Every finding on record at Care Essentials Home Health

The following reflects the findings of the California Department of Public Health during a recertification survey conducted February 24, 2025, through February 27, 2025. Census: 96 Unduplicated Admissions: 281 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 The following Condition of Participation was not met: E 001 §484.102 Emergency preparedness

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: E 001 484.22 Establishment of the Emergency Program (EP) was in compliance as follows: 1. Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 004) 2. Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to 009) 3. Based on interview and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 019) 4. Based on interview and record review, the agency failed to develop and implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 024) 5. Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 032) 6. Based on interview and record review, the agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 034) 7. Based on interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to E 039) The cumulative effect of these systemic practices resulted in the potential to cause the Emergency Preparedness Program (EPP) to indicate ineffective procedures and outdated information. In addition, the potential to place the agency’s patients at risk when: the agency was not prepared to respond to the hazards most likely to occur in the community, the agency was not prepared to work with the emergency management office during an emergency or disaster, the agency did not have a back-up communication plan for governmental agencies able to provide assistance to the agency’s patients during an emergency or disaster, and problems within the Emergency Preparedness Plan had the potential to go unrecognized and unaddressed.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the Governing Body had reviewed its contents. A review of the agency’s policy and procedure titled, "Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a review had been conducted. A review of the agency’s Governing Body Meeting Minutes, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the Governing Body had reviewed the Emergency Preparedness Program. During an interview with the Administrator Designee (AD) and Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:19 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The AD stated he was a member of the Governing Body, and he could not show documented evidence the agency's Emergency Preparedness Program had been reviewed by the Governing Body for the years 2023 or 2024. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018 was conducted. There was no documented evidence to show a requirement to review and update the agency’s Emergency Preparedness Program every two years. A review of the agency’s policy and procedure titled, "Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a requirement to review and update the agency’s Emergency Preparedness Program every two years.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:29 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to their local Emergency Management Office. The Admin/DPCS stated she had not collaborated with the local, regional, State, and Federal emergency preparedness officials and did not know who to report patients or staff they could not reach after an emergency or patients in need of evacuation. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “Staff will work with regional or county emergency management planning agencies, where available, in: A. Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis. B. Defining organization's role in relation to the community-wide emergency management program and the organization's surge capacity. C. Developing an "all-hazards" command structure within the organization that links with the community command structure.”

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain contact information and directions on reporting to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:49 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 6. A means of informing state and local emergency preparedness officials before, during and after an emergency on the following: A. Patients that the organization has been unable to contact to determine service needs. B. Patients in need of evacuation due to their medical or behavioral health conditions of home environment.”

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause patients to suffer an absence of care due to a staff shortage. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had developed an agreement with another agency or business to provide emergency staffing during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:49 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she did not establish an emergency staffing agreement with another home health agency or business and should have. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, was conducted. There was no documented evidence to show a procedure had been developed to address emergency staffing.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain information on a back-up communication plan in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:59 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not developed or implemented an alternate means for communicating with Federal, State, tribal, regional and/or local emergency management agencies. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 3. Primary and alternate means for communicating with the staff, federal, State, tribal, regional and local emergency management agencies.”

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause the agency not to receive help and support from the authority having jurisdiction or provide staff available to help to the authority having jurisdiction. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to local emergency management office to obtain contact information and directions on reporting the agency’s occupancy, needs and staff available to help during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:39 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report the agency's occupancy, needs and availability of on-duty staff. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 7. A means of providing information about the organization's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

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 interview and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show a full-scale community based or tabletop emergency preparedness exercise had been conducted. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 2:20 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not conducted a full-scale community based or tabletop emergency preparedness exercise in 2023 or 2024. A review of the agency's policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “Testing: 1. [Name of agency] will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise. 2. The agency participates in a full-scale exercise that is community-based or individual, facility-based if a community-based exercise is not accessible. A. In the event an actual natural or man-made emergency occurred, the agency will be exempt for 1 year following the onset of the actual event. 3. An additional exercise is conducted and may include, but not limited to: A. A second full-scale exercise that is community-based or individual facility-based, or B. A tabletop exercise led by a facilitator and includes a group discussion, emergency scenarios and prepared questions designed to challenge an emergency plan.”

The following reflects the findings of the California Department of Public Health during a recertification survey conducted February 24, 2025, through February 27, 2025. Census: 96 Unduplicated Admissions: 281 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 The following Condition of Participation was not met: G 940 §484.105 Organization and administration of services

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 interview and record review, the agency failed to transmit OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid Services) within 30 days of the completion date for one of seven sampled patients (Patient 6) when transfer and discharge OASIS assessments were not conducted or transmitted. This failure caused missing and delayed information to CMS with the potential to result in inaccurate reimbursement calculations and quality measurements. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s OASIS assessments from November 16, 2024, to February 26, 2025, was conducted. There was no documented evidence to show the agency had conducted an OASIS transfer assessment or an OASIS discharge assessment. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS confirmed Patient 6 had not received OASIS transfer or discharge assessments and should have. The Admin/DPCS stated since the assessments had not been conducted, they were not transmitted to CMS. A review of the agency’s policy and procedure titled, “OASIS Data Transmission,” dated November 2018, indicated, “PURPOSE: To outline the OASIS data transmission requirements. POLICY: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, … PROCEDURE: 1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the … date assessment completed. A. OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points (i.e. start of care, resumption of care, follow-up, transfer to inpatient facility with or without discharge, discharge to community, and death at home.) B. The organization may take up to thirty calendar days after the date of completion of the comprehensive assessment to enter the OASIS data into their computers using … or software that conforms to all CMS data transmission specifications available on the OASIS website. C. All OASIS data items must be complete, i.e. locked, in order to accurately compute the information necessary for billing Medicare patients under the prospective payment system.”

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for four of seven sampled patients (Patients 1, 2, 5, and 6). This failure had the potential to cause a delay in the determination of Patients 1, 2, 5, and 6’s immediate care and support needs. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a certification period of March 13, 2023, to May 11, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that causes high blood sugar levels). A review of Patient 1’s physician’s referral order dated March 9, 2023, indicated a request for home health services. A review of Patient 1’s initial assessment dated March 13, 2023, indicated the initial assessment had been conducted on March 13, 2023. (The initial assessment had been completed four days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 3:32 PM, the Admin/DPCS stated the referral order from the referring physician was dated March 9, 2023, and the agency needed to admit Patient 1 within 48 hours which would be no later than March 11, 2023, but had not. 2. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 1, 2025, with a certification period of February 1, 2025, to April 1, 2025. Patient 2 had diagnoses that included open wound of right upper arm. A review of Patient 2’s physician’s referral order dated January 27, 2025, indicated a request for home health services. A review of Patient 2’s initial assessment dated February 1, 2025, indicated the initial assessment had been conducted on February 1, 2025. (The initial assessment had been completed five days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 10:35 AM, the Admin/DPCS stated the referral order from the referring physician was dated January 27, 2025, and the agency needed to admit Patient 2 within 48 hours which would be no later than January 29, 2025, but had not. 3. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 6, 2025, with a certification period of January 6, 2025, to March 6, 2025. Patient 5 had diagnoses that included colon cancer. A review of Patient 5’s physician’s referral order dated January 3, 2025, indicated a request for home health services. A review of Patient 5’s initial assessment dated January 6, 2025, indicated the initial assessment had been conducted on January 6, 2025. (The initial assessment had been completed three days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 12:06 PM, the Admin/DPCS stated the referral order from the referring physician was dated January 3, 2025, and the agency needed to admit Patient 5 within 48 hours which would be no later than January 5, 2025, but had not. 4. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s referral order dated November 11, 2024, indicated a request for home health services. A review of Patient 6’s initial assessment dated November 16, 2024, indicated the initial assessment had been conducted on November 16, 2024. (The initial assessment had been completed five days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS stated the referral order from the referring physician was dated November 11, 2024, and the agency needed to admit Patient 6 within 48 hours which would be no later than November 13, 2024, but had not. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” dated November 2018, indicated, “PURPOSE: To provide guidelines for the initial assessments of patients admitted to service and for completing plans of care. POLICY: An initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner).”

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a Registered Nurse (RN) updated the comprehensive assessment for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound had healed and the continued need for the protective orthopedic (the branch of medicine concerned with conditions involving bones and/or muscles) "boot" (a medical device that protects and stabilizes the foot or ankle after an injury) was not re-evaluated in consultation with the orthopedic physician. This failure had the potential to cause Patient 1 to suffer skin irritation and pressure sores from prolonged contact with the “boot.” A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with a Certified Home Health Aide (CHHA 1) and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s Skilled Nursing (SN) visit note by the Admin/DPCS, dated January 21, 2025, indicated, Wound one, Location: right, back of ankle, Type: surgical wound, Wound Status: closed, Surrounding Tissue: normal, Wound Bed Tissue: scabbing, Drainage Type: None, Drainage Amount: None, Drainage Odor: None.” During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated when she had reassessed Patient 1’s right ankle wound as closed and scabbed on January 21, 2025, she should have provided the orthopedic physician with Patient 1’s wound reassessment information and inquired about continuing with the orthopedic “boot” and had not. A review of the agency’s policy and procedure titled, “Ongoing Assessments,” dated November 2018, indicated, “PURPOSE: To provide guidelines for assessments of patients during ongoing care. POLICY: The scope and intensity of ongoing assessments will be determined by the patient's diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE: 1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: … E. Skin integrity … L. Progress toward goals and patient needs and problems. … 3. Reassessments should focus on: A. Patient's response to care. B. Changes in patient condition. C. Changes in patient diagnoses. … 5. Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician. 6. Based on the findings of the reassessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature(s).”

