Homunity Health Services

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: E-0001 COP This condition was not met as evidenced by document review and interview which revealed the agency failed to review and update the emergency plan every two years E-0004; Failed to update the facility/community based risk assessment utilizing the all hazards approach and to include cyber-attacks E-0006; failed to have evidence that the policies and procedures for the risk assessments and communication plan were reviewed and updated at least every 2 years E-0013; failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact within a specific timeframe or an outline of surrounding facilities to ensure patient care is continued E-0021; failed to review and update all contact information every 2 years E-0030; failed to maintain documentation of a training and testing program based on the agency’s risk assessment required for staff E-0036; failed to document the staff’s training to demonstrate knowledge of the agency’s EPP E-0037 and failed to contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based E-0039. The findings: The cumulative effect of these deficiencies has resulted in the Home Health Agency’s inability to ensure the provision of quality of care for the Condition of Participation CFR 484.102: Emergency Preparedness. The collective deficient practice illustrated systemic process failures that have potential to affect all patients receiving home health care service from the agency.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on document review and staff interview, it was determined the agency’s QAPI (Quality Assurance Performance Improvement) failed to ensure to implement and maintain a coordinated agency-wide program for the surveillance investigation, identification, prevention control and investigation of infectious and communicable diseases (G642); failed to ensure performance improvement activities that focus on high risk, high volume or problem-prone area (G646); failed to track adverse patient events (G654); failed to ensure its QAPI program resulted in sustained improvements to its performance and failed to conduct performance improvement projects or initiate new projects for the year (G658) and the agency’s governing body failed to ensure resources were available to implement and maintain quality improvement activities (refer to G660). Condition of Participation CFR 484.102: Emergency Preparedness. Condition-level deficiencies for the Emergency Preparedness Plan (EPP) was cited during this recertification and complaint visit. The cumulative effect of the lack of an effective, ongoing, Agency-wide, data-driven QAPI program resulted in the agency’s failure to identify and correct areas of concern and to improve upon substandard practices. This failure affected the agency’s ability to provide quality care to its patients.”

“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 document review it was determined the agency’s Emergency Preparedness Plan (EPP) failed to review and update the EPP every 2 years. The findings: The agency’s Emergency Preparedness Plan (EPP) was reviewed in the agency. Staff Member #1 provided the MFIs (Medical Facilities Inspectors) with a total of three (3) EPP binders (one (1) large binder and two (2) small binders). The EPP binders did not contain any dates of revisions or updates.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on document review it was determined the agency’s Emergency Preparedness Plan failed to review and update the community risk assessment with strategies identified and the all-hazards approach to include cyber-attacks. The findings: The agency’s Emergency Preparedness Plan (EPP) was reviewed in the agency. The document indicated a community-based risk assessment, utilizing an all-hazards approach, hazards vulnerability analysis for the geographic area that the organization serves was last reviewed July 01, 2021. In addition, the EPP failed to include strategies for addressing emergency events that were identified by the risk assessments and failed to include cyber-attacks that is considered to most likely occur in the surrounding area. The EPP for risk assessment failed to be reviewed and updated at least every two years with identified strategies.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on document review of the agency’s Emergency Preparedness Plan (EPP) it was determined the agency failed to have evidence that the policies and procedures for the risk assessments and communication plan were reviewed and updated at least every 2 years. The findings: The agency’s Emergency Preparedness Plan (EPP) document indicated a risk assessments and communication plans last reviewed on July 01, 2021. In addition, the agency failed to include meeting minutes for the reviewing or updating of the EPP. The EPP failed to review, update or provide meeting minutes to ensure the EPP was reviewed or updated every 2 years.