Every finding on record at A and E Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on February 09, 2026, through February 12, 2026. Census: 34 Unduplicated Admissions: 90 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Emergency Preparedness Conditions of Participation were met. One (1) deficiency was issued.

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 observation, interview, and record review, the agency failed to ensure 1 of 7 staff members was knowledgeable about the location of the agency’s designated and alternate meeting location in case of emergencies. This failure had the potential for a delay in the overall agency communication and coordination of services for all 90 vulnerable patients at risk who received care from the agency. Findings: During an interview on February 11, 2026, at 3:15 PM, with Physical Therapist Assistant (PTA), while at Patient 3’s home, PTA stated that she does not know where the agency’s primary and alternate emergency meeting location was. PTA further stated that she has not been educated or done in-service training regarding emergency preparedness. During an Interview on February 12, 2026, at 12:30 PM, with the Administrator (ADMIN), ADMIN stated, “All staff should have been educated and in-serviced on emergency preparedness, PTA should know the designated and alternate meeting location in case of emergency." During a follow up concurrent interview and record review on February 12, 2026, at 12:55 PM, with ADMIN, the agency's policy and procedure (P&P) titled, “Skilled Nursing In-Service Education,” dated January 2024, was reviewed. The P&P indicated … “Purpose To ensure all skilled nursing staff maintain competency, clinical excellence, and compliance with federal, state, and agency regulations through structured in-service education. Scope: This policy applies to Registered Nurses (RNs), Licensed Practical/Vocational (LPNs/LVNs), Contract or PRN Skilled Nursing Staff 2. Mandatory Topics: The following topics must be covered at minimum annually (or per regulation) Infection prevention and control, OSHA and bloodborne pathogens, Emergency preparedness……" The Admin verified and confirmed that PTA has not completed agency's ’s in-service emergency preparedness training, and this failure has the potential to place vulnerable patients at risk for delays in communication and coordination of services.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on February 09, 2026, through February 12, 2026 Census: 34 Unduplicated Admissions: 90 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Conditions of Participation were met One (1) deficiency was issued

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 interview, and record review, the agency failed to ensure a medication reconciliation (a critical safety process of creating the most accurate list of a patient's current medications including name, dosage, frequency, route, and expiration and comparing it against physician's orders) was conducted for one of seven sampled patients (Patient 1) when one medication, Metformin (the primary medication used to treat diabetes by lowering high blood sugar levels), was found to be expired and available for use. The medication was noted to be 41 days past its expiration date at the time of the recertification survey. This failure had the potential to cause ineffective drug therapy to Patient 1, significant side effects and noncompliance with drug therapy. Findings: During a review of Patient 1’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of February 27, 2025, with a recertification period of December 24, 2025, to February 21, 2026. Patient 1 had diagnoses that included Type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin). During a home visit on February 10, 2026, at 11:00 AM, Registered Nurse 1 (RN 1) and in the presence of Patient 1, an observation of Patient 1’s medications currently available at home were compared with Patient 1’s most current Medication Profile (MP-a comprehensive, up to date document summarizing a patient's medications). During a concurrent observation and interview on February 10, 2026, at 11:15 AM, with RN 1, Patient 1’s medication Metformin was checked. The label on the medication container indicated, “(name of medication) Use before …EXP (expiration): 12/31/2025 (December 31, 2025-medication had been expired for 41 days).” During an interview on February 10, 2026, at 11:30 AM, with RN 1. RN 1 stated, “I should have checked the Metformin expiration date in my medication reconciliation check for patient 1, I did not check it." The RN 1 verified and confirmed Metformin had been expired for 41 days. The RN 1 further stated administering expired Metformin will put Patient 1 at risk of ineffective blood glucose control. During a follow up interview and record review on February 11, 2026, at 12:30 PM with Administrator (ADMIN), the agency’s policy and procedure (P&P) titled, “Medication Administration & High -Risk Medications," dated January 30, 2025, was reviewed. The P&P indicated …"Expired Medications in the Home health Setting I. Purpose. To ensure nurses properly identify, address, educate, and document issues related to expired medications in patient’s homes in compliance with: CMS Condition of Participation (Medication Management & Patient Safety), California Nursing Practice Act, Agency medication management Policy. II Learning Objectives, By the end of this training, staff will be able to: 1. Identify expired medications during home visits 2. Understand risks associated with expired drugs. 3. Implement appropriate nursing actions. 4. Educate patients and caregivers. 5. Properly document findings and interventions." The ADMIN stated that RN 1 should have checked the expiration date of the Metformin for Patient 1. ADMIN further verified and confirmed that Metformin has been expired for 41 days, and Patient 1 may not receive the intended dose, even if the correct dose are administered which can lead to poor blood glucose control and RN 1 did not follow the P&P by not checking expired Metformin for patient 1.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted February 06, 2023 through February 9, 2023. Representing the Department: Surveyors: 35183, 47110 Census: 35 Unduplicated Admissions: 121 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 The following Condition of Participation was not met: E 001 484.102 Establishment of the Emergency Program

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: The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 004) 2. Based on interview and record review, the agency failed to conduct and document a community-based and/or facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets [i.e., rural area versus a large metropolitan area]), for the year 2022, in a universe of 35 patients. (Refer to E 006) 3. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 009) 4. Based on interview and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 019) 5. Based on interview and record review, the agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness officials, for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 031) 6. Based on interview and record review, the agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 034) 7. Based on interview and record review, the agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and “Emergency Preparedness Plan,” for the 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 037) 8. Based on interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for 2021 and 2022 years reviewed, in a universe of 35 patients. (Refer to E 039) The cumulative effect of these systemic practices resulted in the potential to cause the Emergency Preparedness Program (EPP) to indicate ineffective procedures and outdated information. In addition, the potential to place the agency’s patients at risk when: the agency was not prepared to respond to the hazards most likely to occur in the community, the agency was not prepared to work with the emergency management office during an emergency or disaster, the agency did not have contact information for governmental agencies able to provide assistance to the agency’s patients during an emergency or disaster, contracted staff were not trained on what to do during an emergency or disaster and problems within the Emergency Preparedness Plan had the potential to go unrecognized and unaddressed.

