Every finding on record at A&E Home Care LLC

Based on the findings of an unannounced onsite Home Health Agency Medicare Re-Recertification Survey conducted on March 16, 18 and 19, 2026 and offsite on March 17 and 20, 2026, A&E Home Care LLC was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

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 a review of the Emergency Preparedness Program documents provided by the agency, and an interview with the administrator, the agency failed to provide evidence that the emergency preparedness plan was tested annually. Findings include: A review of the hospice emergency preparedness testing was conducted on 3/19/2026 at 1 pm and revealed the following: Agency fail to provide any evidence that exercises to test the emergency preparedness plan was conducted in 2024. A tabletop emergency preparedness exercise was conducted on 10/14/2025; however, there was no after-action analysis report regarding exercise. An interview conducted with the administrator on 3/19/2026 at approximately 2 pm confirmed the above findings.

Based on the findings of an unannounced onsite Home Health Agency Medicare Re-Certification Survey conducted on March 16, 18 and 19, 2026 and offsite on March 17 and 20, 2026, A&E Home Care LLC was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR) and policies, and an interview with the administrator, the agency failed to complete a comprehensive assessment that accurately reflect the patient's status including current health, psychosocial, functional, and cognitive status for one (1) of eight (8) CRs reviewed (CR# 5). Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, "Policy No. 002 – Development of Plan of Treatment" reads, "The plan of treatment will be developed in consultation with agency staff and shall cover pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. ... The therapist and other agency personnel shall participate in developing the plan of treatment..." A policy titled, "Policy No. 090– OASIS transmission" reads, "A&E Home Care will conduct comprehensive, patient-specific assessments that contain Outcomes and Assessment Information Set (OASIS) criteria that accurately reflect the patient’s current health status and include information that may be used to demonstrate the clients progress toward achievement of desired outcomes... Each new client will receive a client-specific comprehensive assessment that will identify the client’s continuing need for home care, will support eligibility for payor source criteria, and will facilitate care planning to meet the client’s needs..." A review of CRs was conducted on 3/17/2026 at 10 am, 3/18/2026 starting at 10:30 am and again on 3/19/2026 starting at 10:30 am. The Start of Care (SOC) and CMS-485 Home Health and Certification Period (CP) are shown below. CR#5, SOC: 3/6/2021, contains documentation that patient utilize trach tube/ventilator for breathing and gastrostomy tube for feeding. File contains a re-certification comprehensive assessment completed agency's RN (registered nurse) on 2/7/2026 for CP 2/8/2026 - 4/8/2026. The comprehensive assessment revealed the following: Vital signs were not assessed. Respiratory assessment reads, “Requires suctioning through day, but remains on RA (room air). Tolerates weekly trach changes without difficulty.” This respiratory assessment did not include breath sounds, work of breathing, or secretion characteristics. Gastrointestinal/enteral feeding assessment reads, “12 Fr (French) 2.0 cm Mini Button in place for feedings – tolerates well.” This gastrointestinal assessment did not include gastrointestinal tube site assessment, no skin condition around stoma, no feeding tolerance details. Functional assessment reads, “Remains dependent on others for all care needs d/t (due to) Dx. (diagnosis)” This assessment did not include activity of daily living breakdown, mobility, transfer details. Psychological assessment reads, “CR#5 is a happy, social young boy.” This assessment did not include formal screening of relationships, living environment, or ability to participate in care. Cognitive status was not assessed. An interview with the administrator on 3/20/2026 at 1:33 pm confirmed the above findings.

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 a review of clinical records (CR) and policies, and an interview with the administrator, the agency failed to complete a comprehensive assessment including 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. for one (1) of eight (8) CRs reviewed (CR# 5). Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, "Policy No. 002 – Development of Plan of Treatment" reads, "The plan of treatment will be developed in consultation with agency staff and shall cover pertinent diagnoses, including... medications and treatments... The therapist and other agency personnel shall participate in developing the plan of treatment..." A policy titled, "Policy No. 090– OASIS transmission" reads, "A&E Home Care will conduct comprehensive, patient-specific assessments that contain Outcomes and Assessment Information Set (OASIS) criteria that accurately reflect the patient’s current health status and include information that may be used to demonstrate the clients progress toward achievement of desired outcomes... Each new client will receive a client-specific comprehensive assessment that will identify the client’s continuing need for home care, will support eligibility for payor source criteria, and will facilitate care planning to meet the client’s needs... III. Drug Regimen Review A. Each comprehensive assessment will include a review of all medications the client is currently using. B. The review is done to identify any potential adverse effects and drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy. C. The nurse will notify the client’s physician of any potential adverse effects and drug interactions or ineffective drug therapy..." A review of CRs was conducted on 3/17/2026 at 10 am, 3/18/2026 starting at 10:30 am and again on 3/19/2026 starting at 10:30 am. The Start of Care (SOC) and CMS-485 Home Health and Certification Period (CP) are shown below. CR#5, SOC: 3/6/2021, contains documentation that patient utilize trach tube/ventilator for breathing and gastrostomy tube for feeding. File contains a re-certification comprehensive assessment completed agency's RN (registered nurse) on 2/7/2026 for CP 2/8/2026 - 4/8/2026. The comprehensive assessment revealed the following: Medication review reads, “There have been no changes to CR#5’s medications.” The comprehensive assessment did not include a complete list of all current medications and a review for 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. An interview with the administrator on 3/20/2026 at 1:33 pm confirmed the above findings.