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure upon transfer and/or discharge all necessary medical information pertaining to the patient’s current course of illness and treatment, was sent to the receiving healthcare facility and healthcare practitioner for two of seven sampled patients (Patients 6 and 7). This failure had the potential to cause Patient 6 and 7 to suffer healthcare complications, including delayed diagnosis, incorrect treatment decisions, and adverse drug interactions (a harmful and unintended reaction to a drug or combination of drugs). 1. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s transfer summaries (a document that provides a concise overview of a patient's current medical condition, including diagnosis, treatment plan, medications, and relevant medical history) and discharge summaries (a written document that details a patient's medical condition upon leaving a healthcare facility, summarizing their admission details, diagnosis, treatment received, current medications, and any necessary follow-up care) from November 22, 2024, to January 14, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 6 or sent to the receiving healthcare facility or healthcare practitioner. 2. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 18, 2024, with a recertification period of September 16, 2024, to November 14, 2024. Patient 7 had diagnoses that included presence of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urinary duct to collect and drain urine). A review of Patient 7’s “Inter-Office Communication Note,” dated October 29, 2024, indicated, “PCG [Primary Caregiver) states that [Patient 7] is in [name of a California city] and does not know when he will be back but needs to be seen by [a Skilled Nurse] for [indwelling urinary catheter] care and needs supplies. [Agency’s Scheduler] told PCG that we do not service the [name of a California city] area, and we would have to redirect to another [Home Health Agency]. [Agency’s Scheduler] called [Patient 7’s medical insurance company] and spoke with [name of a medical insurance company’s representative], she will obtain [physician’s] orders and redirect [as soon as possible]. A review of Patient 7’s physician’s order dated October 29, 2024, indicated, “[Discharge from] home health services, [Patient 7] moved out of service area and will be transferred to another [Home Health Agency].” A review of Patient 7’s transfer summaries and discharge summaries from October 29, 2024, to February 26, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Admin/DPCS on February 26, 2025, at 1:55 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 7 or sent to the receiving healthcare facility or healthcare practitioner. A review of the agency’s policy and procedure titled “Transfer Summary,” dated November 2018, indicated, “PURPOSE: To define the requirements for documentation of a patient transfer to another service provider. POLICY: All patients transferred from the organization will have a transfer summary completed and filed in the clinical record. Definition: Service Provider: Another home health, hospice or health care facility. PROCEDURE: 1. Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer. B. The physical and psychosocial status at the time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Continuing symptom management needs. D. Medication profile. E. A summary of the care provided, and the progress toward achieving goals. F. Any instructions and/or referrals provided to the patient. G. The existence of any Advance Directives known to the organization. H. Date of face-to-face encounter, if during initial certification. I. The date of transfer, which is the date of the last visit made. 2. Completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical record, within two (2) business days of a planned transfer or within two (2) days of becoming aware of an unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer.” A review of the agency’s policy and procedure titled “Discharge Summary,” dated November 2018, indicated, “PURPOSE: To define requirements for documentation of service discontinuation and when patients are discharged from the organization. POLICY: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. PROCEDURE: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: A. The date of discharge, including the date the physician and the patient were informed of discharge. B. The reason for discharge. C. The reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred. D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management needs. G. The overall status of the patient. H. A summary of care or services provided. 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient's discharge. …”

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: Based on observation, interview, and record review, the agency failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound was enclosed in a protective orthopedic (the branch of medicine concerned with conditions involving bones and/or muscles) "boot" (a medical device that protects and stabilizes the foot or ankle after an injury) and the “boot” was not in Patient 1’s plan of care. This failure had the potential to cause Patient 1 to suffer improper use and maintenance of the boot, which was crucial for optimal healing of the injured area by providing the necessary stability and immobilization, while also preventing complications like skin irritation, infection, or improper weight distribution. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with a Certified Home Health Aide (CHHA 1) and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s Resumption of Care Assessment, dated December 31, 2024, was conducted. There was no documented evidence to show the presence of Patient 1’s orthopedic “boot.” A review of Patient 1’s care plan for the certification period of January 1, 2025, to March 1, 2025, was conducted. There was no documented evidence to show Patient 1’s orthopedic “boot” had been care planned. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had conducted Patient 1’s Resumption of Care Assessment on December 31, 2024, and it was her responsibility to care plan Patient 1’s orthopedic “boot” and had not. A review of the agency’s policy and procedure titled, “Care Planning Process,” dated November 2018, indicated, “PURPOSE: To provide clinical direction to clinicians providing direct patient care. POLICY: A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient's condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines). … PROCEDURE: 1. At the time of the initial assessment, the clinician, along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient's identified needs and will review it with the patient and family/caregiver. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to: A. Individualized patient needs, and resultant problems related to care, functional status, and family/caregiver support systems. B. Changes in patient's condition. C. Clinical drug monitoring, as appropriate. D. Pain and symptom management, as appropriate. E. Psychosocial and spiritual needs of patient and family/caregiver, as appropriate. F. Patient treatment choices. G. Patient and caregiver education and training that the organization will provide specific to the patient's care needs.”

