Every finding on record at Abc Home Health Care Plus LLC

On 5/18/26 to 5/20/26, a survey for compliance with Appendix Z, Emergency Preparedness Requirements, §483.73 was conducted during a standard recertification survey. The facility was in compliance.

On 5/18/26 to 5/20/26, a recertification survey was conducted. This resulted in a partial extended survey at ABC Home Health Care Plus LLC. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 40 Total home visits conducted: 03 Parent Location visited, including the addresses as verified while on site ABC Home Health Care Plus LLC 2817 Anthony Lane South Minneapolis MN 55418 Other branch offices for this agency: None Hours of Operation: 9:00 a.m. to 5:00 p.m. Total number of records reviewed: 07

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to report all Outcome and Assessment Information Sets (OASIS) data collected within 30 days of completion for 88 out of 88 submitted records reviewed from 4/1/25-4/30/26. Findings include: The HHA Error Summary by Agency report period of 4/1/2025-4/30/2026 identified an error code of -3330 [error code 3330 means submitted more than 30 days after completion of the new assessment]. The total number of records submitted beyond the 30 days within that period was 88 out of 88 submissions, which equaled 100% of the submissions submitted. During interview on 5/18/26, at 4:00 p.m. the director of nursing (DON) stated she completed all the patient's Outcome and Assessment Information Sets (OASIS) when they were due to be done. The administrator was responsible to electronically submit the OASIS to the Centers for Medicare and Medicaid Services (CMS) system. When interviewed on 5/19/26, at 1:30 p.m. the administrator stated he had been submitting patient OASIS assessments monthly but then realized he was submitting most of them late, so he then changed to submitting the assessments every two weeks and still was submitting many of the assessments late. The administrator was now trying to train someone to complete the OASIS transmissions and then would be going to one time per week for submitting the assessments. Most of the late submissions were because he was not at the agency daily, as he had other facilities he managed. The agency policy Reporting of Oasis Information, revised October 2017, identified the agency must encode and have the capability of transmitting OASIS data for each patient within thirty days of completing any required OASS date set assessment. The agency would electronically transmit completed, encoded, and locked OASIS data for each completed OASIS assessment at least monthly to the system. The agency would have an alternate plan when it was unable to submit OASIS data to the state agency.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure submitted the Outcome and Assessment Information Sets (OASIS) were accurate and reflected the current status of the patient at the time the OASIS was completed for 2 of 7 patients (P1, P5) whose records were reviewed for OASIS assessments. Findings include: P1: P1's plan of care (POC) 4/20/26 to 6/18/26, identified a start of care (SOC) date 2/19/26. Skilled nurse visits (SNV) were ordered four hours a day for 60 days to perform wound care to multiple wound sites, colostomy care, suprapubic catheter care and prevent further skin breakdown and/or deterioration. Skilled nursing setup medications weekly and was to assess and educate caregivers regarding colostomy care and stoma care, urological care, skin care, catheter care, disease management, and medication management. Diagnoses included paraplegia, aphasia, neuromuscular dysfunction of bladder and stage 4 pressure ulcer. P1's POC 2/2/26 to 4/2/26, identified a SOC date 1/15/19. SNV were ordered three times per week as needed for 60 days, to perform colostomy change and stoma care, assess, identify and prevent symptoms skin breakdown and/or deterioration. Skilled nursing setup medications weekly and was to assess and educate caregivers regarding colostomy care and stoma care, urological care, skin care, disease management, and medication management. Diagnoses included paraplegia, aphasia, neuromuscular dysfunction of bladder and stage 4 pressure ulcer. P1's Hospital Discharge Orders dated 2/18/26, identified P1 had a short-term hospital stay 2/16/26 to 2/18/26, for treatment of a right gluteal pressure wound. The agency was notified on 2/18/26, via fax, of new and/or changed medications, treatment orders and to resume home care services. Numerous Discharge Medications were listed which included amoxicillin-clavulanate (an antibiotic) and doxycycline (an antibiotic). P1's SNV dated 2/19/26, identified a resumption of care SNV was made and Resumption of Care (ROC) Outcome and Assessment Information Sets (OASIS) assessment completed. The section for the date the written or verbal referral for initiation or resumption of care had been received by the agency was incorrectly identified as 8/21/23. The section "High Risk Drug Classes" failed to identify P1 was taking antibiotic medications as required. P5: P5's POC 4/30/26 to 6/28/26, identified a SOC 9/2/25. SNV were