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 clinical home visit observations, a review of agency policies, and an interview with the administrator, the agency failed to follow its policy pertaining to infection control for one (1) of one (1) clinical home visits conducted: CR#1. Findings include: A review of agency policies was conducted on 3/19/2026 at 12 pm and 3/20/2026 at 10:30 am. A policy titled, "Policy No. 018R-Hand Hygiene" reads, " (A) Indications for hand hygiene: ... ix. Before and after utilizing gloves... xi. When moving from a contaminated body site to a clean body site during client care... (F) Gloves Use: ... iii. Gloves should be changed when moving from a contaminated body site to a clean body site..." An off-site video call clinical home visit was conducted on 3/19/2026 from 6 pm to 6:25 pm at the home of CR#1. At around 6:15 pm, agency's LPN (Licensed Practical Nurse) provided GJ (Gastrojejunostomy) tube site care. The nurse removed soiled dressing, cleaned the site, and placed nystatin cream and a new dressing. All took place with one pair of gloves. An interview with the administrator on 3/20/2026 at 12:16 pm confirmed the above findings.

Based on the findings of an unannounced Medicare recertification survey conducted onsite April 25, 2023, April 26, 2023, May 15, 2023, and offsite May 1, 2023, May 12, 2023, May 22, 2023, May 23, 2023, and May 24, 2023, A&E Home Care LLC, was found NOT to be in compliance with the following requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness. As a result of the recertification survey, one (1) condition level deficiency for failing to establish and maintain an emergency preparedness program was cited but did not result in immediate jeopardy.

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: Based on the facility failed to comply with all applicable Federal, State and local emergency preparedness requirements regarding establishing and maintaining a comprehensive emergency preparedness program that meets the requirements of this section. This Condition is not met due to agency's complete non-compliance with the above standards. Findings include: On April 25, 2023 at approximately 1:30 p.m., this surveyor requested the Emergency Preparedness plan and documents. The Assistant Administrator/Owner was, "not able to find it." The facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR, Part 484.22, Subpart B, to include the following standards: 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. 3. Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. 4. Include a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the LTC facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts On May 15, 2023, at approximately 2:10 p.m., this surveyor again requested the Emergency Preparedness plan, and again the plan could not be found. On May 15, 2023, at approximately 2:25 p.m., it was confirmed with the office manager that the agency had no Emergency Preparedness plan.

Based on the findings of an unannounced state relicensure and Medicare recertification survey conducted onsite April 25, 2023, April 26, 2023, May 15, 2023, and offsite May 1, 2023, May 12, 2023, May 22, 2023, May 23, 2023, and May 24, 2023, A & E Home Care LLC, was identified to have the following condition level and standard level deficiencies that were determined to be NOT in substantial compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies. As a result of the recertification survey, two (2) condition level and eleven (11) standard level deficiencies were cited,but did not result in immediate jeopardy.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on Interviews and Clinical Record review, it was determined that the agency failed to meet the Patient's plan of treatment requiring frequency of visits, for one of (1), of four, (4) Clinical Records, (CR), reviewed. (CR #1). Findings include: On April 25, 2023, at approximately 1:00 p.m. a review of a document Titled, "Home Health Certification and Plan of Care," revealed a start of care on November 4, 2019, for CF #1. A continued review revealed a primary diagnosis of Stenosis of the Larynx, (a term used to describe a narrowing of the airway), Bypass Trachea to Cutaneous, (Tracheostomy tube insertion procedure), Bronchopulmonary Dysplasia, (chronic respiratory disease that results from complications related to lung injury during the treatment of infant acute respiratory distress syndrome), and Gastro-Esophageal Reflux, (A chronic digestive disease where the liquid content of the stomach refluxes into the esophagus). A further review revealed that on February 20, 2023 the Physician signed an order for, "Skilled Nursing shift care for services up to 10 hours a day for to perform full system assessment, vital signs, Pulse Oximetrey, at the start of shift and as needed for any variations from the baseline, respiratory distress, or signs of illness." Frequency was of visits not documented on the Plan of Care. On April 26, 2023, at approximately 1:30 p.m., in a telephone interview with the official Administrator (#1), it was revealed that CR #1, "Attends school five, (5), days a week." On April 25, 2023, at approximately 1:15 p.m., a review of computerized documentation of visits revealed that during the certification period from February 16, 2023, through April 16, 2023, the following dates yielded missed visits: Week 1: February 17, 2023 (1 Day). Week 2: February 21, 2023, Through February 24, 2023 (4 Days). Week 3: February 27, 2023, through March 3, 2023, (5 Days). Week 4: March 6, 2023, through March 8, 2023, and March 10, 2023 (4 Days). Week 5: March 12, 2023, through March 15, 2023, and March 17, 2023 (4 Days). Week 6: March 21, 2023, through March 22, 2023, and March 24, 2023, (3 Days). Week 7: March 27, 2023, through March 29, 2023, and March 31, 2023, (4 Days). Week 8: April 3, 2023, through April 7, 2023, (5 Days). Week 9: April 10, 2023, through April 14, 2023, (5 Days). On April 25, 2023, at approximately 1:30 p.m., an examination of the documented clock-ins and clock-outs revealed that the mean number of hours spent during visits were 8 hours a day. A review of this documentation revealed no missed visit note or confirmation that the Physician was notified for each missed visit. There was no missed visit policy. On April 26, 2023, at approximately 3:45 p.m. it was confirmed that multiple visits were missed, there was no missed visit policy, and that the Physician was not informed. The Administrator reported to this surveyor that, 'We have a nursing shortage."