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 interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 2:15 PM, was conducted. There was no documented evidence to show a review of its contents had been conducted. A review of the agency’s Governing Body Meeting Minutes for all months in the years 2021 and 2022, on February 9, 2023, at 2:15 PM, was conducted. There was no documented evidence to show the Governing Body had reviewed the Emergency Preparedness Program. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 2:15 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she could not show documented evidence that the agency's Emergency Preparedness Program had been reviewed in 2021 or 2022. A review of the agency policy and procedure titled, “Emergency Operations Plan and Policies,” dated, March 2018, indicated, “Procedure: …The emergency preparedness program includes but is not limited to, the following elements: The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually.”

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 interview and record review, the agency failed to conduct and document a community-based and/or facility-based risk assessment (community/facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; patient population; facility type and potential surrounding community assets [i.e., rural area versus a large metropolitan area]), for the year 2022, in a universe of 35 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond to the hazards most likely to occur in the community. A review of the facility’s Emergency Preparedness Binder, undated, contained two forms, one for a community-based risk assessment and one for a facility-based risk assessment. Both forms were blank. A review of the facility’s “Emergency Preparedness Plan,” undated, indicated, “Hazard Identification, [name of agency] will perform a Hazard Vulnerability Assessment Annually, using an ‘all-hazards approach,’ to identify the risks in the community. This will include Natural Events, Man-Made incidents, and communicable disease and any other risks known to the area. Hazard Vulnerability Assessment: Fire, Earthquakes, Extreme Heat, Population.” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 2:15 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated an All-Hazard Risk Assessment had not been conducted which was why the hazard analysis forms were blank. The Admin/DPCS stated they [office staff] had talked among themselves and came up with the four hazards documented in the Emergency Preparedness Plan. The Admin/DPCS stated, "I don't know why I wrote down population as a hazard." A review of the agency’s policy and procedure titled, “Agency Facility-Based and Community-Based Risk Assessment Policy,” dated, March 2018, indicated, “Policy: The Agency will perform a facility-based and community-based risk assessment utilizing an all-hazards approach in order to develop an emergency plan. …Procedure: 1. Hazard Vulnerability Assessment (HVA) will be conducted and evaluated annually. The Hazard Vulnerability Analysis is an ‘all hazards’ integrated approach to planning that focuses on Agency capacities and capabilities that are critical to preparedness planning for a full spectrum of emergencies or disasters (including internal emergencies and a man-made emergency or natural disaster) in Agency’s location, considering the particular types of hazards which may most likely occur in Agency’s area.”

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 2:25 PM, was conducted. There was no documented evidence to show contact information for local, regional, State, and Federal emergency preparedness officials. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. A review of the agency’s Emergency Preparedness Plan, undated, on February 9, 2023, at 2:25 PM, did not indicate the agency would reach out to and collaborate with local, regional, State, and Federal emergency preparedness officials. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 2:25 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP. The Admin/DPCS stated she had not reached out to their local Emergency Management Office. The Admin/DPCS stated she had not collaborated with the local, regional, State, and Federal emergency preparedness officials and did not know who to report patients or staff they could not reach after an emergency or patients in need of evacuation. A review of the agency’s policy and procedure titled, “Emergency Operations Plan and Policies,” dated March 2018, indicated, “Procedure: …Includes a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the Agency’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. …The Agency will coordinate efforts with area emergency management agencies, to mitigate, prepare, respond, and recover from high priority emergencies that impact the community, e.g., local health department, law enforcement and office of emergency management.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to inform emergency management services about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 2:50 PM, was conducted. There was no documented evidence to show contact information for the agency’s local emergency management office. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain contact information and directions on reporting to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 2:50 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s policy and procedure titled, “Emergency Operations Plan and Policies,” dated March 2018, indicated, “Procedure: …The Administrator, Director of Clinical Services and/or Managers will inform both state and local emergency preparedness officials by telephone or in person about patients in need of evacuation from their homes at any time due to an emergency situation based on the patient’s medical and/or psychiatric condition, home environment and relevant healthcare information assessed in patients’ individual emergency plan.”

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and maintain an emergency preparedness communication plan that included contact information for Federal, State, tribal, regional, and local emergency preparedness officials, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to place the agency’s patients at risk when the agency did not have contact information for governmental agencies able to provide assistance to the agency’s patients during an emergency or disaster. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 3:05 PM, was conducted. There was no documented evidence to show contact information for Federal, State, tribal, regional, and local emergency preparedness officials. There was no documented evidence to show the agency had reached out to Federal, State, tribal, regional, and local emergency preparedness officials to obtain contact information and directions on contacting officials during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 3:05 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS verified the Emergency Preparedness Binder did not contain contact numbers for Federal, State, tribal, regional, and local emergency preparedness officials. The Admin/DPCS stated she had not reached out to Federal, State, tribal, regional, and local emergency preparedness officials to obtain contact information and directions on contacting officials during an emergency or disaster. A review of the agency’s policy and procedure titled, “Communication Plan and Policy for Emergency Operations Plan (EOP),” dated March 2018, indicated, “Policy: The Agency has developed and maintains an emergency preparedness communication plan that complies with federal, state, and local laws. The communication plan is reviewed and updated at least annually. Procedure: …Contact information for the following: Federal, state, tribal, regional, or local emergency preparedness staff. Other sources of assistance.”

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to cause the agency not to receive help and support from the authority having jurisdiction or provide staff available to help to the authority having jurisdiction. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 2:40 PM, was conducted. There was no documented evidence to show contact information for the agency’s local emergency management office. There was no documented evidence to show the agency had reached out to local emergency management office to obtain contact information and directions on reporting the agency’s occupancy, needs and staff available to help during an emergency or disaster. A review of the agency’s Emergency Preparedness Plan, undated, on February 9, 2023, at 2:40 PM, did not indicate the agency would reach out to the authority having jurisdiction to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 2:40 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report the agency's occupancy, needs and availability of on-duty staff. A review of the agency’s policy and procedure titled, “Emergency Operations Plan and Policies,” dated March 2018, indicated, “Procedure: …During an emergency, the following activities will be managed: The Administrator of Clinical Services will provide information by telephone (or in person, if no telephone service exists) about the Agency’s needs and ability to provide any assistance to the local Incident Communication Center or the authority having local jurisdiction during the emergency.”

