Every finding on record at Americare Home Health Care Services Inc

During the recertification survey conducted on 2/24/2026 to 2/26/2026 at Americare Home Health Care Services Inc, a Home Health Agency, Emergency Preparedness was reviewed. Americare Home Health Care Services Inc is not in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate that initial training in emergency preparedness had been provided to 3 of 5 personnel, Staff C, Staff D, and Staff E. The findings include: The surveyor’s review of the personnel records on 2/24/2026 and 2/25/2026 revealed no evidence that Staff C, Staff D, and Staff E received initial training in emergency preparedness. During an interview on 2/25/2026 that started at 10:53 AM, the Administrator said the staff get emergency training during orientation. During an interview on 2/26/2026 at 11:51 AM, Human Resources said all trainings are in the personnel files. The Office Manager, Field Supervisor, and Staffing Coordinator acknowledged that the agency failed to demonstrate that initial emergency preparedness training had been provided during an interview on 2/26/2026 at 2:45 PM.

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 record review and interview, the home health agency failed to conduct exercises to test its emergency plan at least annually. The findings include: The surveyor found no evidence that the home health agency had conducted exercises to test its emergency plan at least annually during record review completed between 2/24/2026 and 2/26/2026. During an interview with the Administrator on 2/25/2026 that started at 10:53 AM, the Administrator said she was not sure of the last date that the Comprehensive Emergency Management Plan had been activated. During an interview with the Director of Nursing (DON) on 2/25/2026 that started at 11:32 AM, the DON said there was a Tabletop Exercise, so the Office Manager must have it. According to the DON, they usually all meet before hurricane season to contact patients to ensure that all of the emergency plans are up to date. On 2/25/2026 at 12:38 PM, the surveyor reviewed the sign-in sheet for the meeting that the DON said was the Tabletop Exercise. The sign-in sheet for the meeting says the following: "I verify that I have read the plan and understand what my duties will be in the event of a hurricane or other disaster. I am aware of the confidential nature of the documents I may required to take outside of the office and will abide by the AHCS policy for protected information (HIPPA)." The sign-in sheet failed to demonstrate that an exercise where there was 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 had been conducted. The Office Manager, Field Supervisor, and Staffing Coordinator acknowledged that the agency failed to demonstrate that exercises to test its emergency plan had been conducted during an interview on 2/26/2026 at 2:45 PM.

A recertification survey was completed on 2/24/2026 to 2/26/2026 at Americare Home Health Care Services Inc. The facility was in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies, Requirements for Home Health Agencies.

During the recertification survey conducted on September 26, 2023, to September 27, 2023, at Americare Home Health Services, a Home Health Agency, Emergency Preparedness was reviewed. Americare Home Health Services is not in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

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 record review and interview, the provider failed to develop strategies for addressing emergency events identified by the risk assessment. Findings include: A review of the provider's emergency preparedness plan revealed no documentation of strategies for addressing emergency events identified by the risk assessment. On 09/27/2023 at 2:21 PM, the director of nursing acknowledged its emergency preparedness plan did not include strategies for addressing emergency events identified by the risk assessment. The surveyor reviewed the home health agency's emergency preparedness plan on 9/26/2023 and 9/27/2023. The plan omitted strategies for addressing emergency events identified by the risk assessment. During an interview conducted with the home health agency's administration, they were unable to demonstrate they had developed strategies for their plan.

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 record review and interview, the provider failed to develop and maintain an emergency preparedness training and testing program that is based on its emergency plan. Findings include: Record review revealed the facility did not develop and maintain an emergency preparedness training and testing program that is based on its emergency plan. On 09/27/2023 at 2:21 PM, the director of nursing acknowledged not developing and maintaining a training and testing program that is based on its emergency plan.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to conduct training in emergency preparedness policies and procedures to all new and existing staff, and individuals providing services under arrangement, consistent with their expected role. Findings include: Record review revealed the facility did not conduct training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, consistent with their expected role during an emergency. On 09/27/2023 at 2:21 PM, the director of nursing acknowledged not conducting training in their emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement, consistent with their expected role.

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 record review and interview, the provider failed to ensure that all employees participated in testing of their emergency plan in preparedness for any disaster. Findings include: Record review revealed no documentation showing that all employees participated in testing their emergency plan of preparedness for any disaster. On 09/27/2023 at 2:21 PM, the director of nursing acknowledged all employees did not participate in the testing of their emergency plan.