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on review of agency policy, agency documentation, and interview with the agency Administrator, the agency provided home health aide services utilizing direct care workers whose training does not meet home health aide training standards. This condition was not met, but did not result in immediate jeopardy, as evidenced by the following standards: 484.80(a)(1)(i-iv) Qualified Hh Aide Successfully Completes 484.80(b)(2) Minimum Hours of Training 484.80(b)(4) HHA Maintains Documentation of Training 484.80(d) 12 Hours Inservice Every 12 Months 484.80(f)(2) Unqualified HH Aide Providing Services

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on staff interview, employee list, personnel files, and training materials, it was determined that the agency failed to demonstrate that all home health aides, (HHA), successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. for three, (3) of five (5) Personnel Files, (PF), reviewed. (PF #3, 4 and 5). Findings include: On April 15, 2023 at approximately 10:00 a.m., a review of 484.80(b) Standard: Content and duration of home health aide classroom and supervised practical training. G760 (Rev. 182, Issued: 09-28-18, Effective: 09-28-18, Implementation: 09-28-18) §484.80(b)(1), revealed that, " Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. " On April 26, 2023 at approximately 1:45 p.m., a review of agency training documents revealed a document Titled, "Abuse and Neglect." This was a Webinar dated September 2013, through the Office of Public Welfare Office of Long Term Living, Body Mechanics training outline, and Policy No, 0818-"Hand Hygiene." There was no evidence that the DCW's or the HHA's had been trained for a minimum of 75 hours on: Self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes in patient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and recordkeeping. There was no evidence of Laboratory training outside of the classroom. Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base. Defines a Direct Care Worker as, The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no number of hours required for DCW training, and competencies. DCW are used by agencies that do not deliver professional care. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #3, titled, " Direct Care Worker, " (DCW), revealed a date of hire on October 19, 2018. There was no admissible evidence for 12 hours of in-service for year 2020, 2021, and 2022. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #4, titled Direct Care Worker, (DCW), revealed a date of hire on September 1, 2019. There was no documentation that the Direct Care Worker met the above requirements. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #5, titled, " Home Health Aide, " (HHA), revealed a date of hire July 23, 2015. There was no clearly documented evidence the HHA met the above requirements for 75 hours of training from the date of hire. On April 26, 2023 at approximately 3:45 p.m., the Administrator/Owner confirmed that two Direct Care Workers was functioning in the same capacity as Home Health Aides. The Assistant Administrator/Owner and a second identified Administrator asked this surveyor, "what was the difference?"

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on staff interview, employee list, personnel files, and training materials, it was determined that the agency failed to demonstrate that all home health aides, (HHA), had completed a minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours for three, (3) of five (5) Personnel Files, (PF), reviewed. (PF #3, 4 and 5). Findings include: On April 26, 2023 at approximately 1:45 p.m., a review of a document Titled, "Abuse and Neglect," a Webinar dated September 2013, through the Office of Public Welfare Office of Long Term Living, Body Mechanics training outline, and Policy No, 0818-"Hand Hygiene." There was no evidence that the DCW's or the HHA's had been trained for a minimum of 75 hours on: self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes in patient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and recordkeeping. There was no evidence of training outside of the classroom. Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base. Defines a Direct Care Worker as, The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no amount of hours required for DCW training, and competencies. DCW are used agencies that do not deliver professional care. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #3, Direct Care Worker, (DCW), revealed a date of hire on October 19, 2018. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #4, Direct Care Worker, (DCW), revealed a date of hire on September 1, 2019. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #5, Home Health Aide, (HHA), revealed a date of hire on July 23, 2015. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. On April 26, 2023 at approximately 3:45 p.m., the Administrator/Owner confirmed that Direct Care Workers was functioning in the same capacity as Home Health Aides. The Assistant Administrator/Owner and a second identified Administrator asked this surveyor, "what was the difference?"