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 interview and record review, the agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and “Emergency Preparedness Plan,” for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to place the agency’s patients at risk when contracted staff were not trained on what to do during an emergency or disaster. During an interview with a Physical Therapy Assistant (PTA 1) on February 7, 2023, at 3 PM, PTA 1 stated the agency had not provided her an in-service on their Emergency Preparedness Program. PTA 1 stated she did not know what the agency expected of her during an emergency or disaster situation. A review of PTA 1’s personnel file was conducted. There was no documented evidence to show PTA 1 had received training on the agency’s emergency preparedness program. A review of the agency’s in-service binder dated 2021 to 2022, on February 9, 2023, at 3:20 PM, was conducted. There was no documented evidence to show contracted staff had been in-serviced on the agency’s Emergency Preparedness Program. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 3:20 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated contracted staff had not been included in the in-service training for the Emergency Preparedness Program. The Admin/DPCS stated she was unaware of this requirement. A review of the agency’s policy and procedure titled, “Emergency Operations Plan (EOP) Training Program,” dated March 2018, indicated, “Procedure: …The Agency will do the following: Provide initial training in emergency preparedness policies and procedure to all new and existing staff, individuals providing services under arrangement and volunteers, (if applicable) consistent with their expected roles. Provide emergency preparedness training at least annually. Maintain documentation of the training. Demonstrate staff knowledge of emergency procedures.”

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 interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office or emergency operation centers.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for all months in the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to cause problems within the Emergency Preparedness Plan to go unrecognized and unaddressed. A review of the agency’s Emergency Preparedness Binder, undated, on February 9, 2023, at 3:38 PM, was conducted. There was no documented evidence to show a full-scale community based or tabletop emergency preparedness exercise had been conducted. A review of the agency’s Emergency Preparedness Plan, undated, did not indicate a plan to conduct emergency preparedness exercises. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 3:38 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not conducted any exercises of the agency’s Emergency Preparedness Program (EPP). The Admin/DPCS stated she was confused between the training of the EPP and the testing of the EPP. The Admin/DPCS stated, “I thought they were one in the same.” A review of the agency’s policy and procedure titled, “Testing Program for Emergency Operations Plan (EOP),” dated March 2018, indicated, “Policy: The Agency will ensure that the Emergency Operations Plan (EOP) is functional through testing and evaluation. Procedure: The Agency will conduct exercises to test the EOP at least annually. The Agency will do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise. The Agency is encouraged to seek out local state emergency agencies and health care coalitions to participate in a full-scale, community-based exercise. If the Agency experiences an actual natural or man-made emergency that requires activation of the EOP, the Agency is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one (1) year following the onset of the actual event. A full-scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and/or ‘boots on the ground’ response (e.g., firefighters decontaminating mock victims). Conduct an additional exercise that may include but is not limited to the following: A second full-scale exercise that is community-based or individual, facility based. A tabletop exercise 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 the EOP. It involves key personnel discussing simulated scenarios, including computer-simulated exercises in an informal setting which can be used to assess plans, policies, and procedures.”

The following reflects the findings of the California Department of Public Health during a recertification survey conducted February 06, 2023 through February 9, 2023. Representing the Department: Surveyors: 35183, 47110 Census: 35 Unduplicated Admissions: 121 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participation were met.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure patients’ rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to three of seven sampled patients (Patients 1, 2, and 3). This failure had the potential to cause a reduced ability of patients to lodge a complaint, resulting in continued delivery of substandard care by the agency. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a recertification period of January 7, 2023 to March 7, 2023. Patient 1 had diagnoses that included unspecified wound to the left foot. During a home visit and on February 7, 2023, at 9:43 AM with a Licensed Vocational Nurse (LVN 1) Patient 1’s home notebook (a paper folder containing home health agency and Patient 1’s medical information) was reviewed. There was no documented evidence to show the state free home health telephone hot line and supporting information had been provided. LVN 1 verified there was no state free home health telephone hot line with supporting information. In a concurrent interview with Patient 1, Patient 1 stated she may have been given the hotline but she did not remember. Patient 1 stated she did not know where the number was documented and did not know what the number was. 2. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 16, 2023, with a certification period of January 16, 2023 to March 16, 2023. Patient 2 had diagnoses that included intervertebral disc degeneration (a breakdown of one or more of the discs of the spine). During a home visit and on February 7, 2023, at 3:48 PM with a Physical Therapy Assistant (PTA 1) Patient 2’s home notebook (a paper folder containing home health agency and Patient 2’s medical information) was reviewed. There was no documented evidence to show the state free home health telephone hot line and supporting information had been provided. PTA 1 verified there was no state free home health telephone hot line with supporting information. In a concurrent interview with Patient 2, Patient 2 stated she did not know anything about a hotline phone number. 3. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 18, 2022, with a recertification period of January 17, 2023 to March 17, 2023. Patient 3 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). During a home visit and on February 8, 2023, at 1:58 PM with a Licensed Vocational Nurse (LVN 2) Patient 3’s home notebook (a paper folder containing home health agency and Patient 3’s medical information) was reviewed. There was no documented evidence to show the state free home health telephone hot line and supporting information had been provided. LVN 2 verified there was no state free home health telephone hot line with supporting information. In a concurrent interview with Patient 3’s daughter, Patient 3’s daughter stated the agency had not provided the hotline phone number. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 3:35 PM, the Admin/DPCS stated the State hotline phone number should have been provided to Patients 1, 2, and 3 and it was not. A review of the agency’s policy and procedure titled, “Patient’s Bill of Rights/Responsibilities and Transfer/Discharge Criteria,” dated March 2018, indicated, “Patients have the right: To be advised of the telephone number and hours of operation of the state's Home Health Agency hotline, that receives complaints or questions about local home care agencies. The hours are 24 hours a day, seven (7) days a week and the telephone number is 909-946-2232. The hotline also receives complaints about advance directives.”