A recertification survey was conducted on 09/26/2023 to 09/27/2023 at Americare Home Health Care Services Inc. The Home Health Agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Subpart A-C, Requirements for Home Health Agencies.

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 clinical record review and interview, the Home Health Agency failed to electronically transmit each completed OASIS (Outcome and Assessment Information Set) assessment to the CMS (Centers for Medicare and Medicaid Services), regarding each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary on 3 out of 9 Sampled Patients (SP). SP#2, SP#4 and SP#7 Findings include: The surveyor conducted clinical record reviews on 09/26/23 to 09/27/23 of SP#2, SP#4 and SP#7. The surveyor’s review of SP#2’s record revealed the patient was admitted to service on 04/02/2015 for skilled nursing service 12 hours a day for 7 days a week. The current Plan of Care certification period is from 09/10/23 to 11/28/23. The recertification assessment completed by the registered nurse is dated 09/01/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed SP#2 is a 22-year-old person. The surveyor’s review of SP#4’s record revealed the patient was admitted to service on 12/07/2016 for skilled nursing service 24 hours a day for 7 days a week. The current Plan of Care certification period is from 09/10/23 to 11/08/23. The recertification assessment completed by the registered nurse is dated 09/07/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed SP#4 is a 28-year-old person. The surveyor’s review of SP#7’s record revealed the patient was admitted to service on 09/10/2006 for skilled nursing service 8 hours a day for 7 days a week. The current Plan of Care certification period is from 08/22/23 to 10/20/23. The recertification assessment completed by the registered nurse is dated 08/21/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#7is a 19-year-old person. The OASIS (Outcome and Assessment Information Set) requirements states that Medicaid Home Health Program, are required to meet Medicare Conditions of Participation for HHA’s (Home Health Agency). Therefore, the provider must complete, record, encode and transmit the OASIS for all Medicaid patients receiving skilled care under this enrollment. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to complete a comprehensive assessment must be updated and revised (including the administration of the OASIS [Outcome and Assessment Information Set]) within the last 5 days of every 60 days in 3 out of 9 Sampled Patients (SP). SP#2, SP#4 and SP#7 Findings include: The surveyor conducted clinical record reviews on 09/26/23 to 09/27/23 of SP#2, SP#4 and SP#7. The surveyor’s review of SP#2’s record revealed the patient was admitted to service on 04/02/2015 for skilled nursing service 12 hours a day for 7 days a week. The current Plan of Care certification period is from 09/10/23 to 11/28/23. The recertification assessment completed by the registered nurse is dated 09/01/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed SP#2 is a 22-year-old person. The surveyor’s review of SP#4’s record revealed the patient was admitted to service on 12/07/2016 for skilled nursing service 24 hours a day for 7 days a week. The current Plan of Care certification period is from 09/10/23 to 11/08/23. The recertification assessment completed by the registered nurse is dated 09/07/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed SP#4 is a 28-year-old person. The surveyor’s review of SP#7’s record revealed the patient was admitted to service on 09/10/2006 for skilled nursing service 8 hours a day for 7 days a week. The current Plan of Care certification period is from 08/22/23 to 10/20/23. The recertification assessment completed by the registered nurse is dated 08/21/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#7is a 19-year-old person. The OASIS (Outcome and Assessment Information Set) requirements states that Medicaid Home Health Program, are required to meet Medicare Conditions of Participation for HHA’s (Home Health Agency). Therefore, the provider must complete, record, encode and transmit the OASIS for all Medicaid patients receiving skilled care under this enrollment. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor. The SP#4 revealed the patient was admitted to service on 12/07/2016 for skilled nursing service 24 hours a day for 7 days a week. The current Plan of Care certification period is from 09/10/23 to 11/08/23. The recertification assessment completed by the registered nurse is dated 09/07/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#4 is a 28-year-old person. The SP#7 revealed the patient was admitted to service on 09/10/2006 for skilled nursing service 8 hours a day for 7 days a week. The current Plan of Care certification period is from 08/22/23 to 10/20/23. The recertification assessment completed by the registered nurse is dated 08/21/2023 which omitted the requirements for the current version of the Outcome and Assessment Information Set (OASIS) items. Further review of the clinical record revealed the SP#7is a 19-year-old person. The OASIS (Outcome and Assessment Information Set) requirements states that Medicaid Home Health Program, are required to meet Medicare Conditions of Participation for HHA’s (Home Health Agency). Therefore, the provider must complete, record, encode and transmit the OASIS for all Medicaid patients receiving skilled care under this enrollment. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor.