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on staff interview, employee list, personnel files, and training materials, it was determined that the agency failed to demonstrate that all home health aides, (HHA) had documentation of training that demonstrates the requirements have been met for three, (3) of five (5) Personnel Files, (PF), reviewed. (PF #3, 4 and 5). Findings include: On April 26, 2023 at approximately 1:45 p.m., a review of agency training documents revealed a document Titled, "Abuse and Neglect." This was a Webinar dated September 2013, through the Office of Public Welfare Office of Long Term Living, Body Mechanics training outline, and Policy No, 0818-"Hand Hygiene." There was no evidence that the DCW's or the HHA's had been trained for a minimum of 75 hours on: Self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes in patient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and recordkeeping. There was no evidence of Laboratory training outside of the classroom. Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base. Defines a Direct Care Worker as, The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no amount of hours required for DCW training, and competencies. DCW are used agencies that do not deliver professional care. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #3, Direct Care Worker, (DCW), revealed a date of hire on October 19, 2018. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training preceded by a minimum of l6 hours of supervised practical training as part of the 75 hours of training. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #4, Direct Care Worker, (DCW), revealed a date of hire on September 1, 2019. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training preceded by a minimum of l6 hours of supervised practical training as part of the 75 hours of training. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #5, Home Health Aide, (HHA), revealed a date of hire on July 23, 2015. There was no documentation that the HHA/DCW had completed a minimum of 16 hours of classroom training preceded by a minimum of l6 hours of supervised practical training as part of the 75 hours of training. On April 26, 2023 at approximately 3:45 p.m., the Administrator/Owner confirmed that Direct Care Workers was functioning in the same capacity as Home Health Aides. The Assistant Administrator/Owner and a second identified Administrator asked this surveyor, "what was the difference?"

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on a review of Personnel Files (PF) it was determined that the agency failed to submit assure that home health aides received twelve hours of in-service training during each 12-month period for three, (3) of five (5) Personnel Files, (PF), reviewed. (PF #3, 4 and 5). Findings include: On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #3, Direct Care Worker, (DCW), revealed a date of hire on October 19, 2018. There was no documentation that confirmed that the HHA/DCW had consistently completed twelve hours of in-service training during each 12-month period from 2018 through 2022. On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #4, Direct Care Worker, (DCW), revealed a date of hire on September 1, 2019. There was no documentation that the HHA/DCW had consistently completed twelve hours of in-service training during each 12-month period from 2019 through 2022. On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #5, Home Health Aide, (HHA), revealed a date of hire on July 23, 2015. There was no documentation that the HHA had consistently completed twelve hours of in-service training during each 12-month period from 2015 through 2022. On April 26, 2023, at approximately 3:45 p.m., the Administrator/Owner confirmed that Direct Care Workers was functioning in the same capacity as Home Health Aides. The Assistant Administrator/Owner and a second identified Administrator asked this surveyor, "what was the difference?"

Unqualified HH aide providing services CFR(s): 484.80(f)(2) (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or This ELEMENT is not met as evidenced by: Based on staff interview, employee list, personnel files, and training materials, it was determined that the agency failed to demonstrate that all home health aides, (HHA), successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. for three, (3) of five (5) Personnel Files, (PF), reviewed. (PF #3, 4 and 5). Findings include: On April 15, 2023, at approximately 10:00 a.m., a review of 484.80(b) Standard: Content and duration of home health aide classroom and supervised practical training. G760 (Rev. 182, Issued: 09-28-18, Effective: 09-28-18, Implementation: 09-28-18) §484.80(b)(1), revealed that, " Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. " On April 26, 2023, at approximately 1:45 p.m., a review of agency training documents revealed a document Titled, "Abuse and Neglect." This was a Webinar dated September 2013, through the Office of Public Welfare Office of Long-Term Living, Body Mechanics training outline, and Policy No, 0818-"Hand Hygiene." There was no evidence that the DCW's or the HHA's had been trained for a minimum of 75 hours on: Self-reliance, principles of nutrition and meal preparation, the aging process, and emotional problems of illness, maintaining a clean, healthful, and pleasant environment, changes in patient's condition that should be reported, work of the agency and the health team, ethics and confidentiality, and recordkeeping. There was no evidence of Laboratory training outside of the classroom. Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base. Defines a Direct Care Worker as, The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no number of hours required for DCW training, and competencies. DCW are used by agencies that do not deliver professional care. On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #3, titled, " Direct Care Worker, " (DCW), revealed a date of hire on October 19, 2018. There was no admissible evidence for 12 hours of in-service for year 2020, 2021, and 2022. On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #4, titled Direct Care Worker, (DCW), revealed a date of hire on September 1, 2019. There was no documentation that the Direct Care Worker met the above requirements. On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #5, titled, " Home Health Aide, " (HHA), revealed a date of hire July 23, 2015. There was no clearly documented evidence the HHA met the above requirements for 75 hours of training from the date of hire. On April 26, 2023, at approximately 3:45 p.m., the Administrator/Owner confirmed that two Direct Care Workers was functioning in the same capacity as Home Health Aides. The Assistant Administrator/Owner and a second identified Administrator asked this surveyor, "what was the difference?"

