A-Z Healthcare Agencies and Homecare LLC

“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 participate in a full-scale community-based exercise or individual facility-based exercise at least every two years to test the emergency plan annually, for three (2022, 2023, and 2024) of three years reviewed. The failure placed the agency’s patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster or emergency. Findings include: During the entrance conference at 10:20 a.m. on 01/17/2025, the Admin/DON self-identified as the disaster coordinator and identified the Alt Admin. as the alternate disaster coordinator. Review of the undated emergency preparedness plan binder revealed the following records: an agency fire drill for the agency’s office building location dated 12/22/2022, an annual tabletop exercise for a simulated emergency of impending severe storm warning dated 12/20/2023, an annual tabletop exercise for simulated emergency of impending winter storm warning dated 12/19/2024, and three undated agency emergency preparedness plan evaluations. Further review of the binder revealed that the agency did not have any documentation that indicated the agency had activated its EP plan during an actual natural or man-made disaster for the years 2022, 2023, and 2024. Continued record review of the emergency preparedness plan records did not identify any records to establish that the agency had participated in a full-scale exercise that was community-based or individual, facility-based functional exercise for the years 2022, 2023, and 2024. During an interview on 01/27/2025 at 2:27 p.m. with the Admin/DON the surveyor asked who was responsible for the agency’s EP program. The Admin stated that she was responsible. The surveyor reviewed the findings and asked why the agency had not conducted the exercises to test its EP plan and maintained documentation, in accordance with federal regulations. The Admin replied, “I remember one year it was a drill [but did not remember the year]. I do remember the tabletops. Maybe it was an omission.” The surveyor asked how the failure could adversely affect the agency’s clients. The Admin stated that it was a safety issue. If an emergency occurred, the staff might not know what to do. Review of agency policy titled, “Emergency Preparedness and Response Plan EC.40” dated 05/01/24 read in part: “...To ensure the Agency complies with all applicable federal, state, and local emergency preparedness requirements... A. The Agency will conduct a facility and community-based risk assessment that uses an all hazards approach prior to establishing an emergency plan to identify potential disasters including, but not limited to, hurricanes, tornadoes, fire, epidemics, pandemics, terrorism, etc., likely to occur in the Agency’s service area... 2. Testing and Training a. The Agency will conduct exercises to test the emergency plan at least annually. The Agency will: (1) Participate in a full-scale community-based exercise every two years. If participation in a community-based exercise is not possible, a facility-based functional exercise will be conducted every two years. The Agency will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e., date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise). If the Agency experiences an actual natural or manmade emergency that requires activation of the emergency plan, the Agency is exempt from engaging in its next required full-scale community-based or facility based functional exercise for one year following the onset of the emergency event. (2) Conduct an additional exercise every two years, opposite the year the full-scale community-based or facility-based functional exercise is conducted, that may include, but is not limited to the following: (a) A second full-scale community-based or facility-based functional exercise, or (b) A mock disaster drill, or (c) A tabletop exercise or workshop that includes 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 (3) The Agency will analyze the Agency’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, assess staff knowledge of emergency procedures and revise the emergency plan, as needed...””

“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 conduct and document PIP(s) annually, for three (2022, 2023, and 2024) of three years reviewed for PIP(s), that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to patient health and safety concerns. Findings include: During an interview on 01/17/2025 10:20 a.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s QAPI records revealed the following: 1st, 2nd, 3rd, and 4th quarterly QAPI reports for 2023 and 2024 and 1st, 2nd, and 3rd quarterly QAPI reports for 2022. Review of the agency’s quarterly QAPI reports did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for the calendar years of 2022, 2023 and 2024. During an interview with the Admin/DON on 01/27/2025 at approximately 2:30 p.m. the surveyor reviewed the findings and asked who was responsible for conducting the PIP(s). The Admin/DON replied, “Me.” The surveyor asked what the agency’s process was for conducting and documenting the projects. The Admin/DON replied, “When it is done, I make sure that it is signed and put in the book. I don’t know what happened.” The surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements (to conduct and document the projects). The Admin/DON stated that, “It’s organization. We need to be more organized.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “There is no continuity of care (where patient care progresses smoothly and is coordinated between all healthcare providers).” Review of agency policy titled, “Quality Assessment Performance Improvement Plan” last reviewed 05/01/2024 read in part: “...III. The Agency will maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS...E. Performance Improvement Projects 1. 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. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects...””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide Patients # 6 and 7 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. The failure caused the clients to not have written advance notice to appeal the discharge decision if desired. Findings include: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 6 as 10/24/2023 and Patient # 7 as 05/03/2024. Inactive Clinical Record # 6: Record review of the clinical records for Patient # 6 revealed a POC for the certification period of 08/26/2023 to 10/24/2023. Review of the POC revealed a start of care date of 08/22/2022 with a principal diagnosis of hypertension (high blood pressure). The POC was dated 08/21/2023 and electronically signed by the Admin/DON. The POC contained an order for skilled nursing visits one time per week for nine and two as needed visits. Continued review of the records revealed a discharge summary signed by the Admin/DON and dated 10/24/2023. Review of the discharge summary revealed a discharge date of 10/24/2023. The discharge summary revealed that Patient # 6 was discharged from the agency with “met and unmet goals...[and] Condition at discharge: Needs Assistance.” Continued review of the discharge summary revealed that the reason for discharge was the patient changed to a health maintenance organization insurance. Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 10/24/2023. The record did not include a written NOMNC. Inactive Clinical Record # 7: Record review of the clinical records for Patient # 7 revealed a POC for the certification period of 03/05/2024 to 05/03/2024. Review of the POC revealed a start of care date of 03/05/2024 with a principal diagnosis of hypertension (high blood pressure). The POC was dated 03/05/2024 and electronically signed by the Admin/DON. The POC contained an order for skilled nursing visits one time per week for one week and two as needed visits, physical therapy visits one time per month for one month to evaluate and treat, and occupational therapy visits one time per month to evaluate and treat. Continued review of the records revealed a discharge summary signed by the Admin/DON and dated 05/03/2024. Review of the discharge summary revealed a discharge date of 05/03/2024. Continued review of the discharge summary did not reveal the reason for discharge. Further review of Patient # 7’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 05/03/2024. The record did not include a written NOMNC. During an interview on 01/27/2025 at 3:00 p.m. with the Admin/DON, the surveyor reviewed the findings and asked who at the agency was responsible for providing the discharge notice. The Admin/DON stated she was responsible. The surveyor asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7. The Admin/DON stated that she could not remember. The surveyor asked how the failure could adversely affect the patients. The Admin/DON stated, “Maybe they could find another way to continue services if needed [appeal the discharge decision].” Review of agency policy titled, “Patient/Client Transfer and Discharge Notices PE.30” last reviewed 05/01/2024 read in part: “ ... III. The Agency will deliver the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily... B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client, or representative (if any) when providing notice of discharge... C. If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure that the individualized plan of care (POC) included the required elements in one of one patient record reviewed, who was legally blind, in that: for (Patient # 5) the POC failed to include all pertinent diagnoses, the frequency and duration of visits to be made, the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The failure placed the patient at risk of having poor health and safety outcomes if skilled nursing visits were missed and risk factors not addressed, due to not having a detailed plan of care. Findings include: Patient # 5 Record review of Patient # 5’s clinical records revealed a POC with a SOC date of 05/11/2024 and a certification period of 11/07/2024 to 01/05/2025. Review of the POC revealed that it was dated 11/06/2024 and signed by the Admin/DON. The POC included a primary diagnosis of hypertension (high blood pressure). The POC read in part: “…Skilled nurse developed the patient plan pf care with the patient/caregiver…involvement. SN to perform vital signs and physical assessment at every visit and report [an increase in severity of health conditions] to physician…” Continued review of the POC revealed that it did not include a diagnosis of legal blindness, any frequency or duration of SN visits, the patient’s psychosocial status, a description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. Further review of the POC revealed “psychosocial status” was listed as “none.” Review of Patient # 5’s SN visit notes dated 11/08, 15, 22, 29/2024, 12/06, 13, 20, 27/2024 revealed that the patient had impaired vision and was legally blind. During an interview with the Admin/DON on 01/27/2025 2:45 p.m., the surveyor reviewed the findings and asked why the POC for Patients # 5 did not include all required elements. The Admin/DON stated, “Maybe, an error on me not going back to review [the POC].” The surveyor asked how the failure could adversely affect the patient. The Admin/DON stated that there could be missed visits and the patient’s health could be affected, “for example like would care being missed.” Review of agency policy titled, “Plan of Care PC.35” dated 05/02/24 read in part: “...III. Each patient/client must receive an individualized written Plan of Care…The individualized Plan of Care must include the following: all pertinent diagnoses; the patient’s mental, psychosocial, and cognitive status… The frequency and duration of visits to be made…A description of the patient’s/client’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors...””