J-Shalom Home Health Service

“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 provide documentation that detailed the agency’s annual testing of a clinically relevant emergency scenario, potential actions taken, and analysis and/or revision of the emergency preparedness program (ERPP) for 3 (2023, 2024, and 2025) of 3 years reviewed. This failure could potentially place patients and staff at risk of harm when the agency is not prepared for a disaster. Findings: Record review of the undated ERPP binder revealed “Inservice/ Exercise Sign in Lists” dated 1/22/2023, 1/22/2024, and 1/3/2025. These forms did not contain documentation of the clinically relevant exercise conducted. The forms failed to document the potential actions taken or the analysis and/or revision of the emergency preparedness program. There was no evidence the agency tested the ERPP in a drill or in an actual emergency event for the three years reviewed. In an interview on 2/24/2026 at 2:25 p.m. the surveyor asked the Administrator (ADM) about the discussion and/or evaluation discussed during these meetings. ADM stated, “We don’t have any patients right now, so we just talk about it [exercise].” In an interview with ADM on 2/25/2026 at 1:38 p.m., the surveyor asked who was responsible for the emergency preparedness program. ADM stated, “Sometimes I do it and sometimes the ADON [Assistant Director of Nurses] does it.” When the surveyor asked how often the ERPP was discussed or activated ADM responded, “At least twice a year. We [agency] normally have a checklist we [agency] use for documentation.” When asked what reasons might cause the forms to not be completed, ADM stated, “I guess it was an oversight that the forms weren’t filled out.” The surveyor asked ADM how not performing the discussions and/or evaluations could affect the patients. ADM stated, “It was always good to show the patient that there is always help and keep the patient informed during bad weather or emergencies. It could affect the patient badly by not getting medicine or food etc.” The agency had a policy (EC.8) titled, “Emergency Preparedness and Response Plan” dated 04/01/18. The policy read in parts, “…Purpose: …II. To ensure the Agency develops, establishes, maintains, and implements emergency preparedness policies and procedures, based on the risk assessment, emergency plan, and communication plan, that will be reviewed and updated at least annually. …Procedure: …III. Preparedness …2. Training and Testing a. As part of the annual internal review, the Agency will test the response phase of its Emergency Preparedness and Response Plan in two (2) exercises per year, if not tested during an actual emergency response…””

“Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA’s policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to retain patient records for five (5) years after the patient’s discharge for 1 (#5) of 5 discharged patient records reviewed. This led to the surveyor’s inability to review the patient care provided by the agency. Findings: Record review of Patient #5’s medical record revealed the patient admitted to the agency’s services on 12/19/2024. The surveyor was unable to locate any documentation in the medical record. In an interview on 2/25/2026 at 1:20 p.m. the surveyor informed the Administrator (ADM) of the inability to locate the plan of care, OASIS, or discharge documentation. ADM stated, “[Agency] sent everything to the Insurance Company because [Patient #5] was an insurance patient and was only on service for a week.” The surveyor asked if the agency retained any of the documentation. ADM stated, “No.” ADM provided the surveyor the documentation provided to the agency for Patient #5 from the hospital prior to admission to services. In an interview on 2/25/2026 at 1:38 p.m. the surveyor asked what the policy was for medical record retention. ADM stated, “I think we’re [agency] supposed to keep them [records] a couple of years.” When the surveyor asked who was responsible for the medical records ADM responded, “I am responsible.” When asked how the agency or the patient could be affected if the agency fails to retain medical records ADM stated, “I guess the investigation. If [agency] doesn’t have it [medical record] [agency] might be flagged for it.” The agency had a policy (IM.13) titled, “Medical Record Information, Retention, and Destruction” dated 06/01/25. The policy read in parts: “…Purpose: to ensure medical record information retention and destruction is in accordance with federal and state laws and regulations. Policy: Agency will maintain all adult medical records for a minimum of seven (7) years after discharge of the patient/ client…””

“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: Based on record review and interview, the agency failed to provide documentation of a completed discharge summary that is sent, within 5 days of discharge, to the physician or other health care professional who will be responsible for providing care and services to the patient after discharge in 5 (#1, #2, #3, #4, and #5) of 5 discharged patients reviewed. This failure could lead to the patient not receiving appropriate care after discharge from the agency. Findings: Record review of Patient #1’s medical record revealed the patient admitted to the agency’s services on 1/19/2022 for hypertension [high blood pressure]. The patient transferred and discharged from the agency on 1/20/2023. The surveyor was unable to locate a discharge summary in the medical record. Record review of Patient #2’s medical record revealed the patient admitted to the agency’s services on 3/27/2023 for a pressure ulcer (wound caused by continued pressure to an area of the body) on the right heel. The patient discharged from the agency on 6/9/2023. The surveyor was unable to locate a discharge summary in the medical record. Record review of Patient #3’s medical record revealed the patient admitted to the agency’s services on 4/26/2024 for renal [kidney] failure. The patient discharged from the agency on 6/21/2024. The surveyor was unable to locate a discharge summary in the medical record. Record review of Patient #4’s medical record revealed the patient admitted to the agency’s services on 11/13/2023 for quadriplegia [paralysis of all four extremities]. The patient discharged from the agency on 9/21/2024. The surveyor was unable to locate a discharge summary in the medical record. Record review of Patient #5’s medical record revealed the patient admitted to the agency’s services on 12/19/2024. The surveyor was unable to locate any documentation in the medical record. In an interview on 2/25/2026 at 1:20 p.m. ADM stated “[Agency} sent everything to the Insurance Company. The patient was only on service for a week before the insurance discontinued services.” The surveyor asked if the agency retained any of the documentation. ADM stated, “No.” ADM provided the surveyor the documentation provided to the agency from the hospital prior to admission to services. In an interview 2/25/2026 at 1:38 p.m. the surveyor asked what the process was for discharging a patient. ADM stated, “[Agency] gives the patient a 5-day notification if [agency] need to discharge the patient. [agency] inform the PCP [primary care physician] and if the patient is transferring to a nursing facility or another home health agency we [agency] call them. We [agency] do a discharge transfer if the patient was going to another home health agency. [Agency] send a discharge notification to the PCP. It [discharge transfer form] was just like a note.” The surveyor asked if the OASIS (standardized data set used by Medicare- certified home health agencies to assess patient outcomes, guide care, and determine reimbursement) or a discharge summary was sent to the PCP after discharge. ADM responded, “No, we [agency] don’t send an OASIS or a discharge summary to the PCP. [OASIS] goes straight to Medicare.” The surveyor asked who was responsible for the discharge paperwork. ADM stated, “Most of the time I am.” When asked how the patient could be affected if the discharge summary was not sent, ADM stated, “The patient might think they are still receiving care.” The agency had a policy (PE.1) titled, “Criteria for Patient Admission, Recertification, and Discharge” dated 12/01/15. The policy read in parts: “…Policy: …IX. The Agency will complete a discharge summary within 48 hours of discharge from home health…” The agency had a policy (PE.6) titled, “Patient Discharge” dated 08/01/14. The policy read in parts: “…Procedure: …A.2.11. Medical record documentation for discharge includes, but is not limited to: Progress toward goals/ Discharge Summary…””