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 interview, and record review, the agency failed to ensure the patients' individualized plans of care contained all the required elements for two of seven sampled patients (Patients 3 and 5) when: 1. For Patient 3: the Physical Therapy (PT) and Occupational Therapy (OT) visit frequencies were not in the plan of care and there were no physician’s orders with PT and OT visit frequencies to update the plan of care. 2. For Patient 5: the Skilled Nursing (SN) frequencies were not in the plan of care and there were no physician’s orders with SN visit frequencies to update the plan of care. This failure had the potential to cause Patients 3 and 5 not to receive the care and services to meet their care planning goals. 1. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of April 3, 2023, with a recertification period of January 22, 2025, to March 22, 2025. Patient 3 had diagnoses that included stiff-man syndrome (a rare chronic disorder that causes muscle stiffness and painful spasms). A review of Patient 3’s care plan dated January 22, 2025, to March 22, 2025, was conducted. There was no documented evidence to show PT or OT visit frequencies. A review of Patient 3’s physician’s orders from January 22, 2025, to February 13, 2025, was conducted. There was no documented evidence to show a physician’s order to update the plan of care for PT and OT visits as follows: A review of Patient 3’s PT visit notes indicated PT had visited Patient 3 on January 23, 28, and 30, 2025, and February 4, 11, and 13, 2025. A review of Patient 3’s OT visit notes indicated OT had visited Patient 3 on January 22, and 27, 2025. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 10:46 AM, the Admin/DPCS verified the PT and OT frequencies were not in Patient 3’s plan of care and there were no physician’s orders to update the plan of care for the PT and OT visits indicated above. 2. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 6, 2025, with a certification period of January 6, 2025, to March 6, 2025. Patient 5 had diagnoses that included colon cancer. A review of Patient 5’s care plan dated January 6, 2025, to March 6, 2025, was conducted. There was no documented evidence to show SN visit frequencies. A review of Patient 5’s physician’s orders from January 6, 2025, to March 6, 2025, was conducted. There was no documented evidence to show a physician’s order to update the plan of care for SN visits as follows: A review of Patient 5’s SN visit notes indicated the SN had visited Patient 5 on January 8, and 31, 2025, and February 9, and 22, 2025. During an interview with the Admin/DPCS on February 27, 2025, at 12:06 PM, the Admin/DPCS verified the SN frequencies were not in Patient 5’s plan of care and there were no physician’s orders to update the plan of care for the SN visits indicated above. A review of the agency’s policy and procedure titled, “Care Planning Process,” dated November 2018, indicated, “PURPOSE: To provide clinical direction to clinicians providing direct patient care. POLICY: A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient's condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines). … PROCEDURE: … 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: … Type, frequency, and duration of above actions. …”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to obtain physician’s orders for one of seven sampled patients (Patient 1) when a Registered Nurse (RN) removed surgical staples from Patient 1’s right ankle without a physician’s order. This failure had the potential to cause Patient 1’s surgical wound to open before it was healed. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with a Certified Home Health Aide (CHHA 1) and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples. A review of Patient 1’s care plan and physician’s orders from January 1, 2025, to February 26, 2025, was conducted. There was no documented evidence to show a physician’s order to remove staples from Patient 1’s right ankle. During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had visited Patient 1 on January 21, 2025, and remove three staples from Patient 1’s right ankle. The Admin/DPCS stated she had not documented the staple removal on her visit note or obtained a physician’s order to remove the staples and should have. A review of the agency’s policy and procedure titled “Verification of Physician Orders,” dated November 2018, indicated, “PURPOSE: To ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. POLICY: Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients.”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to maintain an infection control program that was integrated into the agency’s Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from January 3, 2024, to February 13, 2025, in a universe of 96 patients. This failure had the potential to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections. A review of the agency’s infection control logs from January 3, 2024, to February 13, 2025, was conducted. The infection control logs indicated the dates the infections were identified, the names of the patients, signs and symptoms of the infections, laboratory test results, and the treatments provided. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Office Manager (OM) on February 27, 2025, at 12:45 PM, the Admin/DPCS stated she was responsible for the Infection Control Program and the QAPI Program and the OM stated she collected the patient infection information, filled out the infection control logs and provided the infection control log data to the QAPI Committee on a quarterly basis. A review of the QAPI committee meeting notes and QAPI Program binder from January 3, 2024, to February 13, 2025, was conducted. The QAPI committee meeting notes and QAPI Program binder did not contain documentation showing infection control data had been received, aggregated (gathered together) or analyzed by the QAPI Committee. In a continued interview with the Admin/DPCS and OM, the Admin/DPCS stated the patients’ infections were discussed at the QAPI committee meeting, but the discussions were not documented. The Admin/DPCS stated she was not aware the patients’ infection data needed to be analyzed in order to identify infection trends or develop action plans to improve disease prevention. A review of the agency’s policy and procedure titled “Infection Control Plan,” dated November 2018, indicated, “Introduction: The purpose of the infection control program is to reduce the risk of acquisition and transmission of health care associated infections (HAIs). The infection control program is an integral component of the organization's safety and performance improvement programs. The organization performs an ongoing assessment of the risks for acquisition and transmission of infectious agents across all services and programs. The organization's leaders actively participate in the design and implementation of the infection control program. The organization recognizes that infection prevention and control is a community-wide effort and integrates its efforts with other health care organizations where possible. An infection control program must include planning, surveillance, identification, prevention/control, and reporting. [name of the agency] is committed to the implementation of these policies and procedures to improve patient outcomes and reduce the risk of infection in patients and staff. … PROCEDURE: … 5. The infection control plan will be monitored and evaluated in the annual program evaluation and in conjunction with the review of the organization's safety and performance improvement activities. Surveillance activities, including data collection and analysis, will be used to identify prevention and control risks. The evaluation of the infection control program includes a review of the plan, goals, and risk analysis across all services/programs. A review of the agency’s policy and procedure titled, “Improving Organizational Performance,” dated November 2018, indicated, “PURPOSE: To establish a performance improvement framework, which integrates activities to improve organization performance, manage change, improve patient safety, improve quality of care, treatment or services and reduce the risks for acquisition and transmission of infections. To improve organizational performance by focusing on high risk, high volume, and problem prone areas. … PROCEDURE: 1. Senior management with Governing Body oversight will: A. Participate in educational activities to increase their level of understanding and ability to implement performance improvement activities. The educational activities may include seminars, consultations, readings, periodicals, benchmarking, and review of available information from other organizations regarding the occurrence of sentinel events to reduce the risk of similar sentinel events within the organization. B. Set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance. C. Focus on high risk, high volume, and problem-prone areas. Consider incidence, prevalence, and severity of problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. D. Adopt a scientific, problem-solving approach to performance improvement. The scientific, problem-solving approach will include, minimally:1. Planning for performance improvement with integration of information from other relevant activities … e. Infection control surveillance. …”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a Registered Nurse (RN) provided a Certified Home Health Aide (CHHA) written patient care instructions for one of seven sampled patients (Patient 1) when the CHHA's care plan did not contain special instructions on how to care for Patient 1's orthopedic (the branch of medicine concerned with conditions involving bones and/or muscles) “boot" (a medical device that protects and stabilizes the foot or ankle after an injury). This failure had the potential to cause Patient 1 to suffer skin irritation and breakdown when the CHHA did not clean the area under the “boot” and misalignment of the “boot,” potentially causing delayed healing and increased pain. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with a Certified Home Health Aide (CHHA 1) and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s CHHA plans of care dated December 31, 2024, and January 17, 2025, was conducted. There was no documented evidence to show special instructions for Patient 1’s orthopedic “boot.” During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had created Patient 1’s CHHA plans of care dated December 31, 2024, and January 17, 2025. The Admin/DPCS stated she should have included special instructions on how to care for Patient 1’s orthopedic “boot,” and had not. A review of the agency’s policy and procedure titled “Home Health Aide Plan of Care,” dated November 2018, indicated, “PURPOSE: To define the process for the development and use of the home health aide plan of care. POLICY: Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. PROCEDURE: 1. The patient's Case Manager or other appropriate skilled professional (physical therapist, speech-language pathologist, or occupational therapist), upon initialization of aide services, will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician (or other authorized licensed independent practitioner) orders. 2. The home health aide plan of care will be individualized to the specific patient and will include at least: … H. Specific procedure(s) to be performed, including amount, frequency, and duration. I. Safety measures, including use of specific equipment … The home health aide plan of care will be reviewed with the patient to ensure understanding of the aide’s role in the home.”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to conduct an on-site Certified Home Health Aide (CHHA) supervisory visit every 14 days for two of seven sampled patients (Patients 1 and 4). This failure had the potential to cause inconsistent quality of care, missed opportunities to address changing patient needs, and compromising the well-being of the patient due to improper or inadequate care. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s physician’s order dated January 19, 2025, indicated CHHA services three times a week for one week and two times a week for six weeks. A review of the CHHA’s visit notes from January 19, 2025, to February 17, 2025, indicated the CHHA visited Patient 1 on the following days: January 21, 23, 25, 28, and 30, 2025, and February 4, 6, and 11, 2025. A review of Skilled Nurse (SN) visit notes from January 19, 2025, to February 17, 2025, was conducted. There was no documented evidence to show a CHHA supervisory visit had been conducted every 14 days. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) February 26, 2025, at 4:22 PM, the Admin/DPCS verified the CHHA had not been supervised every 14 days during the time period of January 19, 2025, to February 17, 2025, and should have been. 2. A review of Patient 4’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 1, 2025, with a certification period of January 1, 2025, to March 1, 2025. Patient 4 had diagnoses that included pressure ulcer at the base of the spine (a wound caused by prolonged pressure). A review of Patient 4’s physician’s order dated January 15, 2025, indicated CHHA services one time a week for one week and two times a week for six weeks. A review of the CHHA’s visit notes from January 15, 2025, to February 11, 2025, indicated the CHHA visited Patient 4 on the following days: January 17, 20, 24, 28, and 31, 2025, and February 3, 7, and 10, 2025. A review of Skilled Nurse (SN) visit notes from January 15, 2025, to February 11, 2025, was conducted. There was no documented evidence to show a CHHA supervisory visit had been conducted every 14 days. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) February 27, 2025, at 12:11 PM, the Admin/DPCS verified the CHHA had not been supervised every 14 days during the time period of January 15, 2025, to February 11, 2025, and should have been. A review of the agency’s policy and procedure titled “Responsibilities/Supervision of Clinical Services,” dated November 2018, indicated, “PROCEDURE: … 7. The Clinical Director will ensure that the following supervision is maintained within the organization: A. Home health aides: 1. Home health aide supervisory visits will be conducted on-site at least every fourteen (14) days by skilled personnel. Supervisory visits can be made in conjunction with the home health aide or in his/her absence. A direct observation supervisory visit will be made at least every six (6) months.”

