead to unidentified issues with the emergency plan and prevent the agency from making improvements to increase effectiveness thus place patients at risk of harm or not having their needs met if the agency is not prepared for an actual emergency event. Findings included: Record review of the agency’s undated Emergency Preparedness Plan binder gave no indication the agency implemented a test to review the emergency preparedness plan in 2022, 2023, or 2024. During an interview on 03/25/25 at 2:08 p.m., the Administrator/ Supervising Nurse said she was the Emergency Preparedness coordinator for the agency. The Administrator/ Supervising Nurse said she could not remember if the agency completed testing of the agencies Emergency Preparedness Plan. During an interview on 03/25/25 at 2:40 p.m., the Administrator/ Supervising Nurse said there was no documentation of the testing of the Emergency Preparedness Plan system in 2022, 2023, or 2024. The Administrator/ Supervising Nurse said she knew the Emergency Preparedness Plan was implemented with every event such as a hurricane, but it was not documented. The Administrator/ Supervising Nurse said the Emergency Preparedness Plan should be tested yearly and as needed based on the situation such as a hurricane. The Administrator/ Supervising Nurse said she was responsible for documenting the testing of the Emergency Preparedness Plan system. The Administrator/ Supervising Nurse said the Emergency Preparedness Plan system testing was not documented because the agency did not have active patients. Attempted a telephone interview on 03/25/25 at 3:05 p.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Attempted a telephone interview on 03/26/25 at 11:15 a.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Record review of an Emergency Preparedness and Response Plan policy dated 01/01/13 indicated “… As part of the annual internal review, the agency will test the response phase of its Emergency Preparedness and Response Plan in a planned drill if not tested during an actual emergency response. The planned drill may be tabletop exercise, a functional exercise, or some hybrid of both. …””

“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: Based on record review and interview, the agency failed to measure analyze, and track indicators to improve health outcomes, patient safety and quality of care of the quality assessment and performance improvement program for 2 of 3 calendar years reviewed. (2023 and 2024) These failures could prevent the agency from identifying potential problems and implementing corrective actions to ensure the health and safety of the patients. Findings included: 1. Record review of the undated QAPI binder indicated the plan was last evaluated on 05/11/22. The QAPI Plan gave no indication the agency conducted an annual review of the QAPI Plan for calendar year 2023 or 2024. 2. Record review of the QAPI binder indicated meetings were held on 07/13/22 and 05/11/22. The QAPI binder gave no indication the agency conducted any QAPI meetings for calendar year 2023 or 2024. Attempted a telephone interview on 03/25/25 at 3:05 p.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. During interview on 03/25/25 at 3:55 p.m., the Administrator/ Supervising Nurse said she was over the QAPI program. The Administrator/ Supervising Nurse said she did not think they reviewed the QAPI plan in 2023 or 2024 since they didn’t have patients on services. The Administrator/ Supervising Nurse said the plan should be reviewed quarterly. The Administrator/ Supervising Nurse said she was responsible for ensuring the QAPI plan was reviewed. The Administrator/ Supervising Nurse said the QAPI meetings should be held yearly. The Administrator/ Supervising Nurse said she was responsible for conducting the QAPI meetings. The Administrator/ Supervising Nurse said there were no QAPI meetings in 2023 or 2024 because there were no patients on service during that time. Attempted a telephone interview on 03/26/25 at 11:15 a.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Record review of a Quality Assessment Performance Improvement Plan policy dated 07/01/12 indicated “… Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed by the QAPI/PI Committee. … The QAPI committee will meet at least quarterly or more often, if needed. … Agency leaders/ QAPI Committee will prioritize performance improvement activities. … The program will be evaluated, reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee. …””

“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 record review and interview, the agency failed to have at least one performance improvement project in development or on-going for 2 of 3 calendar years reviewed. (2023 and 2024) These failures could prevent the agency from identifying potential problems and implementing corrective actions to ensure the health and safety of the patients. Findings included: Record review of the undated QAPI binder indicated multiple PIPs for 2022. The QAPI binder gave no indication the agency completed QAPI PIPs for calendar year 2023 or 2024. Attempted a telephone interview on 03/25/25 at 3:05 p.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. During interview on 03/25/25 at 3:55 p.m., the Administrator/ Supervising Nurse said she was over the QAPI program. The Administrator/ Supervising Nurse said there were no QAPI PIPs done in 2023 or 2024. The Administrator/ Supervising Nurse said QAPI PIPs should be done yearly. The Administrator/ Supervising Nurse said she was responsible for completing the QAPI PIPs. The Administrator/ Supervising Nurse said the QAPI PIPs were not done because there were no patients on services due to zero census. Attempted a telephone interview on 03/26/25 at 11:15 a.m. with the Alternate Administrator/ Alternate Supervising Nurse. No answer, voice mail left requesting a return call. Record review of a Quality Assessment Performance Improvement Plan policy dated 07/01/12 indicated “… Agency will develop a plan that is reviewed and updated or revised at least once within the calendar year, or more often if needed by the QAPI/PI Committee. … Agency leaders/ QAPI Committee will prioritize performance improvement activities. … The program will be evaluated, reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/PI Committee. …””