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 record review and interview, the Home Health Agency failed to include in the individualized plan of care the following: 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; and information related to any advanced directives on 9 out of 9 Sampled Patients (SP). (SP#1, SP#2, SP#3, SP#4, SP#5, SP#6, SP#7, SP#8 and SP#9) Findings include: The surveyor conducted clinical record reviews on 09/26/2023 and 09/27/2023 of SP#1, SP#2, SP#3, SP#4, SP#5, SP#6, SP#7, SP#8 and SP#9. The 9 sampled patients’ records all contained a Plan of Care that omitted the description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors; and information related to any advanced directives information requirements. The surveyor conducted an interview with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM. The Director of Nursing/Alternate Administrator acknowledged the surveyor’s findings.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the Home Health Agency failed to have a nurse document the orders in the patient's clinical record, and sign, date, and time the orders in 1 out of 9 Sampled Patients (SP). SP#4 Findings include: Clinical record review of SP#4 conducted on 09/26/23 and 09/27/23 contained form titled "Physician’s Change and Additional Orders to Plan of Care" dated 08/15/23. Further review of the documentation showed it was dated and signed by the physician but omitted the nurse’s signature and time it was received. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor.

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 record review and interview, the Home Health Agency failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 2 out 9 Sampled Patients (SP). SP#4 and SP#6 Findings include: Clinical record review conducted on 09/26/23 to 09/27/23 of SP#4 revealed a Plan of Care with certification period of 09/10/23 to 11/08/23 that read for Skilled Nurse to be provided “24 hours/day x 7 days per week. The Plan of Care states “Skilled assessment, gastrostomy feeds, replace 14FR (French) GT (gastrostomy tube) as necessary, Respiratory assessment, nebulizer treatments prn (as needed), aspiration precautions, ADL (activities of daily living)/assess skin integrity Suprapubic catheter to straight drainage and change each month #18 [name] stat lock (LPN) [licensed practical nurse] or mom may change catheter change bag monthly: Flush with normal saline or sterile water until clear. Use sterile H2O (water) soft-wic sponges. VS (vital signs) q (every) 4 hours. GT (gastrostomy) stoma care w/ (with) soap and water or ½ strength H2O2 daily. Pericare w/soap and water. Aspiration precautions/transfer safety/fall precautions.” Review of the skilled nurse service notes for date range 07/23/23 to 09/09/23 present revealed no 24 hours care rendered on Sunday’s, Friday’s the patient only received 12 hours shift, and on Saturdays only providing skilled nursing service shift of between 8 hours and up to 12 hours out of the 24 hours ordered on the Plan of Care. Further review of the clinical record omitted documentation that the ordering physician was notified of the services not rendered and reason as ordered on the plan of care. Interview conducted with the Staffing Coordinator on 09/27/23 between 11:22AM and 11:32 AM stated that no nurse is scheduled on Sunday’s due to no availability. The Staffing Coordinator stated that on Saturday mostly covered. The Staffing Coordinator added that no coverage before, but as of 9/10/23 they covered 9pm-8am shift for Sunday’s. The Staffing Coordinator confirmed that on Friday nights no nurse is available to cover the shift. Clinical record conducted on 09/26/23 to 09/27/23 of SP#6 revealed a Plan of Care with certification period of 08/08/23 to 10/06/23 that reads “RN/LPN (registered nurse/licensed practical nurse) 24-hour care x 7 days per week x 180 days. The Plan of Care states “Skilled assessment, vital signs q (every) shift, ventilator and O2 (oxygen) management keep O2 sats above 92% may use O2 up to 4l/min (4 liter/minute), tracheostomy care, tracheal airway maintenance, suctioning, nebulizer treatments, gastrostomy/jejunostomy tube care, feedings 22 hours per day. Clean GJ (gastrostomy/jejunostomy) tube site with soap and water or normal saline and trach site with normal saline, medications as ordered. Seizure precautions. Total ADL (activities of daily living) care due to severe mental/cognitive and physical disability.” Review of the skilled nurse service notes for date range 07/23/23 to 09/09/23 revealed no 24-hour care rendered. The registered nurse is being provided service shift of between 9 hours and up to 14 hours out of the 24 hours ordered on the Plan of Care. There is no nursing service note for the date range 8/9/23 to 9/9/23. Further review of the clinical record omitted documentation that the ordering physician had been notified of the services not rendered and reason as ordered on the plan of care. Interview conducted with the Staffing Coordinator on 09/26/23 at 2:49 PM stated that assigned nurse was in the hospital for date range 8/9/23 to 9/9/23 and resumed service on 9/10/23. Interview conducted with the Staffing Coordinator on 09/26/23 at 3:05 PM stated that they don’t inform the physician, they only put the Missed Visit note in the clinical record.