Every finding on record at Able Home Health, Inc.

Federal Recertification Survey On-Site Survey Dates: 4/26/2022 – 4/28/2022 Conditional Level Deficiency Identified at: §484.22 Condition of Participation ("CoP"): Emergency Preparedness Able Home Health, a Home Health Agency, was not in substantial compliance with 42 Code of Federal Regulations 484.22, Condition of Participation: Emergency Preparedness. The following Condition and Standard level requirements were not met:

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, §485.625, §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 document review and interview, the Condition of Participation ("CoP") for Emergency Preparedness was not met as evidenced by the agency's failure to develop an emergency preparedness program that included a detailed emergency plan, policies and procedures, a communication plan, training, and testing. Findings: As of 11/15/2017, a Home Health Agency was required to prepare for potential emergencies by developing an emergency preparedness program that included a detailed emergency plan, policies and procedures, a communication plan, training, and testing. On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, the following standard level deficiencies were identified: 1. Standard: §484.102(a) Emergency Preparedness - Emergency Plan, also known as E-0004 - Based on document review and interview, the agency failed to develop and maintain of an emergency preparedness program that was reviewed and updated at least every two (2) years. See E-0004 for details. 2. Standard: §484.102(a)(1)(2) Emergency Preparedness - Emergency Plan, also known as E-0006 - Based on document review and interview, the agency failed to develop, maintain or review an emergency preparedness plan that was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach, and that included strategies for addressing emergency events identified by the risk assessment. See E-0006 for details. 3. Standard: §484.102(a)(3) Emergency Preparedness - Emergency Plan, also known as E-0007 - Based on document review and interview, the agency failed to develop and maintain an emergency preparedness plan that addressed patient population, including, but not limited to, the type of services the agency had the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. See E-0007 for details. 4. Standard: §484.102(4) Emergency Preparedness - Emergency Plan, also known as E-0009 - Based on document review and interview, the agency failed to ensure the emergency preparedness plan included 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. See E-0009 for details. 5. Standard: §484.102(b) Emergency Preparedness - Policies and Procedures, also known as E-0013 - Based on document review and interview, the agency failed to develop and implement emergency preparedness policies and procedures, based on a risk assessment and the communication plan, and ensure these policies and procedures were updated at least every two (2) years. See E-0013 for details. 6. Standard: §482.15(b)(4) Emergency Preparedness - Policies and Procedures, also known as E-0023 - Based on document review and interview, the agency failed to ensure emergency preparedness policies and procedures that addressed a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. See E-0023 for details. 7. Standard: §482.15(b)(5) Emergency Preparedness - Policies and Procedures, also known as E-0024 - Based on document review and interview, the agency failed ensure the emergency preparedness policies and procedures addressed 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. See E-0024 for details. 8. Standard: §482.15(c) Emergency Preparedness - Communication Plan, also known as E-0029 - Based on document review and interview, the agency failed to ensure an emergency preparedness communication plan that complied with Federal, State and local laws was reviewed and updated at least every two (2) years. See E-0029 for details. 9. Standard: §482.15(c)(1) Emergency Preparedness - Communication Plan, also known as E-0030 - Based on document review and interviews, the agency failed to ensure the emergency preparedness communication plan included contact information for Federal, State, regional and local emergency preparedness staff. See E-0030 for details. 10. Standard: §482.15(c)(2) Emergency Preparedness - Communication Plan, also known as E-0031 - Based on document review and interviews, the agency failed to ensure the emergency preparedness communication plan included contact information for Federal, State, regional and local emergency preparedness staff. See E-0031 for details. 11. Standard: §482.15(c)(3) Emergency Preparedness - Communication Plan, also known as E-0032 - Based on document review and interview, the agency failed ensure the agency's emergency preparedness communication plan included the primary and alternate means for communicating with the clinic staff and federal, state, tribal, regional, and local emergency management agencies. See E-0032 for details. 12. Standard: §482.15(c)(4)-(6) Emergency Preparedness - Communication Plan, also known as E-0033 - Based on document review and interview, the agency failed to ensure the 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 E-0033 for details. 13. Standard: §482.15(c)(7) Emergency Preparedness - Communication Plan, also known as E-0034 - Based on document review and interview, the agency failed to ensure the agency's emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. See E-0034 for details. 14. Standard: §482.15(d) Emergency Preparedness - Training and Testing Program, also known as E-0036 - Based on document review and interview, the agency failed to ensure the agency's emergency preparedness training and testing program was reviewed and updated at least every two (2) years. See E-0036 for details. 15. Standard: §482.15(d)(1) Emergency Preparedness - Training Program, also known as E-0037 - Based on document review and interview, the agency failed to provide emergency preparedness training at least every two (2) years. See E-0037 for details. 16. Standard: §482.15(d)(2) Emergency Preparedness - Testing Program, also known as E-0039 - Based on document review and interview, the agency failed to conduct exercises to test the emergency plan annually. See E-0039 for details. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". It was noted that in an earlier conversation on 4/26/2022 at 10:09 AM, he had stated to the surveyors that he didn't think he could provide surveyors with information for the survey and there was no one else that could assist him with the survey process. On 4/28/2022 at 11:04 AM, the Alternate Administrator/Co-Owner provided the following blanket statement in regard to the Emergency Preparedness requirements, "Whatever is required by state or federal government we have but I cannot provide it to you – this is for everything you are going to ask me". No further information was provided to surveyors as of the exit conference on 4/28/2022. The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

