Every finding on record at Anchor Home Health Care Agency, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 07/17/25. Standard level deficiencies cited.

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 the Agency’s Emergency Preparedness Program review and staff interview, the Agency failed to provide staff training on the Emergency Preparedness Plan at least every 2 years, since 2022. Findings include: 1. The Emergency Preparedness Program was reviewed on 07/15/25. The program lacked documentation indicating the Agency providing staff training since 2022. 2. During an interview with the Director of Nursing on 07/16/25 at 1:00 PM, finding of the Agency failing to provide staff training on the Emergency Preparedness Program at least every 2 years was confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to ensure that the Agency conducted / participated in a full-scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan since 2022. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 07/15/25. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted / participated in any testing exercise or drills since 2022. 2. During an interview with the Director of Nursing on 07/16/25 at 1:00 PM, finding of the Agency failing to conduct testing of the Emergency Plan since 2022 was confirmed.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 07/17/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care SN = Skilled Nurse AM = morning PM = afternoon RN = Registered Nurse

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10), clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. Findings include: 1.The Agency’s Pt. admission folder was reviewed on 07/14/25. The folder lacked documentation of the Agency's transfer and discharge policies. 2. The following home visits were conducted on 07/14/25, 7/15/25 and 07/16/25: Pt. #1. SOC 07/10/25. Pt. #2. SOC 09/23/21. Pt. #3. SOC 07/09/25. Pt. #4. SOC 07/08/25. During the home visits, the Pt. admission folders were observed, and lacked documentation of the Agency's transfer and discharge policies. 3. The following clinical records were reviewed on 07/14/25 and 07/15/25: Pt. #1. SOC 07/10/25. Pt. #2. SOC 09/23/21. Pt. #3. SOC 07/09/25. Pt. #4. SOC 07/08/25. Pt. #5. SOC 04/18/25. Pt. #6. SOC 03/26/25. Pt. #7. SOC 06/03/25. Pt. #8. SOC 08/26/24. Pt. #9. SOC 08/02/24. Pt. #10. SOC 08/16/24. The records lacked documentation the Agency provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 4. During interview with the Director of Nursing, on 07/16/25 at 2:45 PM, it was confirmed the Pt. admission folder reviewed is used for all Pts. admitted to this Agency, and that the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy review, and staff interview, in 5 of 10 clinical records reviewed (Pts # 2, 4, 7, 8 and 9) the Agency failed to assess Pts. for pneumonia status on admission as per Agency policy. Findings include: 1. The following clinical records were reviewed on 07/15/25 and 07/16/25. The records lacked documentation indicating Pts. were assessed for pneumonia status. Pt. #2 SOC: 09/03/21 Pt. #4 SOC: 07/08/25 Pt. #7 SOC: 06/03/25 Pt. #8 SOC: 08/26/24 Pt. #9 SOC: 08/02/24 2. The Agency policy titled " Vaccinations" was reviewed on 07/16/25 and required, "Arranging and Documenting…2…Documentation shall include: ..a.. The assessment for need of the vaccination ...b... Date of offer or referral....c...Patient response to the offer...d...Administration, contraindications, or refusal…e...Any follow – up activities.” 3. During an interview with the Director of Nursing on 07/16/25 at 1:00 PM, finding of clinical records lacking documentation of pneumonia assessment was confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews and staff interview, it was determined in 10 of 10 (Pts. #1, 2, 3, 4, 5, 6,7, 8, 9 and 10) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Director of Nursing (Clinical Manager) and their contact information. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 7/14/25. The folder lacked the name and information to contact the Director of Nursing/Clinical Manager. 2. The following home visits were conducted on 07/14/25, 07/15/25, and 07/16/25. Pt. #1. SOC 07/10/25. Pt. #2. SOC 09/23/21. Pt. #3. SOC 07/09/25. Pt. #4. SOC 07/08/25. During the home visits, the Pt. admission folders were observed, and lacked documentation of the Director of Nursing/Clinical Manager. 3. The clinical records of the following Pts. were reviewed from 07/14/25 to 07/15/25: Pt. #1. SOC 07/10/25. Pt. #2. SOC 09/23/21. Pt. #3. SOC 07/09/25. Pt. #4. SOC 07/08/25. Pt. #5. SOC 04/18/25. Pt. #6. SOC 03/26/25. Pt. #7. SOC 06/03/25. Pt. #8. SOC 08/26/24. Pt. #9. SOC 08/02/24. Pt. #10. SOC 08/16/24. The clinical records reviewed lacked information identifying the Director of Nursing/ Clinical Manager name and contact information. 4. During a staff interview with the (DON) Director of Nursing, on 07/16/25 at 2:45 PM, it was confirmed the same admission folder is given to all Pts. The (DON) confirmed the Agency failed to identify the Director of Nursing/Clinical Manager’s name.