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the patients’ referral order for two of seven sampled patients (Patients 6 and 7). This failure had the potential to cause a delay in the determination of Patient 6 and 7’s immediate care and support needs. 1. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 13, 2023, with a certification period of January 13, 2023, to March 13, 2023. Patient 6 had diagnoses that included hepatic failure (loss of liver function). A review of Patient 6’s referral order dated January 9, 2023, indicated to evaluate patient for admission to home health services. A review of Patient 6’s initial assessment dated January 13, 2023, indicated the initial assessment had been conducted on January 13, 2023. (The initial assessment had been completed four days after the physician’s referral order.) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 2:21 PM, the Admin/DPCS verified Patient 6 had not received the initial assessment within 48 hours of the referral order and should have. 2. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022, to February 10, 2023. Patient 7 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 7’s referral order dated December 10, 2022, indicated to evaluate patient for admission to home health services. A review of Patient 7’s initial assessment dated December 13, 2022, indicated the initial assessment had been conducted on December 13, 2022. (The initial assessment had been completed three days after the physician’s referral order.) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 3:30 PM, the Admin/DPCS verified Patient 7 had not received the initial assessment within 48 hours of the referral order and should have. A review of the agency’s policy and procedure titled, “Initial Assessments/Comprehensive Assessments,” dated March 2018, indicated, “Initial Assessment and Time Frame: A RN [Registered Nurse], PT [Physical Therapist] or SLP [Speech Language Pathologist] must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. …”

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the patients’ comprehensive assessments were completed within five (5) days of the start of care for two of seven sampled patients (Patients 2 and 7) when Patient 2 did not receive an initial Physical Therapy (PT) evaluation and Patient 7 did not receive an initial Medical Social Worker (MSW) evaluation within 5 days of their respective starts of care. This failure had the potential to cause Patient 2 and 7’s needs to go unmet. 1. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 16, 2023, with a certification period of January 16, 2023 to March 16, 2023. Patient 2 had diagnoses that included intervertebral disc degeneration (a breakdown of one or more of the discs of the spine). A review of Patient 2’s plan of care/physician’s order dated January 16, 2023, indicated, “Physical therapy to evaluate and treat.” A review of Patient 2’s Initial PT Evaluation, dated January 23, 2023, indicated the evaluation had been conducted on January 23, 2023. (The initial PT evaluation had been completed seven days after Patient 2’s start of care) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 11:11 AM, the Admin/DPCS stated the PT evaluation was not done within five days from the start of care and should have been. 2. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022, to February 10, 2023. Patient 7 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). Patient 7’s face sheet indicated Patient 7 had been discharged on December 26, 2022. A review of Patient 7’s physician’s admission order dated December 13, 2022, indicated, “MSW [Medical Social Worker] to evaluate.” A review of Patient 7’s MSW visit notes from December 13, 2022, to December 26, 2022, (Patient 7’s discharge date) was conducted. There was no documented evidence to show the MSW conducted an initial evaluation of Patient 7. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 4:15 PM, the Admin/DPCS stated the MSW evaluation was not done and should have been. A review of the agency’s policy and procedure titled, “Initial Assessments/Comprehensive Assessments,” dated March 2018, indicated, “Completion of the Comprehensive Assessment: Must be completed in a timely manner consistent with the patient's needs, but no later than five (5) calendar days after the start of care.”

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 interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of seven sampled patients (Patients 1, 2, and 3) when: 1. For Patient 1: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated the wrong dosing frequency for one medication (Hydrocodone Bitartrate/Acetaminophen-NORCO-a pain medication) and one medication (Meloxicam-a pain and anti-inflammatory medication) indicated on the MP, Patient 1 was not taking. 2. For Patient 2: the MP indicated the wrong dosing frequency for one medication (atenolol-a blood pressure lowering medication) and one medication (methocarbamol-a muscle relaxant) indicated on the MP, Patient 2 was not taking. 3. For Patient 3: the MP indicated the wrong dose for one medication (Levemir-insulin-to lower blood sugar). This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy for Patients 1, 2, and 3. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 12, 2022, with a recertification period of January 7, 2023 to March 7, 2023. Patient 1 had diagnoses that included unspecified wound to the left foot. During a home visit on February 7, 2023, with Licensed Vocational Nurse (LVN 1) and in the presence of Patient 1, an observation of Patient 1’s actual medication bottles available in the home were compared with Patient 1’s most current Medication Profile (MP). During a concurrent observation and interview on February 7, 2023, at 9:46 AM, with LVN 1 and Patient 1, a bottle indicated Hydrocodone Bitartrate/Acetaminophen (NORCO-a pain medication) 5 (five) mg (milligrams-a unit if measurement)-325 mg tablet, oral, 1 (one)-tablet 2 (two) times daily. Maximum dose 2 (two) tablets. Patient 1’s MP indicated Hydrocodone Bitartrate/Acetaminophen 5mg-325mg tablet, oral, 1-tablet 3 times daily as needed for pain. Patient 1 stated she had been taking four tablets of NORCO a day and the doctor had weaned her down to two tablets a day. Patient 1 stated she had been taking two tablets for the past four months. Patient 1 stated she had told the nurse she was taking two tablets. LVN 1 confirmed that the bottle indicated two tablets a day and the medication profile indicated 3 tablets a day. During a concurrent observation and interview on February 7, 2023, at 9:57 AM, with LVN 1 and Patient 1, The MP indicated Meloxicam (a pain and anti-inflammatory medication) 15 mg tablet oral 1 (one) tablet daily as needed for pain. Patient 1 stated she never took this medication even upon admission to the home health agency. LVN 1 verified the meloxicam was on the medication profile and that Patient 1 had stated she had never taken the medication. LVN 1 stated the visiting LVN would verbally ask if there were any changes to the patient's medications as each visit and then update the medication profile accordingly. LVN 1 stated LVNs did not perform medication reconciliation, "The RNs [Registered Nurses] do it at recert. [recertification assessment]." During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 7, 2023, at 11:21 AM, the Admin/DPCS stated her expectation was that the LVNs would asked about changes or updates to the patients medications and perform medication reconciliation at least once a week. The Admin/DPCS stated this did not happen for Patient 1 because the NORCO and Meloxicam orders on the medication profile were incorrect. 2. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 16, 2023, with a certification period of January 16, 2023 to March 16, 2023. Patient 2 had diagnoses that included intervertebral disc degeneration (a breakdown of one or more of the discs of the spine). During a home visit on February 7, 2023, with a Physical Therapy Assistant (PTA 1) and in the presence of Patient 2, an observation of Patient 2’s actual medication bottles available in the home were compared with Patient 2’s most current Medication Profile (MP). During a concurrent observation and interview on February 7, 2023, at 4:01 PM, with Patient 2, a bottle indicated atenolol (a blood pressure lowering medication) 25 mg tablet, take two tablets by mouth every morning and one tablet every evening. The MP indicated atenolol 25 mg tablet, take two tablets by mouth every morning. Patient 2 stated she had been taking the atenolol as directed on the bottle upon admission to the agency. The MP indicated methocarbamol (a muscle relaxant) 500 mg oral, tablet, take 1 (one) tablet 2 (two) times daily for pain. Patient 2 stated she had the medication but never took it and never intended to take it. Patient 2 stated she told the admitting nurse she was not going to take the medication. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 10:09 AM, the Admin/DPCS stated a medication reconciliation should have been done once per week by the visiting LVN so the errors could have been picked up and corrected. 3. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 18, 2022, with a recertification period of January 17, 2023 to March 17, 2023. Patient 3 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). During a home visit on February 8, 2023, with Licensed Vocational Nurse (LVN 2) and in the presence of Patient 3’s daughter, an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current Medication Profile (MP). During a concurrent observation and interview on February 8, 2023, at 1:42 PM, with LVN 2 and Patient 3’s daughter, LVN 2 conducted a medication reconciliation with Patient 3’s medications. The MP indicated Levemir (insulin-to lower blood sugar) 100 units (units-a unit of measurement)/ml (milliliters-a unit of measurement) solution for injection, subcutaneous (under the skin), 40 units every afternoon. The pharmacy label on the package of Levemir indicated 42 units every afternoon. LVN 2 did not compare the pharmacy label on the insulin box with the MP and missed that the dose had changed from 40 units to 42 units every afternoon. LVN 2 stated she should have checked the pharmacy label against the med profile and did not. Patient 3’s daughter stated she did not remember when the dose had changed but the Levemir had been refilled two months ago. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 3:49 PM, the Admin/DPCS stated during medication reconciliation all the bottles and boxes with pharmacy labels need to be compared against the medication profile and the family member and/or patient needed to be involved to see if anything has changed or if they are having any difficulties. A review of the agency’s policy and procedure titled, “Medication Reconciliation,” dated March 2018, indicated, “POLICY: The Agency will reconcile patient's medications at time of admission and on an ongoing basis 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. …PROCEDURE: At time of admission, the admitting RN [Registered Nurse], PT [Physical Therapist], or SLP [Speech Language Pathologist] will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Any concerns or discrepancies will be reconciled by a RN with the patient's physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information. The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by Agency staff and staff acting on behalf of the Agency. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated. …”