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: The agency failed to ensure the Condition of Participation: G 940 484.105 Organization and administration of services was in compliance when: 1. Based on interview, and record review, the agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 2. Based on interview, and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 3. Based on interview, and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 4. Based on interview, and record review, the agency failed to develop and implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 5. Based on interview, and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 6. Based on interview, and record review, the agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 7. Based on interview, and record review, the agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for 2023 and 2024 years reviewed, in a universe of 96 patients. (Refer to G 942) 8. Based on interview, and record review, the agency failed to transmit OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid Services) within 30 days of the completion date for one of seven sampled patients (Patient 6) when transfer and discharge OASIS assessments were not conducted or transmitted. (Refer to G 942) 9. Based on interview, and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for four of seven sampled patients (Patients 1, 2, 5, and 6). (Refer to G 942) 10. Based on observation, interview, and record review, the agency failed to ensure a Registered Nurse (RN) updated the comprehensive assessment for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound had healed and the continued need for the protective orthopedic (the branch of medicine concerned with conditions involving bones and/or muscles) "boot" (a medical device that protects and stabilizes the foot or ankle after an injury) was not re-evaluated in consultation with the orthopedic physician. (Refer to G 942) 11. Based on interview, and record review, the agency failed to ensure upon transfer and/or discharge all necessary medical information pertaining to the patient’s current course of illness and treatment, was sent to the receiving healthcare facility and healthcare practitioner for two of seven sampled patients (Patients 6 and 7). (Refer to G 942) 12. Based on observation, interview, and record review, the agency failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound was enclosed in a protective orthopedic "boot" and the “boot” was not in Patient 1’s plan of care. (Refer to G 942) 13. Based on interview, and record review, the agency failed to ensure the patients' individualized plans of care contained all the required elements for two of seven sampled patients (Patients 3 and 5) when: a. For Patient 3: the Physical Therapy (PT) and Occupational Therapy (OT) visit frequencies were not in the plan of care and there were no physician’s orders with PT and OT visit frequencies to update the plan of care. (Refer to G 942) b. For Patient 5: the Skilled Nursing (SN) frequencies were not in the plan of care and there were no physician’s orders with SN visit frequencies to update the plan of care. (Refer to G 942) 14. Based on interview, and record review, the agency failed to obtain physician’s orders for one of seven sampled patients (Patient 1) when an RN removed surgical staples from Patient 1’s right ankle without a physician’s order. (Refer to G 942) 15. Based on interview, and record review, the agency failed to maintain an infection control program that was integrated into the agency’s Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from January 3, 2024, to February 13, 2025, in a universe of 96 patients. (Refer to G 942) 16. Based on observation, interview, and record review, the agency failed to ensure an RN provided a Certified Home Health Aide (CHHA) written patient care instructions for one of seven sampled patients (Patient 1) when the CHHA's care plan did not contain special instructions on how to care for Patient 1's orthopedic “boot.” (Refer to G 942) 17. Based on interview, and record review, the agency failed to conduct an on-site CHHA supervisory visit every 14 days for two of seven sampled patients (Patients 1 and 4). (Refer to G 942) 18. Based on interview, and record review, the agency failed to ensure the clinical record contained a completed discharge summary sent to the primary care practitioner within five business days of the patient’s discharge and a completed transfer summary was sent within two business days of becoming aware of a planned transfer to a receiving health care facility, for two or seven sampled patients (Patients 6 and 7). (Refer to G 942) The cumulative effect of these systemic practices resulted in the potential: for the EPP to indicate ineffective procedures and outdated information, to place the agency’s patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster, to place the agency’s patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process, to cause patients to suffer an absence of care due to a staff shortage, to place the agency’s patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure, to cause the agency not to receive help and support from the authority having jurisdiction or provide staff available to help to the authority having jurisdiction, to cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed, to result in inaccurate reimbursement calculations and quality measurements, to cause a delay in the determination of Patients 1, 2, 5, and 6’s immediate care and support needs, to cause Patient 1 to suffer skin irritation and pressure sores from prolonged contact with the “boot,” to cause Patient 6 and 7 to suffer healthcare complications, including delayed diagnosis, incorrect treatment decisions, and adverse drug interactions, to cause Patient 1 to suffer improper use and maintenance of the boot, which was crucial for optimal healing of the injured area by providing the necessary stability and immobilization, while also preventing complications like skin irritation, infection, or improper weight distribution, to cause Patients 3 and 5 not to receive the care and services to meet their care planning goals, to cause Patient 1’s surgical wound to open before it was healed, to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections, to cause Patient 1 to suffer skin irritation and breakdown when the CHHA did not clean the area under the “boot” and misalignment of the “boot,” potentially causing delayed healing and increased pain, and to cause inconsistent quality of care, missed opportunities to address changing patient needs, and compromising the well-being of the patient due to improper or inadequate care.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from January 1, 2023, to February 27, 2025, in a universe of 96 patients, when: 1. The agency failed to review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause the EPP to indicate ineffective procedures and outdated information. 2. The agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. 3. The agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to inform emergency management officials about patients in need of evacuation and the needs the patients would require during the evacuation process. 4. The agency failed to develop and implement a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause patients to suffer an absence of care due to a staff shortage. 5. The agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to place the agency’s patients at risk when the agency could not communicate with Federal, State, tribal, regional, and local emergency management agencies in the event of a communications failure. 6. The agency failed to implement a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause the agency not to receive help and support from the authority having jurisdiction or provide staff available to help to the authority having jurisdiction. 7. The agency failed to conduct full-scale emergency preparedness exercises that were community based (a full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional [for example, joint field office, emergency operation centers, etc.] and “boots on the ground” response [for example, firefighters decontaminating mock victims]) or tabletop emergency preparedness exercises (an exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and set a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan), for 2023 and 2024 years reviewed, in a universe of 96 patients. This failure had the potential to cause problems within the Emergency Preparedness Program to go unrecognized and unaddressed. 8. The agency failed to transmit OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid Services) within 30 days of the completion date for one of seven sampled patients (Patient 6) when transfer and discharge OASIS assessments were not conducted or transmitted. This failure caused missing and delayed information to CMS with the potential to result in inaccurate reimbursement calculations and quality measurements. 9. The agency failed to ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for four of seven sampled patients (Patients 1, 2, 5, and 6). This failure had the potential to cause a delay in the determination of Patients 1, 2, 5, and 6’s immediate care and support needs. 10. The agency failed to ensure a Registered Nurse (RN) updated the comprehensive assessment for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound had healed and the continued need for the protective orthopedic (the branch of medicine concerned with conditions involving bones and/or muscles) "boot" (a medical device that protects and stabilizes the foot or ankle after an injury) was not re-evaluated in consultation with the orthopedic physician. This failure had the potential to cause Patient 1 to suffer skin irritation and pressure sores from prolonged contact with the “boot.” 11. The agency failed to ensure upon transfer and/or discharge all necessary medical information pertaining to the patient’s current course of illness and treatment, was sent to the receiving healthcare facility and healthcare practitioner for two of seven sampled patients (Patients 6 and 7). This failure had the potential to cause Patient 6 and 7 to suffer healthcare complications, including delayed diagnosis, incorrect treatment decisions, and adverse drug interactions (a harmful and unintended reaction to a drug or combination of drugs). 12. The agency failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, for one of seven sampled patients (Patient 1) when Patient 1's right ankle surgical wound was enclosed in a protective orthopedic "boot" and the “boot” was not in Patient 1’s plan of care. This failure had the potential to cause Patient 1 to suffer improper use and maintenance of the boot, which was crucial for optimal healing of the injured area by providing the necessary stability and immobilization, while also preventing complications like skin irritation, infection, or improper weight distribution. 13. The agency failed to ensure the patients' individualized plans of care contained all the required elements for two of seven sampled patients (Patients 3 and 5) when: a. For Patient 3: the Physical Therapy (PT) and Occupational Therapy (OT) visit frequencies were not in the plan of care and there were no physician’s orders with PT and OT visit frequencies to update the plan of care. b. For Patient 5: the Skilled Nursing (SN) frequencies were not in the plan of care and there were no physician’s orders with SN visit frequencies to update the plan of care. This failure had the potential to cause Patients 3 and 5 not to receive the care and services to meet their care planning goals. 14. The agency failed to obtain physician’s orders for one of seven sampled patients (Patient 1) when an RN removed surgical staples from Patient 1’s right ankle without a physician’s order. This failure had the potential to cause Patient 1’s surgical wound to open before it was healed. 15. The agency failed to maintain an infection control program that was integrated into the agency’s Quality Assessment Performance Improvement (QAPI) program in order to: identify infection trends (analysis of a pattern), develop action plans and improve disease prevention, from January 3, 2024, to February 13, 2025, in a universe of 96 patients. This failure had the potential to cause trends in infections to go unrecognized, unaddressed and patients to suffer repeated and prolonged infections. 16. The agency failed to ensure an RN provided a Certified Home Health Aide (CHHA) written patient care instructions for one of seven sampled patients (Patient 1) when the CHHA's care plan did not contain special instructions on how to care for Patient 1's orthopedic “boot. “This failure had the potential to cause Patient 1 to suffer skin irritation and breakdown when the CHHA did not clean the area under the “boot” and misalignment of the “boot,” potentially causing delayed healing and increased pain. 17. The agency failed to conduct an on-site CHHA supervisory visit every 14 days for two of seven sampled patients (Patients 1 and 4). This failure had the potential to cause inconsistent quality of care, missed opportunities to address changing patient needs, and compromising the well-being of the patient due to improper or inadequate care. 18. The agency failed to ensure the clinical record contained a completed discharge summary sent to the primary care practitioner within five business days of the patient’s discharge and a completed transfer summary was sent within two business days of becoming aware of a planned transfer to a receiving health care facility, for two or seven sampled patients (Patients 6 and 7). This failure had the potential to cause Patient 6 and 7 to suffer healthcare complications, including delayed diagnosis, incorrect treatment decisions, and adverse drug interactions (a harmful and unintended reaction to a drug or combination of drugs). 1. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the Governing Body had reviewed its contents. A review of the agency’s policy and procedure titled, "Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a review had been conducted. A review of the agency’s Governing Body Meeting Minutes, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the Governing Body had reviewed the Emergency Preparedness Program. During an interview with the Administrator Designee (AD) and Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:19 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The AD stated he was a member of the Governing Body, and he could not show documented evidence the agency's Emergency Preparedness Program had been reviewed by the Governing Body for the years 2023 or 2024. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018 was conducted. There was no documented evidence to show a requirement to review and update the agency’s Emergency Preparedness Program every two years. A review of the agency’s policy and procedure titled, "Emergency Preparedness Plan,” undated, was conducted. There was no documented evidence to show a requirement to review and update the agency’s Emergency Preparedness Program every two years. 2. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:29 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to their local Emergency Management Office. The Admin/DPCS stated she had not collaborated with the local, regional, State, and Federal emergency preparedness officials and did not know who to report patients or staff they could not reach after an emergency or patients in need of evacuation. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “Staff will work with regional or county emergency management planning agencies, where available, in: A. Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis. B. Defining organization's role in relation to the community-wide emergency management program and the organization's surge capacity. C. Developing an "all-hazards" command structure within the organization that links with the community command structure.” 3. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain contact information and directions on reporting to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:49 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 6. A means of informing state and local emergency preparedness officials before, during and after an emergency on the following: A. Patients that the organization has been unable to contact to determine service needs. B. Patients in need of evacuation due to their medical or behavioral health conditions of home environment.” 4. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had developed an agreement with another agency or business to provide emergency staffing during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:49 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she did not establish an emergency staffing agreement with another home health agency or business and should have. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, was conducted. There was no documented evidence to show a procedure had been developed to address emergency staffing. 5. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain information on a back-up communication plan in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:59 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not developed or implemented an alternate means for communicating with Federal, State, tribal, regional and/or local emergency management agencies. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 3. Primary and alternate means for communicating with the staff, federal, State, tribal, regional and local emergency management agencies.” 6. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show the agency had reached out to local emergency management office to obtain contact information and directions on reporting the agency’s occupancy, needs and staff available to help during an emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 1:39 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not reached out to the local emergency management office and did not know the contact information or process to report the agency's occupancy, needs and availability of on-duty staff. A review of the agency’s policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The plan includes the following: … 7. A means of providing information about the organization's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.” 7. A review of the agency’s Emergency Preparedness Binder, from January 1, 2023, to February 27, 2025, was conducted. There was no documented evidence to show a full-scale community based or tabletop emergency preparedness exercise had been conducted. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 2:20 PM, the Admin/DPCS stated she was responsible for the Emergency Preparedness Program (EPP). The Admin/DPCS stated she had not conducted a full-scale community based or tabletop emergency preparedness exercise in 2023 or 2024. A review of the agency's policy and procedure titled, "Emergency Management Plan," dated November 2018, indicated, “Testing: 1. [Name of agency] will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise. 2. The agency participates in a full-scale exercise that is community-based or individual, facility-based if a community-based exercise is not accessible. A. In the event an actual natural or man-made emergency occurred, the agency will be exempt for 1 year following the onset of the actual event. 3. An additional exercise is conducted and may include, but not limited to: A. A second full-scale exercise that is community-based or individual facility-based, or B. A tabletop exercise led by a facilitator and included a group discussion, emergency scenarios and prepared questions designed to challenge an emergency plan.” 8. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s OASIS assessments from November 16, 2024, to February 26, 2025, was conducted. There was no documented evidence to show the agency had conducted an OASIS transfer assessment or an OASIS discharge assessment. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS confirmed Patient 6 had not received OASIS transfer or discharge assessments and should have. The Admin/DPCS stated since the assessments had not been conducted, they were not transmitted to CMS. A review of the agency’s policy and procedure titled, “OASIS Data Transmission,” dated November 2018, indicated, “PURPOSE: To outline the OASIS data transmission requirements. POLICY: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, … PROCEDURE: 1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the … date assessment completed. A. OASIS data is collected and completed by the qualified clinician as part of the comprehensive assessment at the required time points (i.e. start of care, resumption of care, follow-up, transfer to inpatient facility with or without discharge, discharge to community, and death at home.) B. The organization may take up to thirty calendar days after the date of completion of the comprehensive assessment to enter the OASIS data into their computers using … or software that conforms to all CMS data transmission specifications available on the OASIS website. C. All OASIS data items must be complete, i.e. locked, in order to accurately compute the information necessary for billing Medicare patients under the prospective payment system.” 9a. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a certification period of March 13, 2023, to May 11, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that causes high blood sugar levels). A review of Patient 1’s physician’s referral order dated March 9, 2023, indicated a request for home health services. A review of Patient 1’s initial assessment dated March 13, 2023, indicated the initial assessment had been conducted on March 13, 2023. (The initial assessment had been completed four days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 3:32 PM, the Admin/DPCS stated the referral order from the referring physician was dated March 9, 2023, and the agency needed to admit Patient 1 within 48 hours which would be no later than March 11, 2023, but had not. 9b. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 1, 2025, with a certification period of February 1, 2025, to April 1, 2025. Patient 2 had diagnoses that included open wound of right upper arm. A review of Patient 2’s physician’s referral order dated January 27, 2025, indicated a request for home health services. A review of Patient 2’s initial assessment dated February 1, 2025, indicated the initial assessment had been conducted on February 1, 2025. (The initial assessment had been completed five days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 10:35 AM, the Admin/DPCS stated the referral order from the referring physician was dated January 27, 2025, and the agency needed to admit Patient 2 within 48 hours which would be no later than January 29, 2025, but had not. 9c. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 6, 2025, with a certification period of January 6, 2025, to March 6, 2025. Patient 5 had diagnoses that included colon cancer. A review of Patient 5’s physician’s referral order dated January 3, 2025, indicated a request for home health services. A review of Patient 5’s initial assessment dated January 6, 2025, indicated the initial assessment had been conducted on January 6, 2025. (The initial assessment had been completed three days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 12:06 PM, the Admin/DPCS stated the referral order from the referring physician was dated January 3, 2025, and the agency needed to admit Patient 5 within 48 hours which would be no later than January 5, 2025, but had not. 9d. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s referral order dated November 11, 2024, indicated a request for home health services. A review of Patient 6’s initial assessment dated November 16, 2024, indicated the initial assessment had been conducted on November 16, 2024. (The initial assessment had been completed five days after the physician’s referral order) During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS stated the referral order from the referring physician was dated November 11, 2024, and the agency needed to admit Patient 6 within 48 hours which would be no later than November 13, 2024, but had not. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” dated November 2018, indicated, “PURPOSE: To provide guidelines for the initial assessments of patients admitted to service and for completing plans of care. POLICY: An initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner).” 10. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with CHHA 1 and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s SN visit note by the Admin/DPCS, dated January 21, 2025, indicated, Wound one, Location: right, back of ankle, Type: surgical wound, Wound Status: closed, Surrounding Tissue: normal, Wound Bed Tissue: scabbing, Drainage Type: None, Drainage Amount: None, Drainage Odor: None.” During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated when she had reassessed Patient 1’s right ankle wound as closed and scabbed on January 21, 2025, she should have provided the orthopedic physician with Patient 1’s wound reassessment information and inquired about continuing with the orthopedic “boot” and had not. A review of the agency’s policy and procedure titled, “Ongoing Assessments,” dated November 2018, indicated, “PURPOSE: To provide guidelines for assessments of patients during ongoing care. POLICY: The scope and intensity of ongoing assessments will be determined by the patient's diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE: 1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: … E. Skin integrity … L. Progress toward goals and patient needs and problems. … 3. Reassessments should focus on: A. Patient's response to care. B. Changes in patient condition. C. Changes in patient diagnoses. … 5. Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician. 6. Based on the findings of the reassessment, additional orders will be generated and forwarded to the physician (or other authorized licensed independent practitioner) for signature(s).” 11a. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s transfer summaries (a document that provides a concise overview of a patient's current medical condition, including diagnosis, treatment plan, medications, and relevant medical history) and discharge summaries (a written document that details a patient's medical condition upon leaving a healthcare facility, summarizing their admission details, diagnosis, treatment received, current medications, and any necessary follow-up care) from November 22, 2024, to January 14, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 6 or sent to the receiving healthcare facility or healthcare practitioner. 11b. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 18, 2024, with a recertification period of September 16, 2024, to November 14, 2024. Patient 7 had diagnoses that included presence of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urinary duct to collect and drain urine). A review of Patient 7’s “Inter-Office Communication Note,” dated October 29, 2024, indicated, “PCG [Primary Caregiver) states that [Patient 7] is in [name of a California city] and does not know when he will be back but needs to be seen by [a Skilled Nurse] for [indwelling urinary catheter] care and needs supplies. [Agency’s Scheduler] told PCG that we do not service the [name of a California city] area, and we would have to redirect to another [Home Health Agency]. [Agency’s Scheduler] called [Patient 7’s medical insurance company] and spoke with [name of a medical insurance company’s representative], she will obtain [physician’s] orders and redirect [as soon as possible]. A review of Patient 7’s physician’s order dated October 29, 2024, indicated, “[Discharge from] home health services, [Patient 7] moved out of service area and will be transferred to another [Home Health Agency].” A review of Patient 7’s transfer summaries and discharge summaries from October 29, 2024, to February 26, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Admin/DPCS on February 26, 2025, at 1:55 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 7 or sent to the receiving healthcare facility or healthcare practitioner. A review of the agency’s policy and procedure titled “Transfer Summary,” dated November 2018, indicated, “PURPOSE: To define the requirements for documentation of a patient transfer to another service provider. POLICY: All patients transferred from the organization will have a transfer summary completed and filed in the clinical record. Definition: Service Provider: Another home health, hospice or health care facility. PROCEDURE: 1. Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer. B. The physical and psychosocial status at the time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Continuing symptom management needs. D. Medication profile. E. A summary of the care provided, and the progress toward achieving goals. F. Any instructions and/or referrals provided to the patient. G. The existence of any Advance Directives known to the organization. H. Date of face-to-face encounter, if during initial certification. I. The date of transfer, which is the date of the last visit made. 2. Completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical record, within two (2) business days of a planned transfer or within two (2) days of becoming aware of an unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer.” A review of the agency’s policy and procedure titled “Discharge Summary,” dated November 2018, indicated, “PURPOSE: To define requirements for documentation of service discontinuation and when patients are discharged from the organization. POLICY: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. PROCEDURE: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: A. The date of discharge, including the date the physician and the patient were informed of discharge. B. The reason for discharge. C. The reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred. D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management needs. G. The overall status of the patient. H. A summary of care or services provided. 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient's discharge. …” 12. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with CHHA 1 and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s Resumption of Care Assessment, dated December 31, 2024, was conducted. There was no documented evidence to show the presence of Patient 1’s orthopedic “boot.” A review of Patient 1’s care plan for the certification period of January 1, 2025, to March 1, 2025, was conducted. There was no documented evidence to show Patient 1’s orthopedic “boot” had been care planned. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had conducted Patient 1’s Resumption of Care Assessment on December 31, 2024, and it was her responsibility to care plan Patient 1’s orthopedic “boot” and had not. A review of the agency’s policy and procedure titled, “Care Planning Process,” dated November 2018, indicated, “PURPOSE: To provide clinical direction to clinicians providing direct patient care. POLICY: A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient's condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines). … PROCEDURE: 1. At the time of the initial assessment, the clinician, along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient's identified needs and will review it with the patient and family/caregiver. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to: A. Individualized patient needs, and resultant problems related to care, functional status, and family/caregiver support systems. B. Changes in patient's condition. C. Clinical drug monitoring, as appropriate. D. Pain and symptom management, as appropriate. E. Psychosocial and spiritual needs of patient and family/caregiver, as appropriate. F. Patient treatment choices. G. Patient and caregiver education and training that the organization will provide specific to the patient's care needs.” 13a. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of April 3, 2023, with a recertification period of January 22, 2025, to March 22, 2025. Patient 3 had diagnoses that included stiff-man syndrome (a rare chronic disorder that causes muscle stiffness and painful spasms). A review of Patient 3’s care plan dated January 22, 2025, to March 22, 2025, was conducted. There was no documented evidence to show PT or OT visit frequencies. A review of Patient 3’s physician’s orders from January 22, 2025, to February 13, 2025, was conducted. There was no documented evidence to show a physician’s order to update the plan of care for PT and OT visits as follows: A review of Patient 3’s PT visit notes indicated PT had visited Patient 3 on January 23, 28, and 30, 2025, and February 4, 11, and 13, 2025. A review of Patient 3’s OT visit notes indicated OT had visited Patient 3 on January 22, and 27, 2025. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 27, 2025, at 10:46 AM, the Admin/DPCS verified the PT and OT frequencies were not in Patient 3’s plan of care and there were no physician’s orders to update the plan of care for the PT and OT visits indicated above. 13b. A review of Patient 5’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 6, 2025, with a certification period of January 6, 2025, to March 6, 2025. Patient 5 had diagnoses that included colon cancer. A review of Patient 5’s care plan dated January 6, 2025, to March 6, 2025, was conducted. There was no documented evidence to show SN visit frequencies. A review of Patient 5’s physician’s orders from January 6, 2025, to March 6, 2025, was conducted. There was no documented evidence to show a physician’s order to update the plan of care for SN visits as follows: A review of Patient 5’s SN visit notes indicated the SN had visited Patient 5 on January 8, and 31, 2025, and February 9, and 22, 2025. During an interview with the Admin/DPCS on February 27, 2025, at 12:06 PM, the Admin/DPCS verified the SN frequencies were not in Patient 5’s plan of care and there were no physician’s orders to update the plan of care for the SN visits indicated above. A review of the agency’s policy and procedure titled, “Care Planning Process,” dated November 2018, indicated, “PURPOSE: To provide clinical direction to clinicians providing direct patient care. POLICY: A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days, or as patient's condition warrants. The patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient. All clinicians including the physician involved in the patient's care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans (if applicable), clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines). … PROCEDURE: … 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: … Type, frequency, and duration of above actions. …” 14. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with CHHA 1 and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples. A review of Patient 1’s care plan and physician’s orders from January 1, 2025, to February 26, 2025, was conducted. There was no documented evidence to show a physician’s order to remove staples from Patient 1’s right ankle. During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had visited Patient 1 on January 21, 2025, and remove three staples from Patient 1’s right ankle. The Admin/DPCS stated she had not documented the staple removal on her visit note or obtained a physician’s order to remove the staples and should have. A review of the agency’s policy and procedure titled “Verification of Physician Orders,” dated November 2018, indicated, “PURPOSE: To ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. POLICY: Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients.” 15. A review of the agency’s infection control logs from January 3, 2024, to February 13, 2025, was conducted. The infection control logs indicated the dates the infections were identified, the names of the patients, signs and symptoms of the infections, laboratory test results, and the treatments provided. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Office Manager (OM) on February 27, 2025, at 12:45 PM, the Admin/DPCS stated she was responsible for the Infection Control Program and the QAPI Program and the OM stated she collected the patient infection information, filled out the infection control logs and provided the infection control log data to the QAPI Committee on a quarterly basis. A review of the QAPI committee meeting notes and QAPI Program binder from January 3, 2024, to February 13, 2025, was conducted. The QAPI committee meeting notes and QAPI Program binder did not contain documentation showing infection control data had been received, aggregated (gathered together) or analyzed by the QAPI Committee. In a continued interview with the Admin/DPCS and OM, the Admin/DPCS stated the patients’ infections were discussed at the QAPI committee meeting, but the discussions were not documented. The Admin/DPCS stated she was not aware the patients’ infection data needed to be analyzed in order to identify infection trends or develop action plans to improve disease prevention. A review of the agency’s policy and procedure titled “Infection Control Plan,” dated November 2018, indicated, “Introduction: The purpose of the infection control program is to reduce the risk of acquisition and transmission of health care associated infections (HAIs). The infection control program is an integral component of the organization's safety and performance improvement programs. The organization performs an ongoing assessment of the risks for acquisition and transmission of infectious agents across all services and programs. The organization's leaders actively participate in the design and implementation of the infection control program. The organization recognizes that infection prevention and control is a community-wide effort and integrates its efforts with other health care organizations where possible. An infection control program must include planning, surveillance, identification, prevention/control, and reporting. [name of the agency] is committed to the implementation of these policies and procedures to improve patient outcomes and reduce the risk of infection in patients and staff. … PROCEDURE: … 5. The infection control plan will be monitored and evaluated in the annual program evaluation and in conjunction with the review of the organization's safety and performance improvement activities. Surveillance activities, including data collection and analysis, will be used to identify prevention and control risks. The evaluation of the infection control program includes a review of the plan, goals, and risk analysis across all services/programs. A review of the agency’s policy and procedure titled, “Improving Organizational Performance,” dated November 2018, indicated, “PURPOSE: To establish a performance improvement framework, which integrates activities to improve organization performance, manage change, improve patient safety, improve quality of care, treatment or services and reduce the risks for acquisition and transmission of infections. To improve organizational performance by focusing on high risk, high volume, and problem prone areas. … PROCEDURE: 1. Senior management with Governing Body oversight will: A. Participate in educational activities to increase their level of understanding and ability to implement performance improvement activities. The educational activities may include seminars, consultations, readings, periodicals, benchmarking, and review of available information from other organizations regarding the occurrence of sentinel events to reduce the risk of similar sentinel events within the organization. B. Set expectations for performance improvement, set priorities and frequency of data collection and manage processes to improve organization performance. C. Focus on high risk, high volume, and problem-prone areas. Consider incidence, prevalence, and severity of problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. D. Adopt a scientific, problem-solving approach to performance improvement. The scientific, problem-solving approach will include, minimally:1. Planning for performance improvement with integration of information from other relevant activities … e. Infection control surveillance. …” 16. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s acute care hospital’s discharge information dated December 30, 2024, indicated Patient 1 had surgery to her right ankle to remove buried hardware on December 19, 2024. Patient 1 was discharged December 28, 2024, with orthopedic “boot” in place. During Patient 1’s home visit observation and interview with CHHA 1 and Patient 1’s son on February 25, 2025, from 9:56 AM to 11:06 AM, Patient 1 was in a hospital bed in her room and an orthopedic "boot" was noted to Patient 1's right lower leg and foot. CHHA 1 proceeded to give Patient 1 a bed bath (a wash given to someone who is unable to leave their bed) and washed Patient 1's right leg up to the "boot" but no further. CHHA 1 stated Patient 1's son had told her about a month ago not to remove the "boot" and she had reported this to the Administrator/Director of Patient Care Services (Admin/DPCS) who told her to follow the son's direction. Patient 1's son stated his mother had some infected hardware removed from her right ankle in December 2024 and the hospital had placed staples and the "boot" to her right ankle. Patient 1's son stated at the end of last month (January 2025) he had asked the visiting nurse to take the "boot" off because the Admin/DPCS had removed the staples, and the wound had healed but the nurse told him he would have to take his mother to an orthopedic doctor's appointment to receive orders to remove the "boot." Patient 1's son stated it was extremely difficult and painful to move his mother from her bed and transport her to a doctor's appointment, so he “just left the ‘boot’ on.” Patient 1's son stated he would have appreciated assistance from the home health agency to contact the orthopedic doctor to get permission to remove the "boot." Patient 1's son stated it was "Okay" with him if CHHA 1 removed the "boot" and cleaned the right lower leg because the visiting nurses removed and replaced the “boot” at each visit and the wound was healed. A review of Patient 1’s CHHA plans of care dated December 31, 2024, and January 17, 2025, was conducted. There was no documented evidence to show special instructions for Patient 1’s orthopedic “boot.” During an interview with the Admin/DPCS on February 26, 2025, at 3:32 PM, the Admin/DPCS stated she had created Patient 1’s CHHA plans of care dated December 31, 2024, and January 17, 2025. The Admin/DPCS stated she should have included special instructions on how to care for Patient 1’s orthopedic “boot,” and had not. A review of the agency’s policy and procedure titled “Home Health Aide Plan of Care,” dated November 2018, indicated, “PURPOSE: To define the process for the development and use of the home health aide plan of care. POLICY: Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. PROCEDURE: 1. The patient's Case Manager or other appropriate skilled professional (physical therapist, speech-language pathologist, or occupational therapist), upon initialization of aide services, will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician (or other authorized licensed independent practitioner) orders. 2. The home health aide plan of care will be individualized to the specific patient and will include at least: … H. Specific procedure(s) to be performed, including amount, frequency, and duration. I. Safety measures, including use of specific equipment … The home health aide plan of care will be reviewed with the patient to ensure understanding of the aide’s role in the home.” 17a. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 13, 2023, with a recertification period of January 1, 2025, to March 1, 2025. Patient 1 had diagnoses that included infection or inflammation of internal orthopedic implants (a medical device that replaces or supports damaged bones or joints), or prosthetic device (a medical implant that replaces a damaged joint, such as the hip, knee, or ankle). A review of Patient 1’s physician’s order dated January 19, 2025, indicated CHHA services three times a week for one week and two times a week for six weeks. A review of the CHHA’s visit notes from January 19, 2025, to February 17, 2025, indicated the CHHA visited Patient 1 on the following days: January 21, 23, 25, 28, and 30, 2025, and February 4, 6, and 11, 2025. A review of Skilled Nurse (SN) visit notes from January 19, 2025, to February 17, 2025, was conducted. There was no documented evidence to show a CHHA supervisory visit had been conducted every 14 days. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) February 26, 2025, at 4:22 PM, the Admin/DPCS verified the CHHA had not been supervised every 14 days during the time period of January 19, 2025, to February 17, 2025, and should have been. 17b. A review of Patient 4’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 1, 2025, with a certification period of January 1, 2025, to March 1, 2025. Patient 4 had diagnoses that included pressure ulcer at the base of the spine (a wound caused by prolonged pressure). A review of Patient 4’s physician’s order dated January 15, 2025, indicated CHHA services one time a week for one week and two times a week for six weeks. A review of the CHHA’s visit notes from January 15, 2025, to February 11, 2025, indicated the CHHA visited Patient 4 on the following days: January 17, 20, 24, 28, and 31, 2025, and February 3, 7, and 10, 2025. A review of Skilled Nurse (SN) visit notes from January 15, 2025, to February 11, 2025, was conducted. There was no documented evidence to show a CHHA supervisory visit had been conducted every 14 days. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) February 27, 2025, at 12:11 PM, the Admin/DPCS verified the CHHA had not been supervised every 14 days during the time period of January 15, 2025, to February 11, 2025, and should have been. A review of the agency’s policy and procedure titled “Responsibilities/Supervision of Clinical Services,” dated November 2018, indicated, “PROCEDURE: … 7. The Clinical Director will ensure that the following supervision is maintained within the organization: A. Home health aides: 1. Home health aide supervisory visits will be conducted on-site at least every fourteen (14) days by skilled personnel. Supervisory visits can be made in conjunction with the home health aide or in his/her absence. A direct observation supervisory visit will be made at least every six (6) months.” 18a. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s transfer summaries (a document that provides a concise overview of a patient's current medical condition, including diagnosis, treatment plan, medications, and relevant medical history) and discharge summaries (a written document that details a patient's medical condition upon leaving a healthcare facility, summarizing their admission details, diagnosis, treatment received, current medications, and any necessary follow-up care) from November 22, 2024, to January 14, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 6 or sent to the receiving healthcare facility or healthcare practitioner. 18b. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 18, 2024, with a recertification period of September 16, 2024, to November 14, 2024. Patient 7 had diagnoses that included presence of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urinary duct to collect and drain urine). A review of Patient 7’s “Inter-Office Communication Note,” dated October 29, 2024, indicated, “PCG [Primary Caregiver) states that [Patient 7] is in [name of a California city] and does not know when he will be back but needs to be seen by [a Skilled Nurse] for [indwelling urinary catheter] care and needs supplies. [Agency’s Scheduler] told PCG that we do not service the [name of a California city] area, and we would have to redirect to another [Home Health Agency]. [Agency’s Scheduler] called [Patient 7’s medical insurance company] and spoke with [name of a medical insurance company’s representative], she will obtain [physician’s] orders and redirect [as soon as possible]. A review of Patient 7’s physician’s order dated October 29, 2024, indicated, “[Discharge from] home health services, [Patient 7] moved out of service area and will be transferred to another [Home Health Agency].” A review of Patient 7’s transfer summaries and discharge summaries from October 29, 2024, to February 26, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Admin/DPCS on February 26, 2025, at 1:55 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 7 or sent to the receiving healthcare facility or healthcare practitioner. A review of the agency’s policy and procedure titled “Transfer Summary,” dated November 2018, indicated, “PURPOSE: To define the requirements for documentation of a patient transfer to another service provider. POLICY: All patients transferred from the organization will have a transfer summary completed and filed in the clinical record. Definition: Service Provider: Another home health, hospice or health care facility. PROCEDURE: 1. Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer. B. The physical and psychosocial status at the time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Continuing symptom management needs. D. Medication profile. E. A summary of the care provided, and the progress toward achieving goals. F. Any instructions and/or referrals provided to the patient. G. The existence of any Advance Directives known to the organization. H. Date of face-to-face encounter, if during initial certification. I. The date of transfer, which is the date of the last visit made. 2. Completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical record, within two (2) business days of a planned transfer or within two (2) days of becoming aware of an unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer.” A review of the agency’s policy and procedure titled “Discharge Summary,” dated November 2018, indicated, “PURPOSE: To define requirements for documentation of service discontinuation and when patients are discharged from the organization. POLICY: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. PROCEDURE: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: A. The date of discharge, including the date the physician and the patient were informed of discharge. B. The reason for discharge. C. The reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred. D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management needs. G. The overall status of the patient. H. A summary of care or services provided. 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient's discharge. …” During an interview with the Administrator Designee (AD) on February 27, 2025, at 2:30 PM, The AD stated he was a member of the Governing Body (GB) and assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The AD stated the GB had not identified that: 1. The agency did not review and update its Emergency Preparedness Program (EPP) every two years, for the 2023 and 2024 years reviewed. 2. The agency had not collaborated with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 and 2024 years reviewed. 3. The agency had not implemented policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 and 2024 years reviewed. 4. The agency had not developed and implemented a procedure to provide for emergency staffing during a disaster or emergency, for the 2023 and 2024 years reviewed. 5. The agency had not developed a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications failure during a disaster or emergency, for the 2023 and 2024 years reviewed. 6. The agency had not implemented a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 and 2024 years reviewed. 7. The agency had not conducted full-scale emergency preparedness exercises that were community based or tabletop emergency preparedness exercises for 2023 and 2024 years reviewed. 8. The agency had not transmitted OASIS data within 30 days of the completion date for Patient 6 when transfer and discharge OASIS assessments were not conducted or transmitted. 9. The agency did not ensure the patients' initial assessment was completed within 48 hours of the physician's referral date or on the physician-ordered start of care date for Patients 1, 2, 5, and 6. 10. The agency did not ensure an RN updated the comprehensive assessment for Patient 1 when Patient 1's right ankle surgical wound had healed and the continued need for the protective orthopedic "boot" was not re-evaluated in consultation with the orthopedic physician. 11. The agency did not ensure upon transfer and/or discharge all necessary medical information pertaining to the patient’s current course of illness and treatment, was sent to the receiving healthcare facility and healthcare practitioner for Patients 6 and 7. 12. The agency did not ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes and goals, for Patient 1 when Patient 1's right ankle surgical wound was enclosed in a protective orthopedic "boot" and the “boot” was not in Patient 1’s plan of care. 13. The agency did not ensure the patients' individualized plans of care contained all the required elements when: a. For Patient 3: the PT and OT visit frequencies were not in the plan of care and there were no physician’s orders with PT and OT visit frequencies to update the plan of care. b. For Patient 5: the SN frequencies were not in the plan of care and there were no physician’s orders with SN visit frequencies to update the plan of care. 14. The agency did not obtain physician’s orders for Patient 1 when an RN removed surgical staples from Patient 1’s right ankle without a physician’s order. 15. The agency did not maintain an infection control program that was integrated into the agency’s QAPI program in order to: identify infection trends, develop action plans and improve disease prevention, from January 3, 2024, to February 13, 2025. 16. The agency did not ensure an RN provided a CHHA written patient care instructions for Patient 1 when the CHHA's care plan did not contain special instructions on how to care for Patient 1's orthopedic “boot.” 17. The agency did conduct an on-site CHHA supervisory visit every 14 days for Patients 1 and 4. 18. The agency did not ensure the clinical record contained a completed discharge summary sent to the primary care practitioner within five business days of the patient’s discharge and a completed transfer summary was sent within two business days of becoming aware of a planned transfer to a receiving health care facility, for Patients 6 and 7. A review of the agency’s policy and procedure titled “Governing Body,” dated November 2018, indicated, “PURPOSE: To outline the roles and responsibilities of the Governing Body. POLICY: The Governing Body will assume full legal authority and responsibility for the operation of [name of the agency]. The Governing Body of [name of the agency] will serve as the governing authority for the home health program, which will function according to [name of the agency] bylaws. PROCEDURE: … 4. The Governing Body will routinely evaluate to what extent the organization has met the needs of the community for home health, has provided adequate and appropriate care to patients, …”