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on document review of the agency’s Emergency Preparedness Plan (EPP) it was determined the agency failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact within a specific timeframe or an outline of surrounding facilities to ensure patient care is continued. The findings: The agency’s Emergency Preparedness Plan (EPP) policies and procedure failed to have evidence of how to inform State and local officials of any on-duty staff or patients that they are unable to contact within a specific timeframe. In addition, the EPP failed to include an outline of what surrounding facilities such as hospitals or a nursing home it has a transfer agreement with to ensure patient care is continued during an emergency when the patient care is beyond the capabilities of an HHA (Home Health Agency). The EPP failed to outline timeframes for check-in with staff or patients or outline the surrounding area facilities to ensure patient care is continued during an emergency whereas the patient’s care is beyond HHA capabilities.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on document review of the agency’s Emergency Preparedness Plan (EPP) it was determined the agency failed to review and update all contact information every 2 years. The findings: The agency’s Emergency Preparedness Plan (EPP) contact name and information for staff, entities providing services, patient’s physicians and volunteers failed to be reviewed or updated every 2 years. The agency’s DME (Durable Medical Equipment) suppliers were last updated in 2021 and no other contact information was documented. On January 28, 2025, the MFI (Medical Facilities Inspector) requested a current employee list. Staff Member #1 provided the MFI with an employee list that was missing the Alternate Administrator and Physical Therapist name with contact information. The EPP failed to contain reviewed and updated contact information every 2 years.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Plan (EPP) and interview it was determined the agency failed to maintain documentation of a training and testing program based on the agency’s risk assessment required for staff. The findings: The agency’s Emergency Preparedness Plan (EPP) failed to include evidence of a training and testing program to demonstrate knowledge of the agency’s EPP. The EPP indicated a fire drill log with signatures of staff attended on October 23, 2023 and a form titled “Staff Disaster Drill Log” with staff signatures. The Staff Disaster Drill Log did not indicate an agenda or what the disaster was referenced to. On January 29, 2025 at 11 AM, Staff Member #1 revealed no information on what the Staff Disaster Drill Log was about. The EPP failed to document the training and testing program based on the agency’s risk assessment.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of the agency’s Emergency Preparedness Plan (EPP) and personnel files it was determined the agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan. The findings: The agency’s Emergency Preparedness Plan (EPP) failed to include evidence of the staff’s ability to demonstrate knowledge of the agency emergency preparedness plan. On January 29, 2025 at 12 PM the Medical Facilities Inspector (MFI) requested the agency’s current staff list. The MFI chose eight (8) staff members to review as personnel files. The eight (8) personnel files did not contain any training or testing of the agency’s emergency preparedness that reflected the identified risk assessments, policy and procedures or a communication plan. The EPP failed to document the staff’s training to demonstrate knowledge of the agency’s EPP.”

“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 review of the agency’s Emergency Preparedness Plan (EPP) it was determined the plan failed to contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. The findings: The agency’s Emergency Preparedness Plan (EPP) indicated a form titled “Emergency Preparedness Plan” dated December 07, 2024 with five (5) staff signatures out of (11) current staff members . The Emergency Preparedness Plan did not indicate an agenda or what the plan was referenced to. On January 29, 2025 at 11 AM, Staff Member #1 revealed no information on what the Emergency Preparedness Plan was about. The EPP failed contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to ensure that each patient received the home health services according to a written plan of care. Specifically, the agency failed to ensure each patient’s plan of care was individualized and contained patient specific measurable outcomes and goals identified by the Home Health Agency and the patient for two (2) of (10) clinical records reviewed in the survey sample (clinical records for Patient #s 5 and 6). The findings: 1. The clinical record for Patient #5 was reviewed for the period of January 05, 2025 to January 29, 2025. The plan of care failed to contain goals for the patient. In addition, the clinical record indicated no progress notes toward goals or interventions in the Skilled Nursing notes for the period reviewed above. 2. The clinical record for Patient #6 was reviewed for the period of January 12, 2025 to January 29, 2025. The plan of care failed to contain goals for the patient. In addition, the clinical record indicated no progress notes toward goals or interventions in the Skilled Nursing notes for the period reviewed above. On January 29, 2025 at 1 PM, Staff Member #1 revealed no information on why there were no goals for the above noted patients.”