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 interview and record review the agency failed to ensure an individualized plan of care was developed within five days and reviewed, approved, and signed by a physician within 30 days of the patient’s start of care for three of seven sampled patients (Patients 3, 6 and 7) when: 1. For Patient 3, Certified Home Health Aide (CHHA) services were not care planned and there was no frequency of visits to provide CHHA services. 2. For Patient 6, the care plan was not completed within five days of the patient’s start of care because it did not include: the Skilled Nursing (SN) visit frequencies, the Physical Therapy (PT) and Occupational Therapy (OT) evaluations, Patient 6’s intravenous (IV) antibiotic and interventions for the admitting diagnosis. 3. For Patient 7, the plan of care was not reviewed, approved, and signed by a physician within 30 days of the patient’s start of care. This failure caused the agency to provide care that was not care planned or approved by a physician. 1. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 18, 2022, with a recertification period of January 17, 2023 to March 17, 2023. Patient 3 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 3’s recertification assessment dated January 12, 2023, did not indicate CHHA services. A review of Patient 3’s CHHA’s assignment sheet, dated January 17, 2023, indicated the Skilled Nurse (SN) was to provide the following CHHA services one time a week for nine weeks: Bath-Tub/Shower, Personal Care, Assist with Dressing, Hair Care-Brush/Shampoo/Other, Skin Care/Foot Care (Hygiene). A review of Patient 3’s care plan/physician’s order dated January 17, 2023 to March 17, 2023, was conducted. There was no documented evidence to show a visit frequency to provide CHHA services or that CHHA services would be provided. A review of Patient 3’s physician orders from January 17, 2023 to February 8, 2023, was conducted. There was no documented evidence to show a physician’s order with a visit frequency to provide CHHA services or that CHHA services would be provided. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 11:52 AM, the Admin/DPCS stated the agency did not have any CHHA staff at this time. The Admin/DPCS stated she was actively working on hiring CHHA staff. The Admin/DPCS stated the Licensed Vocational Nurses were covering the CHHA services until she could hire CHHA staff. The Admin/DPCS verified the CHHA services were not care planned for Patient 3 and there was no physician’s order with a visit frequency to provide CHHA services or that CHHA services were to be provided. 2. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 13, 2023, with a certification period of January 13, 2023, to March 13, 2023. Patient 6 had diagnoses that included hepatic failure (loss of liver function). Patient 6 was discharged on January 18, 2023. A review of Patient 6’s referral order dated January 9, 2023, indicated, “Home with home health [and] PT [physical therapy]/OT [occupational therapy].” A review of Patient 6’s admission order dated January 13, 2023, indicated, “Admit to home health care services 47-year-old male s/p [status post] hospitalization due to late liver disease. Patient denies any pain. Family will need teaching on how to administer antibiotics as they will be responsible for administering every 12 hours for 6 [six] weeks. …PMH [prior medical history]: liver cirrhosis…Current Medication: …vancomycin [antibiotic] 1 [one].25 GM [grams-a unit of measurement] Injection Administered through IV [intravenous-through vein] 1.25 gm/NS [normal saline] 263 mL [milliliters-a unit of measurement] over 90 minutes Q [every] 12 hours. …Skin: Double lumen [two connections] PICC [peripherally inserted central catheter] line right upper medial [middle] arm…Extremities [arms and legs]: hand grasp equal bilaterally [both] weak, flexion and extension to bilateral lower extremity weak, patient has difficulty standing for long duration of time bilateral lower extremities are weak, ambulates with 2ww [wheeled walker] and standby assistance. …[Diagnosis] Hepatic failure… RN [Registered Nurse] 1w9 [one time a week for nine weeks] RN to administer and instruct family on daily administration of Vancomycin 1.25GM (grams- a unit of measurement)/NS (normal saline) 263 ml over 90 minutes every 12 hours x [times] 6 [six]weeks. Flush PICC (peripherally inserted central catheter) line with normal saline 10 ml (milliliter-a unit of measurement) before and after infusion, heparin [a blood thinning medication] 100units/ [in one] ml, 5 [five] ml after each use. RN to perform PICC line care weekly and as needed for soiling and loss of dressing integrity via sterile technique per home health agency policy and procedure. Once weekly lab [laboratory] draws for CBC [complete blood count], CMP comprehensive metabolic panel], Vancomycin Trough [measures drug levels during treatment] (before dose) …” A review of Patient 6’s plan of care dated January 13, 2023, to March 13, 2023, was conducted. There was no documented evidence to show Skilled Nursing (SN) visit frequencies, Physical Therapy (PT) and Occupational Therapy (OT) evaluations, Patient 6’s intravenous (IV) antibiotic and interventions for the admitting diagnosis had been care planned. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 12:29 PM, the Admin/DPCS stated she was responsible for creating Patient 6’s care plan. The Admin/DPCS stated the care plan was incomplete because she did not have a chance to finish it. 3. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022, to February 10, 2023. Patient 7 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). Patient 7 was discharged on December 26, 2022. A review of Patient 7’s plan of care/physician’s order dated December 13, 2022, to February 10, 2023, was conducted on February 6, 2023. There was no documented evidence to show the physician had reviewed and signed the plan of care. (Thirty-nine working days had passed without a physician’s review and signature). During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 3:30 PM, the Admin/DPCS stated the care plan/physician’s order was supposed to be reviewed and signed by the physician within 30 days and it was not. A review of the agency’s policy and procedure titled, “Plan of Care - … and Physician Orders,” dated March 2018, indicated, “POLICY: Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long-range needs and resources. Each Plan of Care must be signed and dated by the physician. Stamped physician signatures on orders, treatments or other documents that are part of the patient's record are not accepted. The Agency will provide the patient and caregiver with written instructions related to the plan of care. PROCEDURE: Patients are accepted for treatment on the reasonable expectation that Agency can meet the patient's medical, nursing, rehabilitative and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. 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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. … Physician services will be provided by a licensed Doctor of Medicine, Osteopathy or Podiatry and include: …Developing and/or authorizing the Plan of Care. …Submitting signed orders for Plan of Care and changes in accordance with required time frames. …” A review of the agency’s policy and procedure titled, “Orders for Medication and Treatment,” dated February 1, 2019, indicated, “(a) No medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient's attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. …”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure verbal orders were signed, within 30 working days, for one of seven sampled patients (Patient 7). This failure resulted in Patient 7 receiving services and procedures not authorized and approved by a physician. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022, to February 10, 2023. Patient 7 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 7’s verbal physician orders on February 6, 2023, was conducted. There was no documented evidence to show the following verbal physician orders had been signed by a physician: a. Admission order dated December 13, 2022. (Thirty-nine working days had passed without a physician’s signature) b. Occupational Therapy (OT) evaluation and verbal order dated December 14, 2022, with recommended visit frequencies of one time a week for one week and two times a week for three weeks. (Thirty-eight working days had passed without a physician’s signature) c. Physical Therapy (PT) evaluation and verbal order dated December 15, 2022, with recommended visit frequencies of one time a week for one week and two times a week for four weeks. (Thirty-seven working days had passed without a physician’s signature) d. Discharge/Transfer to hospital order dated December 26, 2022. (Thirty working days had passed without a physician’s signature) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 6, 2023, at 4:15 PM, the Admin/DPCS verified the verbal physician’s orders had not been signed by the physician within 30 working days and should have been. A review of the agency’s policy and procedure titled, “Orders for Medication and Treatment,” dated February 1, 2019, indicated, “(a) No medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient's attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. …”