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on a review of home health and home care regulations, personnel files, and an interview with the assistant administrator, the administrator failed to organize and direct the agency's ongoing functions, employ qualified personnel and ensure adequate staff education and evaluations and did not ensure that a qualified person authorized in writing to act in the absence of the administrator. This condition is not met, but did not result in immediate jeopardy, as evidenced by the following standards: 484.105(b)(1) Governing Body 484.105(b)(1)(ii) Responsible for Day to Day Operations 484.105(b)(1)(iii) Ensure that Hha Employs Qualified Personnel 484.105(b)(2) Ensures Qualified Pre-Designated Person

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview with the Assistant Administrator/Owner, organizational chart, observations, Governing Body minutes, the governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program and failed to appoint a qualified alternate administrator. Findings include: On May 1, 2023, approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines an Administrator as: i. A licensed physician. ii. A registered nurse iii. Has training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health care or related health programs. Entry onsite observations of the agency conducted on April 25, 2023, at approximately 11:30 a.m., revealed a person identifying as the "Assistant Administrator/Owner," (later confirmed Licensed Practical Nurse). This was the soul person present at the agency upon the entrance interview and throughout the visit. There was no office personnel present. The Assistant Administrator/Owner reported that, "the official Administrator was sick at the hospital, and unable to answer calls. We are in the process of finding a new Administrator." On 5/24, 2023 a review of On April 26, 2023, between 3:02 and 3:45 p.m., a review of PF #1, (Assistant Administrator/LPN/Owner), revealed a date of hire on November 16, 2016. There was no evidence that PF #1 was currently certified in Cardiopulmonary Resuscitation, (CPR). There was no documented evidence that the LPN's license was current in the file. A license verification was printed from the Pennsylvania State Board of Nursing website, on April 26, 2023, and handed to this surveyor onsite. There was no documented evidence that the LPN, had reviewed a Job Description as an LPN, or an Administrator. There was no evidence that the Assistant Administrator was qualified for the role of an Administrator. A After receiving the Assistant Administrator/LPN/Owner's, (PF#1 ' s), " Resume, " on May 24, 2023, at approximately 11:00 a.m., it revealed no evidence of experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. No evidence was provided that the Assistant Administrator/LPN/Owner was approved by the governing body. There was no evidence that the Assistant Administrator was qualified to function as an Administrator. On May 1, 2023, at 9:37 a.m., this surveyor requested policies for the governing body and any governing body meetings from October 1, 2020, through April 26, 2023, via a telephone call. On May 2, 2023, at approximately 2:00 p.m., the agency submitted two documents: One Titled " Annual Policy Review and Program evaluation /Advisory function, dated August 10, 2021. The second document was Titled," Governing Body-Quarterly Meeting," dated January 29, 2023, without a physician member's presence documented. There was no evidence from August 10, 2021, through December 30, 2022, that quarterly or annual meetings had been conducted by the governing body. There was no evidence of institutional planning, annual policy review, a program evaluation, or Quality assessment and performance improvement (QAPI) tracking. On May 2, 2023, at approximately 2:00 p.m., a document titled, "Policy No. 014 Annual Policy Review," was received via email. It revealed that, "Professional personnel, which includes at least one physician, and one registered nurse will establish and annually review the agency's policies governing scope of services offered, ............" There was no Physician. On April 25, 2023, at approximately 12:45 p.m., the assistant administrator/owner reported that the agency did not have a physician member to conduct the agency annual evaluation, review agency policies governing the scope of services and institutional planning with the governing body/group of professional personnel and that there was no documentation of the evaluation of the agency. On April 26, 2023, at approximately 3:45 p.m. it was confirmed that an Annual Policy review and procedures had not been conducted for calendar year 2022. On May 15, 2023, at approximately 2:00 p.m., upon request the agency produced no evidence that it had a QAPI program that included procedures for measurement and analysis of indicators and addressed the frequency with which such measurement and analysis will occur. The HHA had not maintained a coordinated agency-wide program for the surveillance, investigation, identification, prevention, control, and investigation of infectious and communicable diseases as an integral part of the QAPI program. On April 25, 2023, at approximately 11:45 a.m., this surveyor requested the agency's "Organizational Chart." The Assistant Administrator responded, "We don't have a chart." On April 25, 2023, at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed no "Director of Nursing, (DON)." The Assistant Administrator revealed that the Administrator was also the "Director of Nursing." In an interview conducted on May 19, 2022, with the Administrator/Director of Nurses it was stated that there is no alternate DON. On May 12, 2023, at approximately 2:30 p.m., in a telephone interview conducted with the official Administrator, it was confirmed that the Administrator is also the Director of Nurses, (DON), and there was no appointed alternate DON. While arranging the Departmental home visits, it was revealed that an agency Patient lived 106 miles from the Department's office. When asked about agency's ability to service a Patient living a long distance from the agency office, the Administrator/DON reported that she is lives in the area, and that she is the skilled nurse making home visits for the Patient in question. Regarding the availability to perform the duties of an Administrator/DON for the agency, it was revealed that, "I have never been to the office in Morton Pennsylvania, I have an office here. " I am always available by phone." In considering medical concerns reported by the Assistant manager where she was not accessible for the entrance interview the Administrator/DON stated that, "I fully expect to be able to carry out my duties until the position is filled." On May 15, 2023, at approximately 2:25 p.m., it was confirmed that the agency did not have the qualified staff in place, or documentation to confirm that the governing body was conducting meetings as per the requirements. On May 12, 2023, at approximately 2:30 p.m., it was confirmed in a telephone interview that the Adminstrator/DON lives approximately 106 miles from the agency's office.