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 interview, and record review, the agency failed to ensure the clinical record contained a completed discharge summary sent to the primary care practitioner within five business days of the patient’s discharge and a completed transfer summary was sent within two business days of becoming aware of a planned transfer to a receiving health care facility, for two or seven sampled patients (Patients 6 and 7). This failure had the potential to cause Patient 6 and 7 to suffer healthcare complications, including delayed diagnosis, incorrect treatment decisions, and adverse drug interactions (a harmful and unintended reaction to a drug or combination of drugs). 1. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of November 16, 2024, with a certification period of November 16, 2024, to January 14, 2025. Patient 6 had diagnoses that included hypertension (high blood pressure). A review of Patient 6’s physician’s order dated November 22, 2024, indicated Patient 6 had been transferred to the hospital. A review of Patient 6’s physician’s order dated January 14, 2025, indicated Patient 6 had been discharged from the agency. A review of Patient 6’s transfer summaries (a document that provides a concise overview of a patient's current medical condition, including diagnosis, treatment plan, medications, and relevant medical history) and discharge summaries (a written document that details a patient's medical condition upon leaving a healthcare facility, summarizing their admission details, diagnosis, treatment received, current medications, and any necessary follow-up care) from November 22, 2024, to January 14, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 26, 2025, at 1:43 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 6 or sent to the receiving healthcare facility or healthcare practitioner. 2. A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 18, 2024, with a recertification period of September 16, 2024, to November 14, 2024. Patient 7 had diagnoses that included presence of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder through the urinary duct to collect and drain urine). A review of Patient 7’s “Inter-Office Communication Note,” dated October 29, 2024, indicated, “PCG [Primary Caregiver) states that [Patient 7] is in [name of a California city] and does not know when he will be back but needs to be seen by [a Skilled Nurse] for [indwelling urinary catheter] care and needs supplies. [Agency’s Scheduler] told PCG that we do not service the [name of a California city] area, and we would have to redirect to another [Home Health Agency]. [Agency’s Scheduler] called [Patient 7’s medical insurance company] and spoke with [name of a medical insurance company’s representative], she will obtain [physician’s] orders and redirect [as soon as possible]. A review of Patient 7’s physician’s order dated October 29, 2024, indicated, “[Discharge from] home health services, [Patient 7] moved out of service area and will be transferred to another [Home Health Agency].” A review of Patient 7’s transfer summaries and discharge summaries from October 29, 2024, to February 26, 2025, was conducted. There was no documented evidence to show a transfer summary and/or discharge summary had been created and sent to the receiving healthcare facility and healthcare practitioner. During an interview with the Admin/DPCS on February 26, 2025, at 1:55 PM, the Admin/DPCS verified a transfer summary and discharge summary had not been created for Patient 7 or sent to the receiving healthcare facility or healthcare practitioner. A review of the agency’s policy and procedure titled “Transfer Summary,” dated November 2018, indicated, “PURPOSE: To define the requirements for documentation of a patient transfer to another service provider. POLICY: All patients transferred from the organization will have a transfer summary completed and filed in the clinical record. Definition: Service Provider: Another home health, hospice or health care facility. PROCEDURE: 1. Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer. B. The physical and psychosocial status at the time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Continuing symptom management needs. D. Medication profile. E. A summary of the care provided, and the progress toward achieving goals. F. Any instructions and/or referrals provided to the patient. G. The existence of any Advance Directives known to the organization. H. Date of face-to-face encounter, if during initial certification. I. The date of transfer, which is the date of the last visit made. 2. Completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical record, within two (2) business days of a planned transfer or within two (2) days of becoming aware of an unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer.” A review of the agency’s policy and procedure titled “Discharge Summary,” dated November 2018, indicated, “PURPOSE: To define requirements for documentation of service discontinuation and when patients are discharged from the organization. POLICY: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. PROCEDURE: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: A. The date of discharge, including the date the physician and the patient were informed of discharge. B. The reason for discharge. C. The reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred. D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management needs. G. The overall status of the patient. H. A summary of care or services provided. 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient's discharge. …”