ordered two times weekly for 60 days to assess and educate on impaired respiratory system to identify changes and intervene to minimize complications, perform nutrition education to support disease management, and adherence to diet, perform fall risk assessments and training measures to reduce risk for falls, and diabetic teaching. Diagnoses included malignant neoplasm of tongue and mouth, diabetes, hypertension, liver disease, and encounter for gastrointestinal device. P5's Hospital Discharge Orders dated 4/8/26, identified P5 had a hospital stay 3/9/26 to 4/8/26, for treatment of malnutrition, nasogastric tube placement, pain and inability to tolerate oral intake. The agency was notified of new and/or changed medications, treatment orders and to resume home care services. Numerous Discharge Medications were listed which included apixaban (a blood thinner), olanzapine (an antipsychotic), Oxycodone (a narcotic pain medication), and a Fentanyl patch (narcotic pain medication), P5's SNV dated 4/10/26, identified a SNV was made and a SOC OASIS assessment was completed, instead of the required Resumption of Care OASIS assessment. The date the assessment was completed was incorrectly identified as 9/2/25. The assessment was incorrectly documented as being completed for a start of care instead of the required resumption of care after an inpatient stay. The date the agency received written or verbal referral for initiation or resumption of care was incorrectly identified as 9/2/25. The section "High Risk Drug Classes" failed to identify P5 was taking antipsychotic, anticoagulant, and opioid medications as required. During interview on 5/19/26, at 1:30 p.m. the director of nursing (DON) stated a patient's SOC date should not be changed when a resumption of care (ROC) assessment was completed and P1's and P5's assessments were not completed correctly. It was important to have the assessment dates correct on the OASIS assessments to make sure they are in chronological order. Some of the agency issues were related to the computer system was not pulling the assessments in correct order. The agency policy Reporting of OASIS Information, revised October 2017, identified the agency would ensure that the accuracy of OASIS date reflected the patient's status at time of the assessment and data collection.

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 document review, the agency failed to ensure a comprehensive review of all medications taken was completed for 2 of 5 patients (P4, P5) whose medications were reviewed. Findings include: P4: P4's plan of care (POC) 3/13/26 to 5/11/26, identified a start of care (SOC) date 6/2/22. Skilled nurse visits (SNV) were ordered weekly for 60 days for various assessments and evaluation. Diagnoses included diabetes, depression, chronic obstructive pulmonary disease (COPD), heart disease, asthma, post -traumatic stress disorder (PTSD) and chronic pain. The primary care provider's signature for home care orders and review of the POC date 4/17/26, 26 days after the POC's episode of care was completed. Numerous active medications were listed which included bupropion 300 milligrams (mg) every day, Lantus insulin inject 20 units subcutaneously (SQ) two times per day, losartan 100 mg every day, Novolog insulin inject 5 units SQ three times per day and Ozempic pen injector take 2 mg SQ weekly. P4's recertification SNV dated 5/13/26, identified medications were reconciled, pill box was pre-filled and insulin syringes were pre-filled. P4's most recent Medication List from their primary provider visit 5/15/23, listed numerous active medications which included bupropion 150 mg every day, Lantus insulin 30 units SQ two times per day, losartan 50 mg every day, NovoLog insulin 10 units SQ three times per day, sertraline 100 mg every day, and senna S 8.6-50 mg two tablets in the evening as needed. P4's electronic medical record (EMR) was reviewed and lacked physician orders for the dose changes in P4's bupropion, Lantus insulin, losartan, and NovoLog insulin. The EMR also lacked orders when and/or if P4's sertraline and senna had been discontinued and when/if P4 was prescribed Ozempic. P5: P5's POC 4/30/26 to 6/28/26, identified a SOC 9/2/25. SNV were ordered two times weekly for 60 days to assess and educate on impaired respiratory system to identify changes and intervene to minimize complications, perform nutrition education to support disease management, and adherence to diet, perform fall risk assessments and training measures to reduce risk for falls, and diabetic teaching. Diagnoses included malignant neoplasm of tongue and mouth, diabetes, hypertension, liver disease, and encounter for gastrointestinal device. Numerous active medications were listed to be taken via small bowel tube, unless indicated otherwise. P5's medications included betamethasone valerate 0.1% cream apply 1 gram (g) topically two times per day, hydroxyzine 25 mg by mouth every six hours as needed (PRN), Narcan 4% nasal spray on spray into nostril upon symptoms of opioid overdose PRN, pantoprazole 40 mg delayed release tablet every day by mouth, prochlorperazine 10 mg