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on a review of home health and home care regulations, personnel files, and an interview with the assistant administrator, the administrator failed to organize and direct the agency's ongoing functions, employ qualified personnel, ensure adequate staff education, evaluations and did not ensure that a qualified person was authorized in writing to act in the absence of the administrator. Findings include: On May 1, 2023 approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines an Administrator as: i. A licensed physician. ii. A registered nurse iii. Has training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health care or related health programs. Observations of the agency conducted on April 25, 2023 at approximately 11:30 a.m., revealed a person identifying as the "Assistant Administrator/Owner," (later confirmed Licensed Practical Nurse). This was the soul person present at the agency upon the entrance interview and throughout the visit.There was no office personnel present. The Assistant Administrator/Owner reported that, "the official Administrator was sick at the hospital, and unable to answer calls. We are in the process of finding a new Administrator." On May 12, 2023, at approximately 2:30 p.m., in a telephone interview conducted with the official Administrator, it was confirmed that the Administrator is also the Director of Nurses, (DON), and there was no appointed alternate DON. While arranging the Departmental home visits, it was revealed that an agency Patient lived 106 miles from the Department's office. When asked about agency's ability to service a Patient living a long distance from the agency office, the Administrator/DON reported that she is lives in the area, and that she is the skilled nurse making home visits for the Patient in question. Regarding the availability to perform the duties of an Administrator/DON for the agency, it was revealed that, "I have never been to the office in Morton Pennsylvania, I have an office here. " I am always available by phone." In considering medical concerns reported by the Assistant manager where she was not accessible for the entrance interview the Administrator/DON stated that, "I fully expect to be able to carry out my duties until the position is filled." On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #1, (Assistant Administrator/LPN/Owner), revealed a date of hire on November 16, 2016. As an employee at the agency, there was no evidence that PF #1 was currently certified in Cardiopulmonary Resuscitation, (CPR). There was no documented evidence that the LPN's license was current in the file. (A license verification was printed from the Pennsylvania State Board of Nursing website, on April 26, 2023, and handed to this surveyor onsite). There was no documented evidence that the LPN, had reviewed a Job Description as an LPN, or as an Administrator. A later review of the Assistant Administrator/LPN/Owner's, (PF#1), resume on May 24, 2023 at approximately 11:00 a.m., revealed there was no evidence of experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. No evidence was provided that the Assistant Administrator/LPN/Owner was approved by the governing body. There was no evidence that the Assistant Administrator was qualified to function as an Administrator. On April 25, 2023 at approximately 11:45 a.m., this surveyor requested the agency's "Organizational Chart." The Assistant Administrator responded, "We don't have a chart." On April 25, 2023 at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed no "Director of Nursing, (DON)." The Assistant Administrator revealed that the Administrator was also the "Director of Nursing." On May 12, 2023, at approximately 2:30 p.m., in a telephone interview conducted with the official Administrator, it was confirmed that the Administrator is also the Director of Nurses, (DON), and there was no appointed alternate DON. On April 26, 2023, at approximately 3:00 p.m., a review of the Assistant Administrator, and Administrator/DON's personnel files revealed no written Job Description. This surveyor requested a job description for each person's title. This to include the Administrator, Registered Nurse, home health aides, the governing body, ancillary staff, Direct Care Workers, (DCW), as to their relation to Home health Agency duties. The agency submitted Policy No. 005, Titled, "Skilled Nurse Job Description." This document revealed the duties of a Registered Nurse, (RN), and a Licensed Practical Nurse, (LPN), on one page. There were no additional job descriptions or policies submitted. On May 1, 2023 at approximately 2:00 p.m. a review for Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base, defines a Direct Care Worker as, "The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no amount of hours required for DCW training, and competencies. DCW are used agencies that do not deliver professional care. " On May 1, 2023 approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines a Home health Aide, (HHA), as, "A nonprofessional person who has completed a minimum of 60 hours of classroom instruction prior to or during the first 3 months of employment. The term includes aides who are carefully trained in methods of assisting patients to achieve maximum self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, changes in patient ' s condition that should be reported, work of the agency and the health team, ethics, confidentiality and record keeping." HHA's are trained to work under the supervision of professionals in licensed