“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 document review, employee file review and staff interview, it was determined the agency’s QAPI (Quality Assurance Performance Improvement) program failed to maintain a coordinated agency-wide program for the surveillance investigation, identification, prevention control and investigation of infectious and communicable diseases including TB (Tuberculosis) testing for the agency’s employees. The findings: On January 27, 2025 at 2:20 PM, Staff Member #1 pointed to the agency’s QAPI program binder for review on the MFI’s (Medical Facilities Inspector) worktable. The QAPI binder contained documentation titled, “Quality Assessment Improvement Committee Meeting” date of May 17, 2023 and May 17, 2024. The meetings for both dates mentioned above, also indicated a quarterly review of clinical record findings that was left blank for “Trend Identified” and a typed “None” for “Occurrences Noted” for the following: Safety Violations/Hazards; Sharps/Needlesticks; Laboratory results; Patient/Clients infections and Employee infections. The QAPI program failed to complete the agency’s quarterly review of clinical record findings to maintain an agency-wide program for surveillance investigation, prevention control and investigation of infectious and communicable diseases for the years of 2023 and 2024. Both years indicated the same information. On January 29, 2025 at 1 PM, Staff Member #1 revealed no further information on the agency’s QAPI program related to infection control. In addition, on January 29, 2025, eight (8) employee files were reviewed in the agency with four (4) employees with incomplete TB (Tuberculosis) testing or none. 1.Employee record #3 contained no evidence of a 2nd test in accordance with agency policy. 2.Employee record #5 contained no evidence of a 2nd test in accordance with agency policy. Employee #5 contained another negative TB result on October 27, 2021 (481 days from the July 03, 2020, test). There was no evidence of a 2nd test in accordance with agency policy. 3.Employee record #7 contained no evidence of a 2nd test in accordance with agency policy. 4.Employee record #8 did not contain a TB result or a chest x-ray. There was no evidence of TB testing in accordance with agency policy. The agency was cited for TB testing issues as well by an accrediting organization during the month of October 28-30, 2024. The agency indicated the action to correct this deficiency was re-education on the agency’s TB policy and procedures on November 22, 2024 with an allegation of compliance implemented on December 19, 2022 (this date is a typo by the agency and was meant to be December 19, 2024) by correcting any employee who is missing the TB series. The agency failed to implement and maintain a QAPI program related to infection control by means of surveillance, implementation, identification, or investigation indicated by the QAPI meeting of 2023 and 2024 and the employee files for TB testing.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on staff interview, and document review it was determined the agency failed to ensure its performance improvement activities that must focus on high risk, high volume, or problem-prone areas. The findings: On January 27, 2025 at 2:20 PM, the agency’s QAPI program binder was reviewed. The QAPI binder contained documentation of a Performance Improvement activity on July 08, 2021. The MFIs (Medical Facilities Inspectors) found no documentation of high-risk, high volume or problem prone areas for the years of 2023, 2024 or 2025. On January 28, 2025 at 1:32 PM, Staff Member #1 revealed the agency no longer accepts patients with infusion therapy or wound vacs (negative pressure therapy) due to an accrediting organization survey October 2024 that resulted in loss of deemed status associated with these areas. The agency failed to provide the high-risk areas or problem prone areas related to infusion therapy or wound vacs.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on staff interview, and document review it was determined the agency failed to ensure its performance improvement activities tracked adverse patient events, analyze their causes, and implement preventative actions. The findings: On January 27, 2025 at 2:20 PM, the agency’s QAPI program binder was reviewed. The QAPI binder contained documentation titled, “Quality Assessment Improvement Committee Meeting” date of May 17, 2023 and May 17, 2024. The meetings for both dates mentioned above, also indicated a quarterly review of clinical record findings that was left blank for “Trend Identified” and a typed “None” for “Occurrences Noted” for the following: Safety Violations/Hazards; Adverse advents and Medication errors. Both years indicated the same information for 2023 and 2024. On January 29, 2025 at 1 PM, Staff Member #1 revealed no further information on the agency’s adverse patient events, analyze their causes, and implement preventative actions. The agency failed to provide any adverse event tracking for the last 12 months.”