by mouth every six hours PRN. P5's diet was listed as nothing by mouth (NPO). P5's Discharge Medications dated 4/8/26, identified a list of new and modified discharge medications and instructions. This list did not include betamethasone valerate 0.1% cream apply 1 gram (g) topically two times per day, hydroxyzine 25 mg by mouth every six hours as needed (PRN), Narcan 4% nasal spray on spray into nostril upon symptoms of opioid overdose PRN, pantoprazole 40 mg delayed release tablet every day by mouth, prochlorperazine 10 mg by mouth every six hours PRN. P5's diet was listed as nothing by mouth (NPO). The discharge orders also included a list of medications that were to be stopped. This list included betamethasone cream 0.1%, hydroxyzine 25 mg, Narcan 4%, pantoprazole 40 mg enteric coated tablet, and prochlorperazine. During interview on 5/19/26, at 1:30 p.m. the director of nursing (DON) stated the staff follow the labels on the medication bottles and the medication list, as well as what the family reports to them. She had completed the POC for P5 and had been sure to follow the discharge orders and changed the medications from by mouth to the tube. Family did all the tube care, feeding and medications and there had been some changes. There were no physician orders to reflect any medication or treatment changes that had occurred from the discharge summaries to the patient's POC. She would make sure they were done for now on. The agency policy Medication Management, revised October 2017, identified on admission, the admitting nurse would create and document a complete list of medications the patient was taking at home. Any discrepancies would be reconciled by the nurse with the patient's physician. Medication orders while the patient was receiving care would be compared to the medication list/profile. The medication list/profile would be updated with each new or changed medication s and the patient's medication list in the home would also be updated.

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 interview and document review, the agency failed to ensure the patient's plan of care included all required components in the patient's individualized care plans for 3 of 7 patients (P2, P4, P5) whose care plans were reviewed. Findings include: P2 P2's plan of care (POC) 4/10/26 to 6/8/26, identified a start of care (SOC) date 4/20/24. Skilled nurse visits (SNV) were ordered weekly for 60 days for various assessments and evaluation. Diagnoses included hypertension, pain in right shoulder and traumatic subdural hemorrhage. Active medications were listed on P2's POC which included calcium carbonate two times per day. P2's POC listed no known allergies (NKA). P2's Contracting Therapy Referral dated for certification period 6/19/24 to 8/17/24, listed allergies of calcium and duloxetine. P4 P4's POC 1/12/26 to 3/12/26, identified a start of care (SOC) date 6/2/22. SNV were ordered weekly for 60 days for various assessments and evaluation. Diagnoses included diabetes, depression, chronic obstructive pulmonary disease (COPD), heart disease, asthma, post -traumatic stress disorder (PTSD) and chronic pain. P4's POC listed NKA under the allergy section of the POC. P4's undated Admission Checklist for providers, listed a section for Drug Allergies. Handwritten into this section was listed food allergies of shellfish and iodine. P4's Summary of Physician Visit dated 5/15/23, identified a section titled Allergies. Listed in the allergy section were shellfish, iodine and shrimp flavor as active allergies. P5 P5's POC 4/30/26 to 6/28/26, identified a SOC 9/2/25. SNV were ordered two times weekly for 60 days to assess and educate on impaired respiratory system to identify changes and intervene to minimize complications, perform nutrition education to support disease management, and adherence to diet, perform fall risk assessments and training measures to reduce risk for falls, and diabetic teaching. Diagnoses included malignant neoplasm of tongue and mouth, diabetes, hypertension, liver disease, and encounter for gastrointestinal device. P5's POC listed NKA under the allergy section of the POC. P5's diet was documented as nothing by mouth (NPO). Durable medical supplies lacked any information of a nasojejunal (NJ) tube, enteral feeding, flush syringes and graduates. P5's discharge orders dated4/8/26, identified allergies were reviewed on 4/7/26, and included Baclofen, egg, fish containing products and pork products (for religious purposes). P5 had a nasojejunal tube inserted on 3/31/26 with planned duration of 2 months and would need home education and additional follow up for exchanges. When interviewed on 5/20/26, at 1:36 p.m. the director of nursing (DON) stated the agency staff did not do anything with the feeding tube as the family completed all that type of care, but would be important to have it listed on P5's POC to show the complexity of her care, as well as the supplies that were needed. All allergies should be listed on all patient's POC if they had allergies. The agency was having issues with their current computer system not functioning correctly and the system would prefill a lot to the POC sections automatically. It was a problem they were aware of and staff needed to be sure to review all sections of the POC each time they completed a recertification before it was sent to the physician for signature. The agency policy Care Planning Process, revised October 2017, identified the agency would utilize data and information gathered during patient assessments in the care planning process and care world be provided to meet each patient's specific needs and problems.