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), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain of an emergency preparedness program that was reviewed and updated at least every two (2) years. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency had reviewed their agency's emergency preparedness plan at least every two years. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness plan was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach, and that included strategies for addressing emergency events identified by the risk assessment. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness plan was based on and included a documented, agency-based and community-based risk assessment, utilizing an all-hazards approach, and that included strategies for addressing emergency events identified by the risk assessment. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (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. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed ensure the emergency preparedness plan addressed patient population, including, but not limited to, the type of services the agency had the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness plan addressed patient population, including, but not limited to, the type of services the agency had the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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 document review and interview, the agency failed to ensure the emergency preparedness plan included 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. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness plan included 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. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and implement emergency preparedness policies and procedures, based on a risk assessment and the communication plan, and ensure these policies and procedures were updated at least every two (2) years. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency had emergency preparedness policies and procedures that were updated at least every two (2) years. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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):] 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 document review and interview, the agency failed to ensure emergency preparedness policies and procedures that addressed a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness policies and procedures addressed a system of medical documentation that preserved patient information, protected confidentiality of patient information, and secured and maintained availability of records. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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 document review and interview, the agency failed ensure the emergency preparedness policies and procedures addressed 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. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness policies and procedures addressed use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State or Federally designated health care professionals, to address surge needs during an emergency. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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 document review and interview, the agency failed to ensure an emergency preparedness communication plan that complied with Federal, State and local laws was reviewed and updated at least every two (2) years. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness communication plan that complied with Federal, State and local laws was reviewed and updated at least every two (2) years. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to ensure the emergency preparedness communication plan included the names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness communication plan included the names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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 document review and interviews, the agency failed to ensure the emergency preparedness communication plan included contact information for Federal, State, regional and local emergency preparedness staff. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness communication plan included contact information for Federal, State, regional and local emergency preparedness staff. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed ensure the agency's emergency preparedness communication plan included the primary and alternate means for communicating with the clinic staff and federal, state, tribal, regional, and local emergency management agencies. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness communication plan included the primary and alternate means for communicating with the clinic staff and federal, state, tribal, regional, and local emergency management agencies. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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 document review and interview, the agency failed to ensure the 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. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's 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. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan".

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), §485.625(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 document review and interview, the agency failed to ensure the agency's emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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, 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 document review and interview, the agency failed to ensure the agency's emergency preparedness training and testing program was reviewed and updated at least every two (2) years. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence found in the information provided that indicated the agency's emergency preparedness training and testing program was reviewed and updated at least every two (2) years. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to provide emergency preparedness training at least every two (2) years. Finding: On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, it was noted that the last training was held on 11/29/2018, more than two (2) years ago. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". No further information was provided to surveyors as of the exit conference on 4/28/2022.

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), §485.625(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, 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 document review and interview, the agency failed to conduct exercises to test the emergency plan annually. Finding: On 4/27/2022, the Emergency Program was reviewed and indicated that there was a training on 11/29/2018. As of 4/28/2022, no further evidence was provided. On 4/27/2022, surveyors requested documentation in relation to the agency's emergency preparedness program. The Alternate Administrator/Co-Owner provided a binder with information. Upon review, there was no evidence that the agency had conducted exercises to test the emergency plan annually as required. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan".

Recertification Survey Review of Coronavirus 2019 ("COVID-19") Vaccination of Facility Staff Requirements Survey Dates: 4/26/2022 - 4/28/2022 Able Home Health, a Home Health Agency, was in substantial compliance with all Conditions of Participation outlined in 42 Code of Federal Regulations Part 484, Conditions of Participation for Home Health Agencies, except for 42 CFR §484.102: Emergency Preparedness. Please see E-0001 for details. The following standard level requirements (G tags) have not been met:

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to provide evidence that action was taken to prevent further potential violations, including retaliation, while a complaint was being investigated for three (3) of three (3) complaints reviewed. Findings: On 4/26/2022 at 3:22 PM, the Alternate Administrator/Co-Owner was asked to provide a complaint log for the last twelve (12) months. He stated, "We have had no complaints”. On 4/27/2022 at 9:12 AM, the Alternate Administrator/Co-Owner brought the surveyor a complaint log. There was no evidence provided that indicated any action the agency took to prevent further violations while the complaint was being investigated for three (3) complaints reviewed. On 4/28/2022 at 11:04 AM, the Alternate Administrator/Co-Owner stated he was unable to provide any information in relation to these complaints.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on document review and interview, the facility failed to ensure the implementation of developed policies and procedures for COVID-19 Coronavirus 2019 ("COVID-19"). Findings: The Alternate Administrator/Co-Owner provided surveyors with the agency's policies and procedures in relation to staff COVID-19 vaccination and provided a list that indicated all staff were vaccinated. The surveyors were unable to verify that the agency implemented their policy in relation to securely documenting the COVID-19 vaccination status of all staff and securely documenting the COVID-19 staff of any staff who had obtained any booster doses as recommended by the CDC. On 4/28/2022 at approximately 11:00 AM, the Alternate Administrator/Co-Owner stated he was sure they had it but he was unable to show the surveyors evidence or explain the process. It was noted that in an earlier conversation on 4/26/2022 at 10:09 AM, the Alternate Administrator/Co-Owner had stated to the surveyors that he didn't think he could provide surveyors with information for the survey and there was no one else that could assist him with the survey process.

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 interviews, the agency failed to ensure that a pre-designated person assumed the same responsibilities of the Administrator and obligations as the Administrator in the Administrator’s absence. Findings: On 4/26/2022 at 9:30 AM, surveyors arrived to conduct a recertification survey. Employee #1 stated that the Owner would arrive shortly. On 4/26/2022 between 10:09 AM and 10:15 AM, the Owner stated the following: - His partner, who was the Administrator, was not going to be available to the surveyors during the survey as she was home sick; - He didn’t think he could provide the surveyors with information; - There was no one that could come in to assist; - He was not ready for this survey; - Surveyors could ask for things today, but he had no way of giving the items to the surveyors; - His own computer skills were lacking; - He sent all of his employees home today; and - The person who could provide him with the requested documentation was sick (meaning the Administrator). Surveyors requested and were provided an employee list. This list indicated that there was an Administrator and an Alternate Administrator/Community Relations employee. The Owner stated that he was the Alternate Administrator and the Co-Owner. During the survey (4/26/2022 through 4/28/2022), surveyors requested items and attempted to get more information to clarify information that was received. The Alternate Administrator/Co-Owner was unable to provide information; therefore, failed to assume the responsibilities and obligations of the Administrator as required by regulation. This failure was evidenced by the following: 1. On 4/27/2022 at 12:00 PM, the Alternate Administrator/Co-Owner stated the following in relation to the personnel record reviews, which included the documentation related to Coronavirus 19 vaccination status: a. He could not provide additional evidence to show compliance; and b. He was sure they had it, but he did not know how or where to find the information to show compliance; 2. On 4/27/2022 at 2:19 PM, the Alternate Administrator/Co-Owner stated, “I need until next Friday to give you the documents you have requested”; 3. On 4/27/2022 at 2:57 PM, the Alternate Administrator/Co-Owner stated the following in relation to surveyors requesting Emergency Preparedness and Personnel policies and procedures: He stated, “I cannot until my partner returns”. 4. On 4/28/2022 at 10:55 AM, the Alternate Administrator/Co-Owner was asked to discuss the agency's emergency preparedness program. He stated, "No, I cannot describe the emergency preparedness plan". 5. On 4/28/2022 at 11:30 AM, the Alternate Administrator/Co-Owner was asked to provide the forms that were given on 4/26/2022, that needed to be completed, including the CMS 1572a form. He stated that he was unable to complete the forms and was unsure when he would be able to get them to the surveyors and he emailed them to his partner but has not heard back. As of 4/28/2022, at the exit conference, the Alternate Administrator/Co-Owner provided no further information was provided to surveyors.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observations and interviews, the agency failed to ensure that protected health information in the patient's medical records were safeguarded from unauthorized access. Findings: On 4/26/2022 at approximately 9:30 AM, surveyors were brought to a conference room at the agency. Upon entering the room, there were several patient medical records placed on a cabinet. By the end of the day, no action had been taken to secure the medical records. On 4/27/2022 at approximately 11:15 AM, Employee #1 was asked if patient records are kept in a secure location. She stated, yes, and indicated two (2) locked rooms contain the records. When asked who has keys to the locked rooms, she reported that the Administrator, Alternate Administrator/Co-Owner, and she have keys to the rooms that contain the records. She confirmed that the keys are kept in a lockbox in the conference room (where the surveyors were located and that the lockbox, containing the keys, remained unlocked every day. On 4/27/2022, at approximately 2:00 PM, the Alternate Administrator/Co-Owner entered the room to speak with the surveyors. He approached the lockbox on the wall, locked it, and stated that the lockbox should be kept secure so no one has access to the keys.