agencies that deliver professional care. A DCW does not meet the criteria for a home health aide. On April 26, 2023 at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed that two employees were titled, "Direct Care Workers." The Assistant Administrator confirmed that two Direct Care Workers were functioning in the same capacity as a Home Health Aide. As per Subpart G. Home Health Care Agencies, section 601.6, the DCW ' s did not meet the requirements for a minimum of 60 hours of training as mandated. On April 26, 2023 at approximately 3:00 p.m., the Assistant Administrator/Owner and an Administrator asked this surveyor, "What was the difference between a DCW, and an HHA?" On May 1, 2023 at 9:37 a.m., this surveyor requested policies for the governing body and any governing body meetings from October 1, 2020 through April 26, 2023, via a telephone call. On May 2, 2023, at approximately 2:00 p.m., the agency submitted two documents: One Titled "Annual Policy Review and Program evaluation /Advisory function, dated August 10, 2021. The second was Titled," Governing Body-Quarterly Meeting," dated January 29, 2023. There was no evidence that Governing Body Meetings were conducted for the year 2022. There was no evidence of institutional planning, annual policy review, or a program evaluation for 2021 and 2022. There was no evidence that a physician member was present. On May 1, 2023 at approximately 2:45 p.m., the Assistant Administrator/Owner confirmed that the "Assistant Administrator," (a Licensed Practical Nurse) was the self appointed to be responsible for day to day operations of the agency in place of the absent Administrator.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on a review of home health and home care regulations, personnel files, and an interview with the assistant administrator, the administrator failed to organize and direct the agency's ongoing functions by not ensuring the agency had appointed an alternate director of nursing. Findings include: Observations of the agency conducted on April 25, 2023 at approximately 11:30 a.m., revealed a person whom identifying as the "Assistant Administrator/Owner," (later confirmed Licensed Practical Nurse). This was the soul person present at the agency upon the entrance interview and throughout the visit. There was no office personnel present. The Assistant Administrator/Owner reported that, "the official Administrator was sick at the hospital, and unable to answer calls. We are in the process of finding a new Administrator." On May 12, 2023, at approximately 2:30 p.m., in a telephone interview conducted with the official Administrator, it was confirmed that the Administrator is also the Director of Nurses, (DON), and there was no appointed alternate DON. While arranging the Departmental home visits, it was revealed that an agency Patient lived 106 miles from the Department's office. When asked about agency's ability to service a Patient living a long distance from the agency office, the Administrator/DON reported that she is lives in the area, and that she is the skilled nurse making home visits for the Patient in question. Regarding the availability to perform the duties of an Administrator/DON for the agency, it was revealed that, "I have never been to the office in Morton Pennsylvania, I have an office here. "I am always available by phone." In considering medical concerns reported by the Assistant manager where she was not accessible for the entrance interview the Administrator/DON stated that, "I fully expect to be able to carry out my duties until the position is filled." On April 25, 2023 at approximately 11:45 a.m., this surveyor requested the agency's "Organizational Chart." The Assistant Administrator responded, "We don't have a chart." On April 25, 2023 at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed no "Director of Nursing, (DON)." The Assistant Administrator revealed that the Administrator was also the "Director of Nursing." In an interview with the Administrator/Director of Nursing, on May 12, 2023 at approximately 3:36 p.m., it was confirmed that there is no alternate Director of Nurses.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of home health and home care regulations, personnel files, and an interview with the assistant administrator, the administrator failed to organize and direct the agency's ongoing functions, employ qualified personnel and ensure adequate staff education and evaluations and did not ensure that a qualified person authorized in writing to act in the absence of the administrator. Findings include: On May 1, 2023 approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines an Administrator as: i. A licensed physician. ii. A registered nurse iii. Has training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health care or related health programs. Observations of the agency conducted on April 25, 2023 at approximately 11:30 a.m., revealed a person whom identifying as the "Assistant Administrator/Owner," (later confirmed Licensed Practical Nurse). This was the soul person present at the agency upon the entrance interview and throughout the visit. There was no office personnel present. The Assistant Administrator/Owner reported that, "the official Administrator was sick at the hospital, and unable to answer calls. We are in the process of finding a new Administrator." On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #1, (Assistant Administrator/LPN/Owner), revealed a date of hire on November 16, 2016. There was no evidence that PF #1 was currently certified in Cardiopulmonary Resuscitation, (CPR). There was no documented evidence that the LPN's license was current in the file. A license verification was printed from the Pennsylvania State Board of Nursing website, on April 26, 2023, and handed to this surveyor onsite. There was no documented evidence that the LPN, had reviewed a Job Description as an LPN, or an Administrator. There was no evidence that the Assistant Adminitrator was qualified for the role of an Adminitrator. A later review of the Assistant Administrator/LPN/Owner's, (PF#1), resume on May 24, 2023 at approximately 11:00 a.m., revealed there was no evidence of experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. No evidence was provided that the Assistant Administrator/LPN/Owner was approved by the governing body. There was