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and document review the agency failed to ensure all patient care orders, were part of the plan of care (POC) for of 1 of 3 patients (P3) reviewed during home visits. Findings include: P3's plan of care (POC) 2/4/26 to 4/4/26, identified a start of care (SOC) date 11/8/19. Skilled nurse visits (SNV) were ordered 16 hours per day for 60 days to assess and evaluate seizure activity, impaired respiratory system, skin, gastrointestinal system, genitourinary system, nutrition, pain and fall risk assessment and educate. Staff were to assist with continuous positive airway pressure (cpap) as needed, nebulizer treatments, vest therapy, suctioning, feeding tube, reposition, and mechanical lift transfers. P3's POC listed numerous medications under active orders with instruction to administer by gastrostomy tube (gtube). Diagnoses included On 5/19/26, from 9:30 a.m. to 10:30 a.m., a home visit was conducted with registered nurse (RN)-B. P3 was lying in a hospital bed wearing a nasal cannula to deliver oxygen in his nose. RN-B was observed administering/pushing medications and water flushes via P3's gtube. The water flushes contained 40 cubic centimeters (CC) of water in a 60-cc syringe. RN-B also performed both tracheostomy and oral suction to assist P3 with secretions and administered nebulizer treatments. RN-B stated she would also assist P3 with vest therapy and filling and administering gtube feeding for nutrition over the course of her shift. RN-B had a medication list she followed and checked off to administer medications. P3's Discharge Narrative Summary dated 3/26/26, identified P3 was hospitalized for fever and an increase in seizures. Discharge orders included instructions to resume home diet of Compleat Peds Original Mild formula with five bolus feedings of 200 milliliters (ml) plus 180 ml free water flushes with each feeding. Suction trach as needed, change every two weeks as needed, clean two times per day. Clean g-tube two times per day and flush with 10 ml with medications. Bronchial drainage/chest physiotherapy vest two times per day, up to four times when ill. Oxygen 0.25 to 2 liters (L) a minute to maintain oxygen saturation greater or equal to 92%. P3's Medication Administration Record (MAR) 5/1/26 to 5/20/26, failed to identify the nutritional enteral feeding amount and administration, water flushes or treatments frequency and amounts of administration such as oxygen, suctioning, enteral feeding rates, or vest therapy. P3's Progress Notes 5/1/26 to 5/19/26, lacked documentation of nutritional enteral feeding amount and administration, water flushes or treatments frequency and amounts of administration such as oxygen, suctioning, enteral feeding rates, or vest therapy. P3's skilled nurse visit notes 5/15/26 to 5/19/26, identified various assessments were completed and documented. Narrative notes identified prescribed medications, treatment and care were administered and suctioning was performed when needed. Feeding and hydration was provided and tolerated. The visits notes lacked documentation of when or how often suctioning was performed and what liter of oxygen was administered. The documentation lacked what kind, amount and delivery of feeding was administered as well as amount and time of water flushes. The same clinical narrative note was documented word for word in each visit notes documentation. "Resident remains stable with all vital signs within normal limits. All prescribed medications, treatments, and care were administered as ordered. The resident was repositioned every two hours, and suctioning was performed as needed. A bed bath was provided. The resident was seated in a chair for 45 minutes. Feeding and hydration were provided and well tolerated." During interview on 5/20/26, at 1:36 p.m. the director of nursing (DON) stated there were orders for P3's g-tube, feedings and water flushes and treatments;however, no documentation was provided. The agency policy Plan of Care-CMS #485 and Physician Orders, revised October 2017, identified all patient care orders, including verbal orders, must be recorded in the plan of care. Care and services would be provided according to physician orders. Orders would be current and updated. Drug, services and treatments were administered by staff only as ordered by physician.