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted February 7, 2022 through February 11, 2022. Representing the Department of Public Health: Surveyors: 33786 41459 Census: 84 Unduplicated Admissions: 411 Home Visits with Record Review: 3 Record Reviews without Home Visits: 7 Sample Size: 10 The following Conditions of Participation were not met: E001 484.102 Emergency Preparedness (EP)

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: E 0001 403.748 Establishment of the Emergency Program (EP) was in compliance as follows: 1.Based on interview and record review, the agency failed to ensure the emergency preparedness program plan was updated and reviewed every 2 years. (Refer to E-0004). 2. Based on interview and record review, the agency failed to have strategies for addressing emergency events identified by the risk assessment. (Refer to E-0006). 3.Based on interview and record review, the agency failed to have a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency as part of continuity of operations and services, how the agency plans to continue operations during an emergency and Delegations of authority and succession plans. (refer to E-0007) 4. Based on interview and record review, the agency failed to have a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency as part of continuity of operations and services, how the agency plans to continue operations during an emergency and Delegations of authority and succession plans. (Refer to E-0009). 5. Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan. (Refer to E-0013). 6. Based on interview and record review, the agency failed to have Individual, natural and man made disaster plans for each patient in the comprehensive patient assessment. (Refer to E-0017). 7. Based on interview and record review, the agency failed to develop a policy and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. (Refer to E-0019). 8. Based on interview and record review, the agency failed to develop policies and procedures when the agency did not have a transfer arrangement with the local health care facilities to ensure patient care is continued and the actions the agency would be required to take due to the inability to make contact with staff or patients and reporting capabilities to the local and State emergency officials. (Refer to E-0021). 9. Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency.(Refer to E-0023) 10. Based on interview and record review, the agency failed to develop policies and procedures for the use of volunteer support from individuals with varying levels of skills and training and the contacting off-duty staff during an emergency and procedures to use staff from other facilities and state. (Refer to E-0024). 11.Based on interview and record review, the agency failed to develop policies and procedures for a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. (refer to E-0029). 12. Based on interview and record review, the agency failed to have a communication plan with names and contact information for Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers. (Refer to E-0030). 13. Based on interview and record review, the agency failed to have an emergency preparedness plan which included contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance. (Refer to E-0031). 14. Based on interview and record review, the agency failed to have an emergency preparedness plan to include a Primary and alternate means for communicating with Facility staff and Federal, State, tribal, regional, and local emergency management agencies. (Refer to E-32). 15. Based on interview and record review, the agency failed to develop policies and procedures for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care. (Refer to E-0033). 16. Based on interview and record review, the agency failed to develop policies and procedures for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. (Refer to E-0034). 17. Based on interview and record review, the agency failed to develop and maintain an emergency preparedness training and testing program. (Refer to E-36). 18. Based on interview and record review, the agency failed to 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 provide emergency preparedness training at least every 2 years. (Refer to E-37). 19. Based on interview and record review, the agency failed to Participate in a full-scale exercise that is community-based, conduct a individual, facility-based functional exercise, conduct a mock disaster drill, conduct a tabletop exercise that is led by a facilitator, and maintain documentation of all full scale community based exercises, individual and facility based functional exercise, mock disaster drills, and tabletop exercises. (Refer to E-39)