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 interview and record review, the agency failed to measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services, and operations, for the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, dated 2021 to 2022, was conducted. The QAPI binder contained data collection on patient infections but no other quality indicators. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 1:34 PM, the Admin/DPCS stated she was responsible for the QAPI Program. The Admin/DPCS stated the only quality indicator tracked in 2021 and 2022, was patient infections. The Admin/DPCS stated she was not aware of the extensiveness and scope of the requirement for indicator tracking. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated March 2018, indicated, “POLICY: The Agency will establish an ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program. Procedure: … Data collection must include: High risk processes: patients are placed at risk of serious consequences or deprived of care if care is not provided correctly, not provided when indicated or provided when not indicated. High volume processes: care/service/process occurs frequently or affects large numbers of patients/staff. Problem prone processes: care/service/process tends to produce problems for patients or staff. Data collection asks these questions in prioritizing process: Is process, function, or service consistent with the Agency's mission, vision, and plans? Has Agency listened to customers' and staff’s ideas about a well-designed process, function, or service? What industry information is available to assist Agency in decision making and comparative analysis? Data collection includes developing indicators for each major function or process determined to be improved. Data collection will be ongoing, and frequency will be determined by the process improvement activity and the QAPI committee. Sources of information from which data may be collected include (but are not limited to): Measures derived from OASIS data (when applicable), Adverse event reports, Home visits, Patient medical records, Patient/caregiver interviews, Staff interviews, Policies/procedures, Incident reports, Medication profiles, On-call logs, Supervisory visit observation, Peer review, Patient perception of care surveys, Recommendations from federal, state and accreditation surveys and other regulatory agencies.”

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services. In addition, the agency’s Governing Body (GB) failed to approve the frequency and detail of the Quality Assessment Performance Improvement (QAPI) program’s data collection, from the 2021 and 2022 years reviewed, in a universe of 35 patients. This failure had the potential for the agency to miss statistically significant data from OASIS reports and fail to identify patient population trends. In addition, the GB may miss an opportunity to correct ineffective data collection. A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, dated 2021 to 2022, was conducted. The QAPI binder contained data collection on patient infections but no other quality indicators. The QAPI binder did not contain documented evidence to show a quality indicator had been chosen from the following OASIS reports: Home Health Compare, Outcome-Bases Quality Monitoring (OBQM) Potentially Avoidable Events Report and Patient Listing, Outcome-Based Quality Improvement (OBQI) Outcome Report, Patient/Agency Characteristics Report, Submission Statistics by Agency Report, or the Error Summary Report by Home Health Agency. A review of the agency's "Governing Body Minutes," binder, undated, was conducted. There was no documented evidence to show the Governing Body (GB) approved the frequency and detail of the QAPI program’s data collection. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 1:49 PM, the Admin/DPCS stated she was responsible for the QAPI Program. The Admin/DPCS stated the only quality indicator tracked in 2021 and 2022, was patient infections. The Admin/DPCS stated she had not chosen a quality indicator to track from the OASIS reports. The Admin/DPCS stated she was a member of the GB and could not show the GB had approved the frequency and detail of the QAPI program’s data collection. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated March 2018, indicated, “PROGRAM SCOPE: … The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. …The frequency and detail of the data collection must be approved by the Governing Body. …PROCEDURE: … Sources of information from which data may be collected include (but are not limited to): Measures derived from OASIS data (when applicable). … The Agency will collect data about: … Adverse Event Outcome data, Outcome Based Quality Improvement data, Home Health Compare Data. …A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee. The reports are forwarded to the Governing Body. Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement. … USE OF OASIS DATA: The Home Health Agency utilizes the following OASIS reports: Home Health Compare, Outcome-Bases Quality Monitoring (OBQM) Potentially Avoidable Events Report and Patient Listing, Outcome-Based Quality Improvement (OBQI) Outcome Report, Patient/Agency Characteristics Report, Submission Statistics by Agency Report, Error Summary Report by Home Health Agency. Quality Assessment and Performance Improvement (QAPI) activities include obtaining and systematically analyzing OASIS reports to: Collect and trend data to monitor performance, recognize statistically significant data, identify patient population trends, establish criteria for focused review, Identify and reduce risk.”