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure all services were provided as ordered via the provider and/or ensure the physician was notified when services were not provided as ordered for 3 of 7 patients (P1, P2, P5) reviewed for skilled nursing services. Findings include: P1 P1's plan of care (POC) 4/20/26 to 6/18/26, identified a start of care (SOC) date 2/19/26. Skilled nurse visits (SNV) were ordered four hours a day for 60 days to perform wound care to multiple wound sites, colostomy care, suprapubic catheter care and prevent further skin breakdown and/or deterioration. Skilled nursing setup medications weekly and was to assess and educate caregivers regarding colostomy care and stoma care, urological care, skin care, catheter care, disease management, and medication management. Diagnoses included paraplegia, aphasia, neuromuscular dysfunction of bladder and stage 4 pressure ulcer. On 5/19/26, from 11:30 a.m. to 12:00 p.m., a skilled nurse visit was observed with registered nurse (RN)-A. RN-A completed P1's dressing changes to his foot and sacral ulcers and instructed family member (FM)-B on wound care technique. FM-B stated the nurses came every day of the week for wound care and in addition, setup P1's medications in a daily med box every Sunday. FM-B shrugged and did not reply when asked if nurses stay four hours each day. RN-A stated the nurses came and did the wound care, assisted FM-B with transfer, peri care or bathing if needed and medications were setup by the nurse that visited on Sundays. The nurse visits typically were a half hour to two hours long and did not take four hours daily. RN-A stated the director of nursing (DON) came to do the recertification visits. The daily scheduled nurses mainly completed wound care. P1's electronic medical record (EMR) reviewed 4/20/26 to 5/18/26, identified P1 received SNV daily, however, visits typically ranged from a half hour to two hours in length and not the ordered four hours daily. P1's medical record lacked documentation P1's physician had been notified P1 was not receiving four hours of skilled nursing care daily. When interviewed on 5/19/26, at 2:30 p.m. the DON stated the agency was working with social services and P1's case worker to get approval for the four hours per day of skilled nursing but it had not been approved yet. The agency was doing skilled nurse visits seven days per week but not furnishing four hours day of skilled nurse visits at this time. A verbal order was needed to reflect what services the agency was currently furnishing and P1's POC needed to be updated. Further, they were only billing for the hours they provided. P2 P2's POC 4/10/26 to 6/8/26, identified a SOC date 4/20/24. SNV were ordered weekly for 60 days to observe and assess skin, genitourinary system, dementia and pain, to identify changes and intervene to minimize complications. Perform fall risk assessment and implement training measures to reduce risk of falls, provide management of chronic kidney disease and teaching related to risk for pressure ulcers, medication regimen and pathophysiology of disease process. Diagnoses included hypertension, pain in right shoulder and traumatic subdural hemorrhage. P2's POC 2/9/26 to 4/9/26, identified a SOC date 4/20/24. SNV were ordered weekly for 60 days to observe and assess skin, genitourinary system, dementia and pain, to identify changes and intervene to minimize complications. Perform fall risk assessment and implement training measures to reduce risk of falls, provide management of chronic kidney disease and teaching related to risk for pressure ulcers, medication regimen and pathophysiology of disease process. Diagnoses included hypertension, pain in right shoulder and traumatic subdural hemorrhage. P2's EMR 2/9/26 to 5/19/26, identified P2 received SNV two times per week 2/9/26 through 4/8/26, instead of the ordered one time per week. P2's medical record lacked documentation P2's physician had been notified of the increase in P2's SNV. During joint interview with the administrator and DON on 5/19/26, at 1:30 p.m. the DON stated a mistake had been made with P2's SNV, and visits should have been reduced to one time per week starting on 2/9/26, but they had not been. The DON stated the primary nurse must not have been notified the SNV had been decreased. P5 P5's POC 4/30/26 to 6/28/26, identified a SOC 9/2/25. SNV were ordered two times weekly for 60 days to assess and educate on impaired respiratory system to identify changes and intervene to minimize complications, perform nutrition education to support disease management, and adherence to diet, perform fall risk assessments and training measures to reduce risk for falls, and diabetic teaching. Diagnoses included malignant neoplasm of tongue and mouth, diabetes, hypertension, liver disease, and encounter for gastrointestinal device. P5's EMR 4/30/26 to 5/19/26, identified P5 received SNV one time per week 4/30/26 to 5/19/26, instead of the ordered two times per week. P5's medical record lacked documentation P5's physician had been notified of the decrease in SNV. During joint interview with the administrator and DON on 5/19/26, at 1:30 p.m. the DON stated they had thought P5 would need more frequent SNV due to her complex condition, but family provided much of the care, and they were not wanted or P1 was always off somewhere with the family. The DON stated a verbal order had not been obtained to decrease the SNV and should have been. The agency policy Plan of Care - CMS #485 and Physician Orders, revised October 2017, identified each patient must receive the home health services that were written in the individualized plan of care that identified patient specific measurable outcomes and goals and was established, periodically reviewed and signed by the physician. Care and services would be provided according to physician orders. Drug, services and treatments were administered by staff only as ordered by the physician.