An investigation was conducted on 7/22/24 for Complaint #242757/107446. The agency was not in compliance with Standards for home health agencys, at 42 CFR 484. Abbreviations: # = number Pt. = Patient Pts = Patients SN = Skilled Nurse POC = Plan of Care SOC = Start of Care PsOC = Plans of Care G-tube = gastrostomy tube OASIS = Outcome and Assessment Information Set

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on a review of clinical records, Agency policy and staff interview, it was determined that in 1 of 2 (Pt. #2) closed clinical records reviewed, the Agency failed to conduct appropriate discharge planning, prior to Agency discharge. Findings include: 1. Pt. #2 was admitted for Home Health services on 2/1/24 and 5/2/24 with the primary diagnosis of Other Disorders of Nervous System. The clinical record was reviewed on 7/22/24. The clinical record contained documentation that Pt. #2 received 2 episodes of care/starts of care in 2024. The first SOC visit was conducted on 2/1/24 for the certification period of 2/1/24 to 3/31/24. During this certification period, the Pt. primarily received SN services for G-tube care/maintenance, and Foley catheter changes/maintenance. Pt. #2 was hospitalized on 3/11/24 for G-tube removal. The SN resumed care on 3/14/24 for primarily G-tube site wound care and monthly Foley catheter changes/maintenance. The SN established goals for discharge during the SOC visit on 2/1/24. However, this record lacked documentation of discharge planning with the Pt./representative from 2/8/24 to the last SN visit conducted on 3/30/24. The SN completed an "OASIS-E Discharge Non-Visit" comprehensive assessment form on 3/31/24. The second SOC was conducted on 5/2/24 and the Agency discharged Pt. #2 on 6/10/24 (certification period was 5/2/24 to 6/30/24). The SN provided service weekly from 5/2/24 to 6/6/24 for primarily G-tube site wound care, and Foley catheter monthly changes/maintenance. Discharge planning was not initiated with the Pt./representative until the last day of service on 6/6/24. The Agency’s "OASIS-E Discharge Non-Visit" comprehensive assessment completed by the SN on 6/10/24 lacked documentation that the Pt./representative was provided with referrals for wound care suppliers, and other home health agencies to provide monthly Foley catheter changes/maintenance. The Communication Note completed by the SN and dated 5/30/24 included; "The patient's... has a history being rude and not communicationg pleasantly. Putting in a communication note in now because the wife has repeately called... in the past to complain about dressing bandages that are not appropriate for the patient's wound as well as requesting extra supplies that are unnecessary." The Communication Note dated 6/6/24, and completed by the SN on 6/25/24 included; "...Patient... called the office and was told that services will end next week. Patient... stated that... will go with another company." 2. The Agency’s policy titled; “Patient Discharge from Agency” was reviewed on 7/22/24 and included; “Discharge planning is initiated for every patient beginning at the time of admission and continued until the actual date of discharge… 3. Prior to discharge, the home care team will conference on the progress to goals, pending discharge date, and follow-up needed… 6. Verbal notice of planned discharge will be provided to the patient/representative at least 3 days prior to discharge… 9. Upon discharge, the patient will receive oral or written information as appropriate regarding continuing care needs and available resources…” 3. During an interview with the Administrator and Director of Nursing on 7/22/24 at 3:20 PM, both confirmed the above findings.