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 interview and record review, the agency’s Governing Body (GB) failed to provide oversight for its Quality Assessment and Performance Improvement (QAPI) Program for the 2021 and 2022 years reviewed, in a universe of 35 patients when: 1. The Governing Body failed to oversee the QAPI Program to ensure the measurement and analysis of quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services, and operations. 2. The Governing Body failed to oversee the QAPI Program to ensure the use of quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services. In addition, the agency’s Governing Body (GB) failed to approve the frequency and detail of the Quality Assessment Performance Improvement (QAPI) program’s data collection. This failure had the potential to cause the agency to provide inferior care and services to its patients. 1. A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, dated 2021 to 2022, was conducted. The QAPI binder contained data collection on patient infections but no other quality indicators. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 1:34 PM, the Admin/DPCS stated she was responsible for the QAPI Program. The Admin/DPCS stated the only quality indicator tracked in 2021 and 2022, was patient infections. The Admin/DPCS stated she was not aware of the extensiveness and scope of the requirement for indicator tracking. 2. A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder, dated 2021 to 2022, was conducted. The QAPI binder contained data collection on patient infections but no other quality indicators. The QAPI binder did not contain documented evidence to show a quality indicator had been chosen from the following OASIS reports: Home Health Compare, Outcome-Bases Quality Monitoring (OBQM) Potentially Avoidable Events Report and Patient Listing, Outcome-Based Quality Improvement (OBQI) Outcome Report, Patient/Agency Characteristics Report, Submission Statistics by Agency Report, or the Error Summary Report by Home Health Agency. A review of the agency's "Governing Body Minutes," binder, undated, was conducted. There was no documented evidence to show the Governing Body (GB) approved the frequency and detail of the QAPI program’s data collection. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 9, 2023, at 1:49 PM, the Admin/DPCS stated she was responsible for the QAPI Program. The Admin/DPCS stated the only quality indicator tracked in 2021 and 2022, was patient infections. The Admin/DPCS stated she had not chosen a quality indicator to track from the OASIS reports. The Admin/DPCS stated she was a member of the GB and could not show the GB had approved the frequency and detail of the QAPI program’s data collection. A review of the agency's "Governing Body Minutes," binder, undated, was conducted for the years 2021 and 2022. There was no documented evidence to show the Governing Body (GB) had received a written report from the QAPI Coordinator that included a summary of all activities included as part of the QAPI Plan. There was no documented evidence to show the QAPI Coordinator had provided the detail and frequency of data collection to the GB for review and approval. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), on February 9, 2023, at 2 PM, the Admin/DPCS stated she had not provided the GB a written report that included a summary of all activities included as part of the QAPI Plan or provided the detail and frequency of data collection for the years 2021 and 2022, to the GB for review and approval. The Admin/DPCS stated she was a member of the GB. The Admin/DPCS stated the GB had not identified the QAPI committee’s failure to measure and analyze data in order to assess the agency’s processes of care, services, and operations, or chose a quality indicator from OASIS reports for the years 2021 and 2022. The Admin/DPCS stated the GB had not approved the frequency and detail of the QAPI program’s data collection for the years 2021 and 2022. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated March 2018, indicated, “POLICY: The Agency will establish an ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program. PROGRAM SCOPE: … The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. …The frequency and detail of the data collection must be approved by the Governing Body. … RESPONSIBILITY/ACCOUNTABILITY: The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented, and maintained. The Governing Body must ensure that the program reflects: The complexity of its organization and services. Involves all Agency 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. The Governing Body takes actions that address the Agency's performance across the spectrum of care, including the prevention and reduction of medical errors. Addresses priorities for improved quality of care and patient safety. Ensures that all improvement actions are evaluated for effectiveness. Addresses any findings of fraud or waste. Administrative responsibility for the QAPI plan is delegated to the Administrator/Director of Clinical Services, who, in tum, assigns certain QAPI activities to other staff members. The Administrator/Director of Clinical Services will be responsible for: ensuring adequate resources are available, assigning adequate number of staff, allowing staff sufficient time to participate in QAPI activities and instituting appropriate information systems (manual and/or computer) for collecting and analyzing data. The Administrator/Director of Clinical Services is responsible for assigning staff to the QAPI committee. The QAPI committee will be responsible for coordinating all QAPI activities, reviewing collection of data, analyzing data, assisting staff in developing improvement activities, planning actions, collecting data, and analyzing the effectiveness of action and implementing effective actions. The QAPI committee will meet on a regular basis and will report findings to the Administrator/ Director of Clinical Services, who, in turn, will report to the Governing Body. Results will also be communicated by the QAPI committee to staff, including contract staff.” PROCEDURE: … Data collection must include: High risk processes: patients are placed at risk of serious consequences or deprived of care if care is not provided correctly, not provided when indicated or provided when not indicated. High volume processes: care/service/process occurs frequently or affects large numbers of patients/staff. Problem prone processes: care/service/process tends to produce problems for patients or staff. Data collection asks these questions in prioritizing process: Is process, function, or service consistent with the Agency's mission, vision, and plans? Has Agency listened to customers' and staff’s ideas about a well-designed process, function, or service? What industry information is available to assist Agency in decision making and comparative analysis? Data collection includes developing indicators for each major function or process determined to be improved. Data collection will be ongoing, and frequency will be determined by the process improvement activity and the QAPI committee. Sources of information from which data may be collected include (but are not limited to): Measures derived from OASIS data (when applicable), Adverse event reports, Home visits, Patient medical records, Patient/caregiver interviews, Staff interviews, Policies/procedures, Incident reports, Medication profiles, On-call logs, Supervisory visit observation, Peer review, Patient perception of care surveys, Recommendations from federal, state and accreditation surveys and other regulatory agencies.…A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee. The reports are forwarded to the Governing Body. Failure to achieve expected levels of performance will be documented and an explanation delineated to identify opportunities for improvement. … USE OF OASIS DATA: The Home Health Agency utilizes the following OASIS reports: Home Health Compare, Outcome-Bases Quality Monitoring (OBQM) Potentially Avoidable Events Report and Patient Listing, Outcome-Based Quality Improvement (OBQI) Outcome Report, Patient/Agency Characteristics Report, Submission Statistics by Agency Report, Error Summary Report by Home Health Agency. Quality Assessment and Performance Improvement (QAPI) activities include obtaining and systematically analyzing OASIS reports to: Collect and trend data to monitor performance, recognize statistically significant data, identify patient population trends, establish criteria for focused review, Identify and reduce risk.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its staff followed the agency’s policy and procedure and professionally accepted infection control practices for one of seven sampled patients (Patient 2) when a Physical Therapy Assistant (PTA 1) did not follow clean bag technique (a set of procedures to follow to prevent the healthcare worker's bag from contaminating a patient’s home or becoming contaminated itself) when obtaining Patient 2’s vital sign readings (vital sign readings routinely monitored by medical professionals and health care providers include the following: heart rate and blood pressure). This failure had the potential to cause spread of infection and disease amongst the agency’s patients. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 16, 2023, with a certification period of January 16, 2023 to March 16, 2023. Patient 2 had diagnoses that included intervertebral disc degeneration (a breakdown of one or more of the discs of the spine). During a home visit and on February 7, 2023, at 3:12 PM with a Physical Therapy Assistant (PTA 1). PTA 1 entered Patient 2’s home, greeted Patient 2 and placed her medical bag on Patient 2’s kitchen floor without placing a barrier between the bag and the floor. PTA 1 directed Patient 2 to sit down in a recliner in the living room so PTA 1 could take her vital signs. PTA 1 then took a hold of the strap of her medical bag and drug it along the floor to the recliner to retrieve her supplies. During an interview with PTA 1 on February 7, 2023, at 4:22 PM, PTA 1 stated she did not know about clean bag technique. PTA 1 stated she did not know about putting a barrier between her bag and the surfaces in a patient's home. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 10:09 AM, the Admin/DPCS stated all contracted services were provided the agency’s policies and procedures and were required to follow them when caring for the agency’s patients. The Admin/DPCS stated PTA 1 should have followed the agency’s policy and procedure titled, “Bag Technique,” dated June 2018, and did not. A review of the agency’s policy and procedure titled, “Bag Technique,” dated June 2018, indicated, “PURPOSE: To prevent contamination of the nursing bag. To prevent cross-contamination and spread of infectious organisms. …EQUIPMENT: Nursing bag with impermeable lining, Paper towels, Fresh newspapers or other suitable barrier, Leak-proof and puncture-proof container for bag storage in the car, Liquid soap (bar soap can be a haven for bacteria) (Note: antiseptic hand cleanser may be used instead of liquid soap) and plastic trash bag. PROCEDURE: …The inside of the nursing bag should be regarded and maintained as a clean area. Transport the nursing bag in the car on top of a supply of fresh newspapers. In addition, the bag should be stored in a clean area of the car, preferably in a plastic or cardboard container designated for such use. Once in the patient's home, select the cleanest and most convenient work area and spread the newspaper. Place the bag on the newspaper. …”