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure a patient's individualized plan of care was reviewed by the primary care provider at least once every 60 days, beginning with the start of care date for 2 of 7 patients (P4, P6) whose plan of cares were reviewed. Findings include: P4's plan of care (POC) 1/12/26 to 3/12/26, identified a start of care (SOC) date 6/2/22. Skilled nurse visits (SNV) were ordered weekly for 60 days for various assessments and evaluation. Diagnoses included diabetes, depression, chronic obstructive pulmonary disease (COPD), heart disease, asthma, post -traumatic stress disorder (PTSD) and chronic pain. The primary care provider's signature for home care orders and review of the POC date 4/17/26, 26 days after the POC's episode of care was completed. P6's POC 11/23/25 to 1/21/26, identified a SOC date 4/2/24. SNV were ordered weekly for 60 days for various assessments and evaluation. Diagnoses included hypertension and kidney disease. The primary care provider's signature for home care orders and review of the POC was dated 1/29/26, 8 days after the POC's episode of care was completed. On 5/19/26, at 1:30 p.m. during joint interview with the administrator and director of nursing (DON), the administrator stated they sent the POC to the provider via fax and at times it was difficult to get them back signed in a timely manner. The administrator stated they could not control when the physician signed the patient's POC. The DON stated she was aware of the late review and signatures on patient's POC, but it was not up to them. The agency policy Plan of Care - CMS #485 and Physician Orders, revised October 2017, identified the total plan of care would be reviewed and signed by the attending physician and agency personnel involved in the patient's care as often as the severity of the patient's condition required, but at least once every sixty days.

On 6/20/23 through 6/21/23, a survey for compliance with Appendix Z, Emergency Preparedness Requirements for HHA, §483.73(b)(6) was conducted during a standard recertification survey. The facility was NOT in compliance. The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Because you are enrolled in ePOC, your signature is not required at the bottom of the first page of the CMS-2567 form. Upon receipt of an acceptable electronic POC, an onsite revisit of your facility may be conducted to validate substantial compliance with the regulation has been attained.

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 document review the facility failed to review and maintain, a comprehensive Emergency Preparedness Program. (EPP). This had the potential to affect all patients who receive home care from the agency. Findings include: The facility EPP dated 2018, lacked evidence of review or revision. When interviewed on 6/21/23 at 2:30, the Administrator stated the EPP had not been reviewed or revised since he started with the company and verified work was needed to be done to ensure the EPP was complete and accurate. A facility policy for Emergency Preparedness was requested but not received.

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 document review, the facility failed to ensure documentation of collaboration efforts with local and state emergency preparedness authorities. This had the potential to affect all patients who receive home care from the agency. The agency’s Emergency Preparedness Plan (EPP) dated 2018, lacked documentation of coordination and collaboration efforts with the pertinent local and state authorities. When interviewed on 6/21/23 at 2:30 p.m., the Administrator stated the agency needed to work on identifying agencies and contact information for local and state authorities to ensure collaborative efforts were taken during emergency events.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to develop and implement emergency preparedness policies and procedures that included a system to ensure the care needs of the patients continue to be met during an emergency. This had the potential to affect all patients receiving home care from the agency. The agency’s Emergency Preparedness Plan dated 2018, outlined the need for patient an emergency plan to be included on the plan of care, but lacked indication of policy or procedure was developed on how to carry out the plan for patients during an emergency. When interviewed on 6/21/23 at 2:30 p.m. the Administrator stated the agency did not have this procedure and acknowledged the emergency preparedness policies and procedures were lacking and continued to be a work in progress.