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 a review of clinical records, Agency policy and staff interview, it was determined that in 2 of 3 (Pts. #1 and 2) clinical records reviewed of Pts. that required wound care, the Agency failed to ensure PsOC included a description of the wound care to be provided. Findings include: 1. Pt. #1 was admitted for Home Health services on 7/21/23 with the primary diagnosis of Pressure Ulcer of Right Buttock, Stage 4. The clinical record was reviewed on 7/22/24. The clinical record contained the POC for the certification period of 7/21/23 to 9/18/23 that required: "SN indicated for wound care management based on physician orders due to inherent complexity of the wound..." The SOC comprehensive assessment dated 7/21/23, and SN visit note dated 7/24/23 included documentation that the SN applied "negative pressure wound therapy". The POC lacked instructions or a description for the negative pressue wound therapy (procedure, supplies to be used, and amount of suction pressure). 2. Pt. #2 was admitted for Home Health services on 2/1/24 with the primary diagnosis of Other Disorders of Nervous System. The clinical record was reviewed on 7/22/24. The clinical record contained documentation that Pt. #2 was hospitalized on 3/11/24 for G-tube removal. The SN resumed care on 3/14/24 for primarily G-tube site wound care and monthly Foley catheter changes/maintenance. The SN wrote a verbal order on 3/14/24 that included: “…difficult PEG tube removal…Nursing for G tube removal wound care…” The POC for the “Resumption of Care Following Hospital Stay” for the certification period of 2/1/24 to 3/31/24 included “Keep Skin around tubing clean and dry. Apply dressing or ointments as ordered…” The Resumption of Care verbal order and POC for the Resumption of Care Following Hospital Stay lacked instructions for the wound care (wound care supplies to be used, procedure, and frequency of the wound care). 3. The Agency's policy titled, "Plan of Care" was reviewed on 7/22/24 and included; "...2. The plan of care must include services rendered by a registered nurse... 3. The plan of care shall include... j. Treatments... n. Types of services and specific procedures to be performed..." 4. During an interview with the Administrator and Director of Nursing on 7/22/24 at 3:20 PM, the Director of Nursing confirmed the Resumption of Care verbal order, and POC for the Resumption of Care Following Hospital Stay lacked a description of the wound care to be provided.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy, Pt. admission folder, and staff interview, it was determined in 1 of 1 (Pt. #2) closed clinical records reviewed, the Agency failed to ensure the Pt./representation was provided with resource information of suppliers upon Agency discharge, wherein the Pt. required supplies and/or skilled care upon discharge. Findings include: 1. Pt. #2 was admitted for Home Health services on 2/1/24 and 5/2/24 with the primary diagnosis of Other Disorders of Nervous System. The clinical record was reviewed on 7/22/24. The clinical record contained documentation that Pt. #2 received 2 episodes of care/starts of care in 2024. The first SOC visit was conducted on 2/1/24 and Pt. #2 was discharged on 3/31/24 (at the end of the certification period). Pt. #2 was hospitalized on 3/9/24 for G-tube removal. The Agency resumed care on 3/14/24 for primarily G-tube site wound care and monthly Foley catheter changes/maintenance. The record lacked discharge planning after the SOC visit on 2/1/24. The agency’s Non-Visit Discharge assessment form completed by the SN, and dated 3/31/24 lacked documentation that the Pt./representative was provided with referrals for wound care suppliers, and other home health agencies to provide monthly Foley catheter changes and maintenance. The second SOC was conducted on 5/2/24 and the agency discharged the Pt. on 6/10/24 (certification period was 5/2/24 to 6/30/24). The SN provided service weekly from 5/2/24 to 6/6/24 primarily for G tube site wound care, and Foley catheter monthly changes/maintenance. Discharge planning was not initiated until the last day of service on 6/6/24. The Agency’s Non-Visit Discharge assessment form completed by the SN, and dated 6/10/24 lacked documentation that the Pt./representative was provided with referrals for wound care suppliers, and other home health agencies to provide monthly Foley catheter changes and maintenance. 