Golden Years Homecare Specialists II

“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 develop and maintain an emergency preparedness plan that included an annual evaluation at least every 2 years for one of one Emergency Preparedness Plan. This failure could result in the agency’s ability to effectively communicate with the clients during an emergency activation within the community, as well as ineffectively protecting the needs of the clients in an emergency situation. Review of agency policy titled “Emergency Preparedness Plan Policy” dated 11/15/17 revealed: The Emergency Preparedness Plan must be reviewed and updated at least annually (484.22(a)). Interview with CFO on 9/2/26 at 11:15 AM in reference to missing annual evaluation for Emergency Preparedness. Asked CFO who was responsible for annual evaluation for Emergency Preparedness documentation. CFO stated this documentation is included at all annual meetings and is the responsibility of CFO and Alternate Administrator. CFO provided binder that included the Governing Body, referred to dated 12/20/25 meeting minutes. Asked CFO if agency included Emergency Preparedness annual evaluation annually as required per agency policy. CFO stated the agency previously included the annual evaluation documentation annually but then stated he had been informed this was not required since the documentation was included in the policy. Interview with Alternate Administrator on 9/3/26 at 10:00 AM in reference to annual evaluation for Emergency Preparedness. Asked Alternate Administrator if she was aware of the policy for Emergency Preparedness for the agency that included an annual evaluation annually. She stated the agency had been completing the annual evaluation annually, however; to her knowledge to did not believe this had been included in the Governing Body Meetings over the previous years. Review of the agency binder of documentation titled, “Governing Body Meeting Minutes” dated 12/20/25 revealed annual evaluation of agency items including QAPI, Patient Status, Annual Program Review, Budget for 2026, and Administrator Update. Documentation failed to include annual evaluation of Emergency Preparedness Plan. Review of agency’s policy titled “Emergency Preparedness Plan Policy” dated 11/15/17 revealed agency policy stated the plan, and related policies and procedures must be reviewed and updated at least annually.”

“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 reviews and interviews, the agency failed to implement performance improvement activities that included analysis of agency services, areas for improvement, or problem areas that could lead to negative outcomes to the agency and their clients. This failure could result in significant risks to health or safety of the clients receiving care through the agency. Review of agency QAPI documentation included meetings with minutes that included complaints, client satisfaction results, and infection documentation. The information did not include performance improvement projects that agency had ongoing or completed for years 2023, 2024, and 2025. Interview with the DON on 9/2/26 at 3:30 PM in reference to missing performance improvements projects, which she stated due to the agency being so small there have been no major issues in which would warrant a PIP. DON stated their annual evaluation includes their infection control monitoring, client satisfaction reporting, and agency employee communication in coordination with agency policy. She stated the updates, if any, would have been completed by the Alternate Administrator and implemented into the documentation by DON, however, they did not have any projects to implement over the previous years (2023, 2024, 2025). Interview with Alternate Administrator on 9/3/26 at 10:00 AM in reference to performance improvement projects agency has in place currently or has completed in the past 3 years. Alternate Administrator stated she focuses on improvements that are individualized based on each employee, what the employee needs was her response. Asked Alternate Administrator if the agency focused on a ‘whole’ what improvements were needed as identified at least one per year based on state guidelines. She responded that the plan for improvements will be clearly defined in the minutes from each annual evaluation, which will be the performance improvement project for the agency. She voiced understanding of the need for having PIP in place, regardless of the size of the agency. DON with Alternate Administrator voiced she had already started making the adjustments to include performance improvement projects that would include the PIP for clearly defined documentation in the QAPI binder. Review of QAPI policy titled “Quality Assessment Improvement Plan” dated 11/15/17 revealed ‘Agency leadership has taken goals and objectives into consideration with annual evaluation for QAPI processes and needs for improvement. The Governing Body will be involved in the review and approval of any process or program changes to improve the QAPI program. Review of policy titled “Annual Program Evaluation” dated 9/23/19 revealed ‘Agency administrative staff and the Governing Body participate in an annual evaluation of the Agency’s performance in relation to its mission, purpose and objectives.”