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 document review, the facility failed to develop and implement emergency preparedness policies and procedures that included a system to inform state and local emergency preparedness officials of the need for patient evacuations from their residences during an emergency. This had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked documentation to include a system for informing state and local emergency preparedness officials about patients in need of evacuation from their residences at any time, due to an emergency. When interviewed on 6/21/23 at 2:30 p.m. the Administrator stated the agency did not have this policy or procedure and acknowledged the emergency preparedness policies and procedures were lacking and continued to be a work in progress.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to develop and implement emergency preparedness policies and procedures that included a system to address required actions needed when there was an inability to contact staff or patients and reporting capabilities to the local and state emergency officials during an emergency. This practice had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked documentation to include what actions were required if unable to contact patients or staff in the event of an emergency. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified the emergency plan did not include information regarding the inability to contact staff or patients during an emergency and how this information would be reported to local and state officials.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to develop and implement emergency preparedness policies and procedures to preserve patient information, protect confidentiality of patient information, and secure and maintain availability of records in the event of an emergency. This had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked policies or procedures to ensure the agency would have access to medical records in the event of an emergency or how continuity of medical care would be addressed. When interviewed on 6/21/23 at 2:30 p.m. the Administrator stated they have a cloud system to upload the physical copies and updated care plans. The administrator further stated there is a binder that staff should be saving a physical copy of the care plan and medication list. The administrator verified there was no official policy or procedure in place but was hopeful it was working and things were updated.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to develop and implement emergency preparedness policies and procedures to address the need for volunteers or increased staffing needs in an emergency. This practice had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked documentation to include a system for volunteer use or strategies to ensure adequate staffing was available during emergency situations. When interviewed on 6/21/23 at 2:30 p.m. the Administrator verified the emergency plan did not include policies or procedures on staffing or volunteer use and acknowledged emergency preparedness policies and procedures were lacking and continued to be a work in progress.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to develop a comprehensive written emergency communication plan that included contact information for patients, patient physicians, and federal, state, regional and local emergency agencies. Furthermore, the facility failed to ensure a communication plan was in place that addressed a means of providing information about facility's needs, and its ability to help the authority having jurisdiction, to ensure a method for sharing patient information to include medical information, general condition, and location. This had the potential to affect all 21 patients receiving home care from the agency. See E0030: The facility failed to ensure their emergency preparedness communication plan included all required and updated information including names and contact information for the following: entities providing services under arrangement, patients' physicians, and volunteers. See E0031: The facility failed to ensure their emergency preparedness communication plan included all required contact information for the local, state, and federal emergency preparedness staff. See E0033: The facility failed to ensure their emergency preparedness communication plan included a method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. See E0034: The facility failed to ensure their emergency preparedness communication plan included a means of communicating information about the agency’s ability to aid the authority having jurisdiction over the emergency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to ensure their emergency preparedness communication plan included all required and updated information including names and contact information for the following: entities providing services under arrangement, patients' physicians, and volunteers. This practice had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked indication the plan included contact information for entities providing services under arrangement, and patients’ physicians. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified the emergency plan did not include contact numbers for any arranged services, patient’s physicians, or possible volunteers. The administrator verified there were components of the facility’s program that needed to be added.

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 document review, the facility failed to ensure their emergency preparedness communication plan included all required contact information for the local, state, and federal emergency preparedness staff. This had the potential to affect all patients receiving home care services from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked indication the plan included contact information local, state, and federal emergency preparedness staff. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified the emergency plan did not contain contact information for local, state, and federal emergency contact information. The administrator further stated the contact information needed to be developed.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure their emergency preparedness communication plan included a process for communicating patient information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. This had the potential to affect all patients receiving home care from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked a policy and procedure that addressed how the facility would share information with outside resources during an emergency. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified there was not a communication procedure or policy directing staff what information needed to be available to share with other providers during an emergency.