2. The Pt. admission folder was reviewed on 7/22/24 and contained the Agency's “Discharge Instructions” form. Both episodes of care indicated above lacked documentation the SN had completed, and provided the Pt./representative the agency’s “Discharge Instructions” form. Thie SN/Agency are required to document information regarding the next doctor’s appointment, medication instructions, skin/wound care instructions, schedule for laboratory tests (if applicable), reasons to contact their physician, any additional comments, and instructions. The clinical records for both episodes of care lacked documentation that a "Discharge Instructions" form was completed for Pt. #2. 3. The Agency’s policy titled; “Patient Discharge from Agency” was reviewed on 7/22/24 and required: “Discharge planning is initiated for every patient beginning at the time of admission and continued until the actual date of discharge… 3. Prior to discharge, the home care team will conference on the progress to goals, pending discharge date, and follow-up needed… 6. Verbal notice of planned discharge will be provided to the patient/representative at least 3 days prior to discharge… 9. Upon discharge, the patient will receive oral or written information as appropriate regarding continuing care needs and available resources…” 4. During an interview with the Administrator and Director of Nursing on 7/22/24, the Director of Nursing confirmed the Agency failed to ensure the Pt./representation was provided with resource information upon Agency discharge.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt/Pts = Patient/Patients POC= Plan of Care SOC= Start of Care (>)= Greater Than (<)= Less Than SN= Skilled Nurse RN= Registered Nurse BP= Blood Pressure O2= Oxygen Covid-19= Coronavirus 2019 E= Employee Temp.= Temperature

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on Clinical Records review, policy review, and staff interview, it was determined the Agency failed to ensure informed consents included the disciplines providing care and the frequency of care provided. This was found in 6 out of 10 (Pt. #1, 2, 3, 6, 7, and 9) clinical records reviewed. Findings include: 1. The following clinical records were reviewed beginning 3/29/22 at 10:45 AM through 3/30/22 at 11:30 AM. Pt. #1. SOC 3/05/22 Pt. #2. SOC 1/31/22 Pt. #3. SOC 2/11/22 Pt. #6. SOC 2/23/22 Pt. #7. SOC 2/25/22 Pt. #9. SOC 10/08/21 The clinical records included a consent form titled, “Notice of Payment Responsibility.” The consent form included a box with 5 subsections. Subsection 1 titled, “Service Ordered by Physician and subsection 5 titled, “Anticipated # of visits.” The consent form lacked documentation of which services the patients would be receiving and the anticipated number of visits. 2. A policy titled, “Clinical Records” was reviewed on 3/31/22 at 10:00 AM. The policy included, “…The clinical records shall contain…2. The Client Service Agreement, which includes: a. Consent for home care services from Anchor Home Health Care, including specific disciplines to be provided…” 3. During interviews with the Administrator and Director of Nursing beginning at 12:10 PM on 3/30/22, the above findings were confirmed. The Director of Nursing stated the patients should consent to the services and expected frequency of visits prior to the start of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure care was provided as indicated in the POC and specific to the Pt. This was found in 3 of 10 (Pts. #3, 4, and 6) clinical records reviewed. Findings include: 1. Pt. #3. SOC 2/11/22. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 3/29/22 at 10:45 AM. The record contained the POC effective 2/11/22 to 4/11/22, which included the Physician’s order: “Notify Physician of vital sign parameters out of range: Blood Sugar, Fasting: Greater Than (>) 250, Less Than () 300, Less Than () 110, Less Than () 101, Less Than () 24, Less Than () 7. O2 Saturation: Less Than () 170, Less Than () 90, Less Than () 250, Less Than () 300, Less Than (<) 60,” and “SN to monitor blood sugar levels…” The SN visit note dated 3/7/22 lacks documentation of Pt. #6’s blood sugar level, or a reason why Pt. #6’s blood sugar level could not be obtained. 4. During an interview with the Administrator and Director of Nursing on 3/30/22 at 12:10 PM, the above findings were confirmed. The Director of Nursing stated Patient’s pain level, vital signs and blood sugar level, if applicable, should be obtained and documented during each SN visit. If for some reason the Patient’s vital signs/blood sugar level cannot be obtained, the reason why should be documented on the SN visit note.

