Every finding on record at Belle Vie Home Health LLC

Based on a recertification survey conducted from January 5, 2026, through January 12, 2026, it was determined that the home health agency was not in compliance with the Conditions of Participation for Emergency Preparedness, as outlined in 42 Code of Federal Regulations 484.22 and 484.102, and a deficiency was cited.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not ensure individual emergency plans (IEPs) were developed for patients during a natural or man-made disaster or emergency. Specifically, the HHA could not provide copies of IEPs for 10 of 10 patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.) Findings include: Surveyors completed a review of the medical records of patients 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 on January 12, 2026. IEPs could not be located in any of the 10 patients' medical records. On January 8, 2026 at 09:46 AM, the surveyor emailed the administrator. The administrator was asked to provide copies of IEPs for all patients reviewed. The administrator responded, that the clinicians reviewed emergency preparedness with every patient on admission, including the patient’s specific risks and needs, but “…our current practice has not included providing individualized written emergency preparedness plans to patients.”

Based on a recertification survey conducted from January 5, 2026, through January 12, 2026, it was determined that the home health agency was in compliance with the 42 Code of Federal Regulations (CFR) for home health agencies as follows: 484.50 Patient Rights 484.55 Comprehensive Assessment of Patients 484.60 Care planning, coordination of services, and quality of care 484.70 Infection prevention and control 484.75 Skilled Professional Services 484.80 Home Health Aide Services 484.105 Organization and Administration of Services 484.110 Clinical Records No deficiencies were cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not maintain an emergency plan that was based on and included a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: On 5/9/2022, surveyors requested the HHA's emergency preparedness plan and risk assessment for review. The provided documentation included the following: “Risk Assessment: Axis In-Home Total Knee and Hip Rehabilitation is in Utah County, Utah. Current patients live within Salt Lake, Utah and adjacent counties. The State of Utah Division of Emergency Management identifies the following potential disaster risks relevant and realistic, based off the demographic location of these counties: Avalanche, dam failure, drought, flood, geologic hazards, severe weather (including snow and wind), space weather, wildfire, earthquake and climate change (https://dem.utah.gov/hazards-and-mitigation/). Other risks may include terrorist attacks, cyber-attacks, or power outages.” On 5/11/2022 at 9:00 AM, an interview was conducted with the administrator (ADM). Surveyors asked if they had created a risk assessment specific to their HHA. The ADM stated they had researched online and found the State’s risk assessment but had not developed an agency specific risk assessment.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record reviewed, it was determined the home health agency (HHA) did not ensure individual emergency plan's (IEP) were developed for each HHA patient during a natural or man-made disaster. Specifically, the HHA did not provide IEP's for each patient as part of the comprehensive assessment for 10 out of 10 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings include: 1. During a recertification survey from 5/9/2022 through 5/11/2022, the medical records of patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 were reviewed. For 10 of 10 medical records reviewed no evidence could be found to indicate an IEP had been developed for any of the sampled patients. 2. On 5/11/2022 at 9:00 AM, an interview was conducted with the director of nursing (DON). When asked about patient IEP’s, the DON stated they had emergency preparedness information in the admit packet that was provided to patients but they did not discuss or prepare an IEP for each patient.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the home health agency(HHA) failed to operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. Specifically, the home health agency did not submit a request for change of address at least 30 days before changing the location of the agency. Additionally, the agency was providing services under two different agency names while having only one provider number. (Patient identifiers: 1,2 ,3, and 4) Findings include: 1. The HHA failed to ensure licensing requirements were met. Specifically, per state licensing requirements the HHA did not submit a request for agency action/license application to amend the license status at least 30 days before changing the location of the agency. (Refer to Tag G-860) 2. On 5/9/2022 at 9:29 AM, a telephone call was made to the home health agency. The person answering the telephone stated Axis in Home/Total Knee and Hip Rehabilitation. ON 5/9/2022 at 10:21 AM, a telephone call was made to the administrator (ADM). The ADM stated the agency was Axis in Home doing business as (DBA) Total Knee and Hip Rehabilitation. The ADM stated the agency used both names depending on the admitting diagnosis of the patient. The ADM stated if they were admitting a patient after a total knee or hip surgery, the agency name was Total Knee and Hip Rehabilitation. For all other patient diagnoses the agency name was Axis in Home. The ADM stated it was confusing to patients who did not have knee or hip surgery to have the agency’s name be Total Knee and Hip Rehabilitation. A review of the patient admission packet was completed on 5/9/2022. The packet indicated both Axis in Home and Total Knee and Hip Rehabilitation printed on the paperwork. Telephone interviews were conducted with patient’s 1, 2, 3, and 4 on 5/10/2022. Three of the four patients stated they had not heard of the agency Total Knee and Hip Rehabilitation. They stated the agency providing care to them was named Axis in Home. A review of the state agency license database and CMS database revealed the legal name of the agency was Total Knee and Hip Rehabilitation. Additionally, there was no documented evidence the agency had a documented and approved approved DBA with the state agency and CMS.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure licensing requirements were met. Specifically, per state and Centers for Medicare and Medicaid (CMS) licensing requirements the HHA did not submit a request for agency action/license application to amend the license status at least 30 days before changing the location of the agency. Findings include: On 5/9/2022, an attempt was made to enter the agency for a recertification survey. The surveyor went to the address that was recorded in the CMS and the state agency database. The surveyor had also checked the internet site for the correct address and directions to the agency. Upon arrival at the location, the agency was not located at the posted address. A call was made to the agency on 5/9/2022 at 9:27 AM. The person answering the phone stated the agency had moved their office several months ago and provided the current address of the agency. Note: The agency was located in another city. The surveyor attempted to enter the agency and found the door locked and no one present at the agency. A call was made to the agency on 5/9/2022 at 10:13 AM. The person who answered stated they only use the office for meetings, training, and interviews. She stated she was at the office a couple of times a week for a few hours. The person provided the telephone number of the administrator (ADM). On 5/9/2022 at 10:21 AM, the ADM was contacted by telephone. The ADM stated that they had moved the agency office in June 2021. He stated the agency had completed all the forms necessary to change the address for both the state agency and CMS at that time. The ADM further stated the office manager could be at the office in a short amount of time if necessary since she only lived 5 minutes away from the office. Upon further review, the state agency had no record of the appropriate forms being completed and submitted to the state agency and CMS to amend the agency license.