“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 staff interview and document review, it was determined the agency’s QAPI (Quality Assurance and Performance Improvement) plan failed to conduct Performance Improvement Projects (PIPs) each year. Specifically, the agency’s PIPs were not current or accurate from quarter to quarter for the year and the agency failed to initiate new projects. failed to initiate new projects. The findings: On January 27, 2025 at 2:20 PM, the agency’s QAPI program binder was reviewed. The QAPI binder contained documentation titled, “Quality Assessment Improvement Committee Meeting” date of May 17, 2023 and May 17, 2024 and listed four items with data collection from the last three (3) months as follows: OASIS validation reports; OBQI reports; Clinical chart audits and Complaint logs as follows: 1. The OASIS report identified clinicians not adding patient allergies during the start of care with the process significantly improved with only two (2) start of care were noted without allergies and a goal of progressing. 2. The OBQI report was marked as “N/A” (not applicable). 3. The clinical chart audit report identified CMS 485 late with only one (1) incomplete with 48 hours of admission within a month and a goal of progress/improving. 4. The complaint log report identified the log as not updated routinely with a goal of progress/improving. The agency’s QAPI of May 17, 2023 and May 17, 2024 indicated the same information for both years. The QAPI failed to measure the progress achieved on these projects with current and accurate information every quarter for the year. No new PIPs were initiated throughout the year and no 2025 PIPs were identified in QAPI. On January 29, 2025 at 1 PM, Staff Member #1 revealed no further information on the agency’s QAPI regarding PIPs for the years and pointed to the QAPI binder on the MFI’s (Medical Facilities Inspector) worktable in the agency.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on document review, it was determined the facility failed to ensure the agency’s quality improvement program was ongoing, defined, implemented, and maintained. The findings: The agency’s quality assessment performance improvement (QAPI) materials were reviewed on January 27, 2025. Limited quality improvement activities were conducted in 2023, 2024 and thus far in 2025 (refer to G642, G644, G646, G654, G656 and G658).”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on employee file review, interview, and document review, it was determined the agency failed to test its employees for TB (tuberculosis) according to the CDC (Centers for Disease Control and Prevention) healthcare employee recommendations for four (4) of eight (8) employee files reviewed in the survey sample (Employee records for Employee #s 3, 5, 7, and 8). The findings: On January 29, 2025, the employee files were reviewed in the agency. 1.Employee record #3 with a hire date of July 23, 2024, contained a negative TB result on May 23, 2024. There was no evidence of a 2nd test in accordance with CDC recommendations. 2.Employee record #5 with a hire date of August 13, 2020, contained a negative TB result on July 03, 2020. There was no evidence of a 2nd test in accordance with agency policy. Employee #5 contained another negative TB result on October 27, 2021 (481 days from the July 03, 2020, test). There was no evidence of a 2nd test in accordance with CDC recommendations. 3.Employee record #7 with a hire date of August 31, 2023, contained a negative TB result on January 13, 2025. There was no evidence of a 2nd test in accordance with CDC recommendations. 4.Employee record #8 with a hire date of November 09, 2023, did not contain a TB result or a chest x-ray. There was no evidence of TB testing in accordance with CDC recommendations . A review of the agency policy on “Policy and Procedures for Tuberculosis Testing” with no date of review read in part as: 2. TB Testing Procedures A. Tuberculin Skin Test-Mantoux Test Administered via an intradermal injection of 0.1 ml of purified protein derivative into the forearm. The injection site is examined 48-72 hours later for an induration (raised, hardened area). According to the CDC two-step testing for TB is used for base line testing of health care personnel in the United States. If the second TB skin test is negative than a 2nd TB test should be done 1-3 weeks later. The two-step testing evaluates an individual for active TB or latent TB. Reference: https://www.cdc.gov/tb/php/tb-programs/index.html According to the Virginia Department of Health with recommendations from the CDC, all healthcare employees should have baseline screening for TB before working onsite. The two-step TB skin test or a single IGRA blood test. The results are then evaluated to determine if the employee is permitted to work. Reference:https://www.vdh.virginia.gov/content/uploads/sites/175/2023/03/Screening-and-Testing-for-Tuberculosis-2023_Final.pdf On January 29, 2025, at 1:18 PM, Staff Member #1, Staff member #2 and Staff Member #4 revealed not understanding the two-step TB testing and thought if it was negative then a second one did not need to be performed.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on clinical record review, interviews, home visits and agency procedure, it was determined the agency failed to ensure accurate and complete medication lists were documented in four (4) of (10) clinical records reviewed in the survey sample (clinical records for Patient #’s 1, 5, 7 and 10). The findings: 1. The clinical record for Patient #1 was reviewed for the period of January 21, 2025 to January 29, 2025. The plan of care indicated Skilled Nurse visits twice a week for eight (8) weeks. A home visit was conducted on January 27, 2025 at 3 PM with Staff Member #3. The medication list was reviewed with the patient’s caregiver. The patient’s caregiver revealed MiraLAX 1 capful every day for years and Metoprolol 37.5 mg twice a day and prn (as needed) filled on January 01, 2025. The agency’s medication list failed to contain the two medications as mentioned above. 2. The clinical record for Patient #5 was reviewed for the period of January 05, 2025 to January 29, 2025. The plan of care indicated Skilled Nurse visits twice a week for eight (8) weeks. A telephone call from the MFI (Medical Facilities Inspector) was conducted on January 28, 2025 at 11:50 AM. The medication list was reviewed with the patient and revealed Dual Action Advil is taken every day and not listed on the medication list. The patient’s caregiver also revealed Dual Action Advil has been taken for years. The agency’s medication list failed to contain the medication as mentioned above. 