no evidence that the Assistant Administrator was qualified to function as an Administrator. On April 25, 2023 at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed no "Director of Nursing, (DON)." The Assistant Administrator revealed that the Administrator was also the "Director of Nursing." On May 12, 2023, at approximately 2:30 p.m., in a telephone interview conducted with the official Administrator, it was confirmed that the Administrator is also the Director of Nurses, (DON), and there was no appointed alternate DON. While arranging the Departmental home visits, it was revealed that an agency Patient lived 106 miles from the Department's office. When asked about agency's ability to service a Patient living a long distance from the agency office, the Administrator/DON reported that she is lives in the area, and that she is the skilled nurse making home visits for the Patient in question. Regarding the availability to perform the duties of an Administrator/DON for the agency, it was revealed that, "I have never been to the office in Morton Pennsylvania, I have an office here. "I am always available by phone." In considering medical concerns reported by the Assistant manager where she was not accessible for the entrance interview the Administrator/DON stated that, "I fully expect to be able to carry out my duties until the position is filled." On April 26, 2023, at approximately 3:00 p.m., a review of the Assistant Administrator, and Administrator/DON's personnel files revealed no written Job Description. This surveyor requested a job description for each person's title. This to include the Administrator, Registered Nurse, home health aides, the governing body, ancillary staff, Direct Care Workers, (DCW), as to their relation to Home health Agency duties. The agency submitted Policy No.005, Titled, "Skilled Nurse Job Description." This document revealed the duties of a Registered Nurse, (RN), and a Licensed Practical Nurse, (LPN), on one page. There were no additional job descriptions or policies submitted. On May 1, 2023 at approximately 2:00 p.m. a review for Title 28. Health And Safety, Part IV. Health Facilities, Subpart H. Home Care Agencies and Home Care Registries, Chapter 611. Home Care Agencies And Home Care Registries, General, §611.1. Legal Base, defines a Direct Care Worker as, "The individual employed by a home care agency or referred by a home care registry to provide home care services to a consumer. There are no amount of hours required for DCW training, and competencies. DCW are used agencies that do not deliver professional care. " On May 1, 2023 approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines a Home health Aide, (HHA), as, "A nonprofessional person who has completed a minimum of 60 hours of classroom instruction prior to or during the first 3 months of employment. The term includes aides who are carefully trained in methods of assisting patients to achieve maximum self-reliance, principles of nutrition and meal preparation, the aging process and emotional problems of illness, changes in patient ' s condition that should be reported, work of the agency and the health team, ethics, confidentiality and record keeping." HHA's are trained to work under the supervision of professionals in licensed agencies that deliver professional care. A DCW does not meet the criteria for a home health aide. Note that federal requirements include 75 hours of training that was also not met. On April 26, 2023 at approximately 12:45 p.m., a review of the document titled, "Active Employee List, " revealed that two employees were titled, "Direct Care Workers." The Assistant Administrator confirmed that two Direct Care Workers were functioning in the same capacity as a Home Health Aide. As per Subpart G. Home Health Care Agencies, section 601.6, the DCW ' s did not meet the requirements for a minimum of 60 hours of training as mandated. On April 26, 2023 at approximately 3:00 p.m., the Assistant Administrator/Owner and an Administrator asked this surveyor, "What was the difference between a DCW, and an HHA?" On April 25, 2023 at approximately 11:45 a.m., this surveyor requested the agency's "Organizational Chart." The Assistant Administrator responded, "We don't have a chart." On May 1, 2023 at approximately 2:45 p.m., the Assistant Administrator confirmed that the "Assistant Administrator," (an LPN) was self appointed to be responsible for the day to day operations of the agency in place of the absent Administrator. On May 12,2023 it was learned that the Administrator/ DON had never been to the office, lives over two hours away, and had no alternate DON.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on a review of personnel files and an interview with the alternate administrator, the administrator did not ensure that when the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. Findings include: Observations of the agency conducted on April 25, 2023 at approximately 11:30 a.m., revealed a person identifying as the "Assistant Administrator/Owner," (a Licensed Practical Nurse). This was the only person present at the agency upon the initial visit. On May 1, 2023 approximately 2:05 p.m., a review of The 28 Pa. Code, Part IV, Health Facilities Subpart G. Chapter 601 defines an Administrator as: i. A licensed physician. ii. A registered nurse iii. Has training and experience in health service administration and at least 1 year of supervisory or administrative experience in home health care or related health programs. On April 26, 2023 between 3:02 and 3:45 p.m., a review of PF #1, (Assistant Administrator/LPN/Owner), revealed a date of hire on November 16, 2016. There was no evidence that PF #1 was currently certified in Cardiopulmonary Resuscitation, (CPR). There was no documented evidence that the LPN's license was current in the file. A license verification was printed from the Pennsylvania State Board of Nursing website, on April 26, 2023, and handed to this surveyor onsite. There was no documented evidence that the LPN, had reviewed a Job Description as an LPN, or an Administrator. There was no evidence that the Assistant Adminitrator was qualified for the role of an Adminitrator. On April 25, 2023 at approximately 11:45 a.m., this surveyor requested the agency's "Organizational Chart." The Assistant Administrator responded, "We don't have a chart."