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: A. Based on personnel COVID-19 vaccination record review, Agency policy, and staff interview, it was determined the Agency failed to ensure its employee COVID vaccination policy included criteria for evaluation and acceptance of employee requests for exemption from the COVID-19 vaccination. This was found in 1 of 13 (E #7) employees reviewed for compliance with COVID-19 vaccinations, and has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. E #7’s COVID-19 vaccination status was reviewed on 3/29/22 at 10:00 AM. E #7 filled out a “COVID-19 Vaccine Religious Exemption Form,” dated 12/4/21, on which E #7 placed a checkmark in the box “Religious Exemption.” Attached to this document was a statement which read “I do not believe vaccination should be required for anyone and I don’t want to put something in my body if it is not for sure safe.” There was no documentation E #7’s declination was evaluated or accepted by the Agency. 2. The Agency policy titled “Mandatory Vaccination Policy” was reviewed on 3/29/22 at 10:30 AM. The policy required: "…Employees may request an exception form this mandatory policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination. Employees also may be legally entitled to a reasonable accommodation if they cannot be vaccinated because of a…conflict with a sincerely held religious belief, practice, or observance…” The policy lacks criteria for evaluating/accepting employee requests for exemption. 3. During an interview with the Administrator and Director of Nursing on 3/30/22 at 12:10 PM, the above finding was confirmed.

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: A. Based on observation, Agency policy, and staff interview, it was determined the Agency failed to ensure a pre-designated Alternate Administrator was in place during the Administrator’s absence. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. Upon entrance to the Agency on 3/28/22 at 9:00 AM, the Administrator was not present. The Director of Nursing stated the Administrator “would not be in this week.” Surveyor inquired who the Alternate Administrator was, and the Director of Nursing replied she did not know. 2. On 3/28/22 at 9:30 AM, the Administrator called on the phone, and stated he was out of town, and did not recall who the designated Alternate Administrator was, but would have the Agency staff look into it. 3. On 3/28/22 at 10:50 AM, E #8 presented a document titled “Governing Body Meeting,” dated 10/16/12, which named the Director of Nursing as the “acting Administrator when required.” At the bottom of this document were the sections “Signed as evidence of this meeting,” and “Date”—both of these sections were left blank. 4. The Agency policy titled “Alternate Administrator” was reviewed on 3/30/22 at 11:00 AM. The policy required: “...In the event the Administrator is unavailable, a designated qualified alternate will assume the Administrator’s duties and responsibilities…The Administrator or Alternate Administrator will be available at all times during operating hours…” 5. During an interview with the Administrator and Director of Nursing on 3/30/22 at 12:10 PM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure clinical record documents were complete. This was found in 3 of 10 (Pts. #4, 5, and 2) clinical records reviewed. 3. Pt. # 2 SOC 1/31/22 Primary Diagnosis: Hypertension. The clinical record was reviewed on 3/30/22 at 10:00 AM. The record included a document titled, “Notice of Medicare Provider Non-Coverage.” The document included a signature section that included, “…I have been notified that coverage of my services will end on the effective date indicated on this notice…” The document included the patient's signature. The document lacked the signature date and the date in which home health services end. 4. During an interview with the Administrator and Director of Nursing beginning at 12:10 PM on 3/30/22 the above findings were confirmed. Findings include: 1. Pt. #4. SOC 12/13/21. Primary Diagnosis: Overactive Bladder. The clinical record was reviewed on 3/29/22 at 12:10 PM. The record included a document titled “Notice of Medicare Non-Coverage.” This document was signed by the Pt., but the date the Patient’s current home health services will end, and the date the document was signed were left blank. 2. Pt. #5. SOC 3/4/22. Primary Diagnosis: Other Lymphoid Leukemia Not Having Achieved Remission. The clinical record was reviewed on 3/29/22 at 1:50 PM. The record included a document titled “Notice of Medicare Non-Coverage.” This document was signed by the Pt., but the date the Patient’s current home health services will end, and the date the document was signed were left blank.