3. The clinical record for Patient #7 was reviewed for the period of January 18, 2025 to January 29, 2025. The plan of care indicated Physical Therapy visits once a week for one (1) week then three (3) times a week for two (2) weeks. A home visit was conducted on January 28, 2025 at 3:15 PM with Staff Member #2. The medication list was reviewed with the patient’s caregiver. The patient’s caregiver revealed Tramadol HCL 50 mg every 8 hours for pain as needed and filled on August 30, 2024; Senna 8.6 mg every day at bedtime as needed for constipation and filled on November 26, 2024; Furosemide 20 mg 1 tablet in the morning and 1 tablet in the evening and filled on June 24, 2024; Tylenol 500 mg as needed for pain. The agency’s medication list failed to contain the medications as mentioned above. 4. The clinical record for Patient #10 was reviewed for the period of January 20, 2025 to January 29, 2025. The plan of care indicated Skilled Nurse once a week for five (5) weeks. A home visit was conducted on January 28, 2025 at 12:05 PM with Staff Member #2. The medication list was reviewed with the patient. The patient revealed Adderall XR 1 pill everyday and filled on October 21, 2024; Triamcinolone Acetonide ointment 0.1% to affected areas daily and filled on September 28, 2024; Amoxicillin Clav 875-125 mg 1 tablet twice a day x 10 days and filled on January 17, 2025; Metaxalone 400 mg 1 pill three times a day and filled on September 20, 2024; Metformin 100 mg twice a day and filled on August 05, 2024; Trulicity 0.75 mg/0.5 ml pen give 0.75 mg subcutaneously once a week for 30 days and Repatha 140 mg/ml inject 1 ml into the skin every 14 days and patient reports this medication was filled months ago. The agency’s medication list failed to contain the medications as mentioned above. On January 29, 2025, Staff Member #2 revealed the discharge medication list is reported as the patient’s most accurate list and is used as the patient’s medication list unless there are changes. A review of the agency policy on “Medication Reconciliation Policy” with no date of review read in part as: Medication Reconciliation is a critical component of medication management , aiming to ensure that individuals receive the correct medications as intended by their healthcare providers. The process involves: Collecting; Obtaining a current list of the individuals medications, including prescriptions, over – the - counter drugs, and supplements. Comparing: Reviewing the collected medication list against the physician’s orders and the medications the individual is actually taking to identify and discrepancies. Correcting: Addressing any discrepancies by consulting with the prescribing physician or pharmacist to ensure accuracy. Communicating: Sharing the updated and accurate medication information with all members of the healthcare team and the individual receiving care. The agency failed to update each patient’s medication profile as noted above.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observations and interviews, it was determined the agency failed to provide each patient written information regarding the patient’s medication regimen based on the medication review conducted by the Home Health Agency for (10) of (10) clinical records reviewed in the survey sample (clinical records for Patient #s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). The findings: A home visit for Patient #1 was conducted on January 27, 2025 at 3 PM with Staff Member #3. During the home visit the Home Health Agency paperwork was reviewed with Patient #1 caregiver. The paperwork including the Home Health Admission Booklet did not contain a written medication list. A telephone call to Patient #5 from the MFI (Medical Facilities Inspector) was conducted on January 28, 2025 at 11:50 AM. The MFI reviewed the Home Health Agency paperwork with Patient #5. Patient #5 revealed the paperwork including the Home Health Admission Booklet did not contain a written medication list. A home visit for Patient #7 was conducted on January 28, 2025 at 3:15 PM with Staff Member #2. During the home visit the Home Health Agency paperwork was reviewed with Patient #7’s caregiver. The paperwork including the Home Health Admission Booklet did not contain a written medication list. A home visit for Patient #10 was conducted on January 28, 2025 at 12:05 PM with Staff Member #2. During the home visit the Home Health Agency paperwork was reviewed with Patient #10. The paperwork including the Home Health Admission Booklet did not contain a written medication list. On January 29, 2025 at 1:15 PM, Staff Member #1 and Staff member #2 revealed no written medication list is given to the patients and did not know this was a requirement.”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure its Quality Assessment Performance Improvement Plan (QAPI) ensured sustained improvements. Specifically, the home health agency failed to ensure a Condition Level Deficiency previously cited were corrected on subsequent survey. The findings: During an accreditation organization survey ending October 30 2024, the agency was cited for a condition level deficiency related to the agency’s EPP (Emergency Preparedness Plan). This deficient practice has not been corrected at the time of this recertification and complaint survey and remains out of compliance with a condition level finding at the current recertification survey (see E-0001). In addition, the QAPI failed to indicate documentation of Emergency Preparedness Plan. The agency’s QAPI materials were reviewed on January 27, 2025 and indicated no documentation regarding EPP for the years of 2023, 2024 or 2025. On January 29, 2025 at 1 PM, Staff Member #1 revealed no further information on the agency’s sustained improvements or the EPP.”