Every finding on record at Acacia Home Health, Inc.

The following deficiencies were noted at the on-site, unannounced recertification survey on July 15 thru July 17, 2024. The Home Health Agency is recommended to continue to provide services: Home Health Services. Kristy Egg RN BSPH Compliance Manager July 18, 2024

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of policies and procedures, staff interview and documentation provided it was determined the facility failed to facilitate a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Failure to ensure a facility- based and community-based risk assessment increases the potential risk to staff, patients and caregivers. Review of the facilities Emergency Preparedness plan revealed that there was no community-based or facility-based risk assessment. Interview with Employee #6 and #7 confirmed that there was no community or facility-based risk assessment included in the Emergency Preparedness documentation.

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 review of policies and procedures, interview and documentation it was determined the facility failed to ensure that a secondary communication method was included in the patient information. Failure to include the secondary method of communication during an emergency increases the potential risk that patients and caregivers will not receive timely information during emergencies. Findings include: Review of facility patient intake packet failed to include the required information on a secondary communication method for updated status during a time of emergency. Interview with Employee $6 and #7 confirmed that no information on a secondary method of communication was included in the patient information packet.

Based on the requirements in 42 CFR 484 Subparts A, B, and C, the following deficiencies were found during the on-site Federal recertification survey conducted on July 15, 2024 to July 17, 2024 for Event #6390D-H1. The facility is approved and recommended to continue providing the following services: Home Health Agency. Kristy Egg RN BSPH Compliance Officer Manager HHA HSPC July 18, 2024

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on document review and interview it was determined that the facility failed to inform patients of the right to access auxiliary aids and language services at no cost to the individual, including oral interpretation and written translations. The failure to ensure language access poses a risk to patient care. Findings include: Interview with Employee #6 and #7 on July 16, 2024 confirmed that no language access services were made available to patients.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on review of policies and procedures, personnel records and staff interview it was determined that the facility failed to ensure that home health aids were receiving the required 12 hours of education hours during each 12-month period. Failure to provide the education poses a risk of patient injury. Review of facility policy "Personnel Records",D-180, "there must be in-service hours documented in each home health aids personnel file." Interview with Employee #6 and #7 confirmed that no in-service documentation was included in the personnel files for Employee #8 and #9

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on review of facility policies and procedures, documents and staff interview it was determined that the failed to ensure that the Governing Body appointed an administrator. Failure to maintain implementation of facility's policies and procedures poses a risk to administrative services for patients. Findings include: Review of facility documents revealed that no governing body minutes for the appointment of the current administrator. Interview with Employee #6 and #7 confirmed that no governing body minutes existed to notify of a change in administrator.