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that an onsite visit to the patient's home no less frequently than every 14 days is conducted for supervision of the Home Health Aide (HHA) by a Registered Nurse or other appropriate skilled professional in 1 out of 9 Sampled Patient (SP). SP#6 Findings include: Clinical record review conducted on 09/26/23 to 09/27/23 of SP#6 revealed patient received Skilled Nursing (SN) and Home Health Aide (HHA) services provided by the home health agency. The provider failed to demonstrate that HHA supervisions were conducted every 14 days from last documented supervision dated 05/19/23 to 08/24/23 which is an interval of 97 days. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on personnel record review and interview, the agency failed to ensure that a registered nurse or other appropriate skilled professional made an annual on-site visit to the location where patients received care to observe and assess each aide while he or she performed care. For 1 out of 7 Staff (A). Findings include: Record review revealed that Staff A is an active home health aide with a hire date of 06/27/2022. Further record review revealed no documentation showing that a registered nurse made an annual on-site visit to the location where patients received care from Staff A, to observe and assess Staff A’s performance of care. On 09/27/2023 at 2:21 PM, the director of nursing acknowledged not having documentation to demonstrate that annual on-site visits were made to the location where patients received care from Staff A to observe and assess Staff A’s performance of care.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to ensure that the Registered Nurse (RN) conducted a supervisory visit of the Home Health Aide (HHA) while the HHA was providing patient care, no less frequently than every 60 days, who is not receiving skilled care service in 1 out of 9 Sample Patients (SP). SP#3 Findings include: Clinical record review of SP#3 conducted on 09/26/23 to 09/27/23 revealed that SP#3 is receiving home health aide services for assistance with personal care. Further review of the clinical record revealed supervisory visits were conducted on 04/22/23 and 06/19/23, which is an interval of 58 days; then from the last documented supervisory visit dated 06/19/23 to 09/26/23 reveals an interval of 99 days have passed with no documented supervisory visit(s) conducted. Interview conducted with the Director of Nursing/Alternate Administrator on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged findings made by the surveyor.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency is unable to demonstrate a completed discharge summary for 2 out of 9 Sampled Patients (SP). (SP#8 and SP#9) Findings include: Closed record reviews of SP#8 and SP#9 were conducted on 09/26/23 to 09/27/23. The clinical records for SP#8 and SP#9 omitted a discharge summary that includes such as listing the reason for admission to home health; the type of services provided and frequency of services; any Lab data (as applicable); and complete summary of care/outcomes in meeting the goals in the Plan of Care. An interview was conducted with the Director of Nursing on 09/27/2023 between 2:18 PM and 2:42 PM acknowledged that the clinical records for SP#8 and SP#9 are incomplete, missing the required notations as previously mentioned.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency failed to maintain documentation which demonstrates that an individual may furnish home health services on behalf of a Home Health Agency only after that individual has successfully completed a competency evaluation program for 1 out of 3 personnel file review. (Staff A) Findings include: Personnel files review conducted on 09/22/22 revealed the Staff A is a Home Health Aide with a date of hire of 07/11/22. Further review of the Staff A personnel record contained a titled document "Home Health Aide Competency Test – Practical Part" that omitted documentation distinguish between skills evaluated during patient care and those in a laboratory/office setting, the form was blank. Interview conducted with the Office Manager on 09/22/22 at 4:19 PM reviewed the personnel record for Staff A and confirmed that the form was blank.