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 document review, the facility failed to ensure their Emergency Preparedness Plan included a means of communicating information about the agency’s ability to aid the authority having jurisdiction over the emergency. This had the potential to affect all patients receiving home care from the agency. The agency's Emergency Preparedness Plan dated 2018, lacked a policy and procedure that addressed how the facility would communicate information about the agency’s ability to aid the authority having jurisdiction over the emergency. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified there was not a communication plan or policy directing staff what information and how to communicate availability of assistance to those who oversee the emergency efforts.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to develop and maintain a written emergency preparedness training and testing program based on the agency’s emergency plan, risk assessment, policies, and procedures. This had the potential to affect all patients receiving home care from the agency. See E0039: The facility failed to conduct a full-scale exercise, or a facility-based exercise to test their emergency preparedness program yearly or to document activation on their emergency preparedness plan or incident command system in response to an actual emergency event the agency experienced during the last year.

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 document review, the facility failed to conduct a full-scale exercise, or a facility-based exercise to test their emergency preparedness program yearly or to document activation on their emergency preparedness plan or incident command system in response to an actual emergency event the agency experienced during the last year. This had the potential to affect all patients who receive home care from the agency. The agency’s documentation of their emergency preparedness training exercises was requested however was not received. When interviewed on 6/21/23 at 2:30 p.m., the Administrator verified a full-scale exercise had not been completed and believed there was a facility exercise completed at one time, but was unable to find documentation.

On 6/20/23 through 6/21/23,a recertification survey was conducted. This resulted in a partial extended, survey at ABC Home Health Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 27 Total home visits conducted: 3 There were no branch offices. Hours of Operation: 9:00 a.m. to 5:00 p.m. Total number of records reviewed: 8

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure scheduled visits that were ordered by the physician were provided as indicated in the plan of care (POC) for 3 of 8 patients (P4, P2, P6) who currently receive home care services. P2's POC for recertification period 5/10/23 through 7/8/23, indicated P2 should have received skilled nursing (SN) visits once per week for 60 days. P2's medical record reviewed from 5/10/23 through 5/31/23. The medical lacked revealed P2 was seen by SN on 5/10/23. The record lacked evidence of any further SN visits for P2. P2's discharge summary dated 5/31/23 revealed P2 was being discharged from skilled services. P6's POC for recertification period 4/22/23 through 6/20/23, indicated P6 should have received SN visits once per week for 60 days. P6's medical record reviewed 4/22/23 through 6/20/23. The medical record revealed P6 was last seen by SN on 5/25/23. The record lacked evidence of any further SN visits for P6. On 6/21/23 at 9:30 a.m., P6 stated the agency called him about a week ago to discuss SN services and that was the only time he talked with the agency since 5/25/23. P6 verified the agency had not been out to do a SN visit since 5/25/23. On 6/21/23 at 9:40 a.m., the director of nursing (DON) stated she was aware P2 and P6 had not received skilled nursing services per POC and that nothing had been documented in P2's or P6's medical record regarding the missed SN visits. DON stated her usual practice had been to document any missed visits in the medical record. DON further stated it was important for patients to get scheduled SN visits per POC. Agency policy, Skilled Professional services noted nursing care will be provided in accordance with the patient's Plan of care under the supervision of a registered nurse. P4's POC dated 4/18/23-6/16/23, indicated P4 had diagnoses of left-side hemiplegia (paralysis on the left side) and stroke. P4's POC further indicated provider orders for skilled nurse (SN) visits 3 times a week for assessment, medication management, and care of P4's suprapubic catheter and colostomy. P4's SN visit notes for the week dated 5/28/23-6/3/23, indicated P4 received 2 out of 3 SN visits. P4's SN visit notes for the week dated 6/4/23-6/10/23, indicated P4 received 1 out of 3 SN visits. P4's POC dated 2/17/23-4/17/23, indicated provider orders for SN visits 3 times a week for assessment, medication management, and care of P4's suprapubic catheter and colostomy. P4's SN visit notes for the week dated 3/26/23-4/1/23, indicated P4 received 1 out of 3 SN visits. During entrance conference on 6/20/23, at 9:30 a.m. the Administer verified a visit week was Sunday through Saturday. When interviewed on 6/21/23, at 9:30 a.m. the Director of Nursing (DON) verified P4 was a complex patient and had orders to visit 3 times a week to help manage his catheter and ostomy and ensure his wounds remained healed. DON stated the nurse usually seeing P4 had an emergency, and she was attempting to cover the visits, but had been unsuccessful. DON further stated the expectation was to follow the provider orders and doing so was important to minimize any health risks or hospitalizations for the patients and to help them be safe in their homes.