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure Certified Home Health Aide (CHHA) service needs were reassessed and additional CHHA visits requested, from the physician, for one of seven sampled patients (Patient 3) when Patient 3’s family was struggling with helping Patient 3 with her activities of daily living (ADLs- activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). This failure resulted in increased levels of Patient 3’s family’s stress and exhaustion due to caring for Patient 3’s needs and their own. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 18, 2022, with a recertification period of January 17, 2023 to March 17, 2023. Patient 3 had diagnoses that included Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). During a home visit with Patient 3 and Patient 3’s family member on February 8, 2023, at 2:13 PM, Patient 3’s family member stated the responsibilities for caring for Patient 3 fell to her. Patient 3’s family member stated Patient 3 required assistance every morning and evening in getting out of bed, cleaned, dressed and toileted and then provided breakfast and/or dinner. Patient 3’s family member stated the times Patient 3 needed her help coincided with the times her children needed her help especially with all the extracurricular after school activities. Patient 3’s family member stated it was overwhelming. Patient 3’s family member stated the agency had not discussed CHHA services with her and it was a visiting Physical Therapist (PT) that told her the agency could bathe Patient 3. Patient 3’s family member stated a nurse from the agency bathed Patient 3 once per week, “I didn’t know they could help me more than that.” A review of Patient 3’s recertification assessment dated January 12, 2023, conducted by the Administrator/Director of Patient Care Services (Admin/DPCS), did not indicate CHHA services. A review of Patient 3’s CHHA’s assignment sheet, dated January 17, 2023, indicated the Skilled Nurse (SN) was to provide the following CHHA services one time a week for nine weeks: Bath-Tub/Shower, Personal Care, Assist with Dressing, Hair Care-Brush/Shampoo/Other, Skin Care/Foot Care (Hygiene). A review of Patient 3’s care plan/physician’s order dated January 17, 2023 to March 17, 2023, was conducted. There was no documented evidence to show a visit frequency to provide CHHA services or that CHHA services would be provided. A review of Patient 3’s physician orders from January 17, 2023 to February 8, 2023, was conducted. There was no documented evidence to show a physician’s order with a visit frequency to provide CHHA services or that CHHA services would be provided. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 8, 2023, at 3:49 PM, the Admin/DPCS stated the agency did not have any CHHA staff at this time. The Admin/DPCS stated she was actively working on hiring CHHA staff and the Licensed Vocational Nurses were covering the CHHA services until she could hire CHHA staff. The Admin/DPCS verified the CHHA services were not care planned for Patient 3 and there was no physician’s order with a visit frequency to provide CHHA services or that CHHA services were to be provided. The Admin/DPCS stated she had conducted Patient 3's recertification assessment but the family's needs were not clear enough to her to increase the SN visits with CHHA services to help relieve the family's pressure. The Admin/DPCS stated she had provided the family with phone numbers to private caregivers so they could hire additional help to care for Patient 3. A policy and procedure for updates to the comprehensive assessment was not provided.