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness program plan was updated and reviewed every 2 years. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Finding: During a review of the agency's Emergency Preparedness Program plan on February 11, 2022 at 1 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show agency's emergency preparedness program plan was updated and reviewed every 2 years. During an interview with the DNS on February 11, 2022 at 1:15 PM, the DNS confirmed there was no documented evidence to show agency's emergency preparedness program plan was updated and reviewed every 2 years. The DNS stated, "It was not done." A request for the agency's policy and procedure for updates and review of emergency preparedness program plan every 2 years was made. The facility did not provide a policy and procedure. The DNS stated, "I don't have one." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

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, the agency failed to have strategies for addressing emergency events identified by the risk assessment. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Finding: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 9:30 AM with the Director Of Nursing Services (DNS), there was no documented evidence to show agency's had strategies for addressing emergency events identified by the risk assessment. During an interview with the DNS on February 11, 2022 at 9:40 AM, the DNS confirmed there was no documented evidence to show the agency had strategies for addressing emergency events identified by the risk assessment. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for documenting strategies for addressing emergency events identified by the risk assessment. The facility did not provide a policy and procedure. The DNS stated, "I don't have one." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency, how the agency plans to continue operations during an emergency and delegations of authority and succession plans as part of the continuity of operations and services during an emergency. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond to an emergency. Finding: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 1:35 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show agency's had a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency, how the agency plans to continue operations during an emergency and Delegations of authority and succession plans as part of the continuity of operations and services during an emergency. During an interview with the DNS on February 11, 2022 at 1:45 PM, the DNS confirmed there was no documented evidence to show the agency had a written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency as part of continuity of operations and services, how the agency plans to continue operations during an emergency and Delegations of authority and succession plans. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for written emergency plan which addresses the agency's patient populations that would be at risk during an emergency event, services that the agency would be able to provide during an emergency and any plans to address services needed that cannot be provided by the agency during an emergency, how the agency plans to continue operations during an emergency and Delegations of authority and succession plans as part of the continuity of operations and services during an emergency. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency’s policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to collaborate with local, Regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts to maintain an integrated response during an emergency. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 2 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show guidance was in place to contact and document collaborative planning efforts with local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during an emergency. During an interview with the DNS on February 11, 2022 at 2:10 PM, the DNS confirmed there was no documented evidence to show guidance was in place to contact and document collaborative planning efforts with local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency. The DNS stated, "It was not done." A request was made for the agency's policy and procedure to contact and document collaborative planning efforts with local, regional, State, and Federal emergency preparedness officials to maintain an integrated response during an emergency. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations.”

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 10:45 AM with the Director Of Nursing Services (DNS), there was no documented evidence to show the agency developed and implemented an emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan. During an interview with the DNS on February 11, 2022 at 10:50 AM, the DNS confirmed there was no documented evidence to show the agency develop and implemented emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for development and implementation of emergency preparedness policies and procedures based on the emergency plan, risk assessment, and the communication plan. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations.”

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, the agency failed to have Individual, natural or man made disaster plans for each patient in the comprehensive patient assessment. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 11:45 AM with the Director Of Nursing Services (DNS), there was no documented evidence to the agency had individual, natural, or man made disaster plans for each patient in the comprehensive patient assessment. During an interview with the DNS on February 11, 2022 at 11:50 AM, the DNS confirmed there was no documented evidence to show the agency had individual, natural, or man made disaster plans for each patient in the comprehensive patient assessment. The DNS stated, "It was not done." A request was made for the agency's policy and procedure to have individual, natural or man made disaster plans for each patient in the comprehensive patient assessment. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations.”

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a policy and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process in an emergency.. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 10:00 AM with the Director Of Nursing Services (DNS), there was no documented evidence to show the agency developed a policy and procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process in an emergency. During an interview with the DNS on February 11, 2022 at 10:15 AM, the DNS confirmed there was no documented evidence to show guidance was in place to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process. The DNS stated, "It was not done." A request was made for the agency's policy and procedure to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process in an emergency. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures when 1.The agency did not have a transfer arrangement with the local health care facilities to ensure patient care is continued during an emergency. 2. The actions the agency would be required to take due to the inability to make contact with staff or patients and reporting capabilities to the local and State emergency officials during an emergency. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Finding: 1.During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 11 AM with the Director Of Nursing Services (DNS), there was no documented evidence to show the agency had a transfer arrangement with the local health care facilities to ensure patient care is continued during an emergency. During an interview with the DNS on February 11, 2022 at 11:15 PM, the DNS confirmed there was no documented evidence to show the agency had a transfer arrangement with the local health care facilities to ensure patient care is continued during an emergency. The DNS stated, "It was not done." 2. During an review of the agency's Emergency Preparedness Program on February 11, 2022 at 11: 20 AM with the Director of Nursing Services (DNS), there was no documented evidence to show the actions the agency would be required to take due to the inability to make contact with staff or patients and reporting capabilities to the local and State emergency officials during an emergency. During an interview with the DNS on February 11, 2022 at 11:30 AM, the DNS confirmed there was no documented evidence to show the actions the agency would be required to take due to the inability to make contact with staff or patients and reporting capabilities to the local and state emergency official during an emergency. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for transfer arrangement with the local health care facilities and the actions the agency would be required to take due to the inability to make contact with staff or patients and reporting capabilities to the local and State emergency officials. The facility did not provide a policy and procedure. The DNS stated, "I don't have one." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 4:45 PM with the Director Of Nursing Services (DNS), there was no documented evidence the agency develop and implement emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency. During an interview with the DNS on February 11, 2022 at 4:50 PM, the DNS confirmed there was no documented evidence to show the development and implementation of emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for the development and implementation of emergency preparedness policies and procedures, based on the emergency plan, risk assessment, and the communication plan that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records during an emergency. The DNS stated, “I don’t have that.” During a review of the policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures for 1. The use of volunteer support during an emergency from individuals with varying levels of skills and training. 2. The contacting off-duty staff during an emergency and procedures to use staff from other facilities and state or federally-designated health professionals. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: 1.During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 2 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show a policy and procedure had been developed for the use of volunteer support during an emergency from individuals with varying levels of skills and training. During an interview with the DNS on February 11, 2022 at 2:50 PM, the DNS confirmed there was no documented evidence in the emergency preparedness program to show a policy and procedure had been developed for the use of volunteer support during an emergency from individuals with varying levels of skills and training. The DNS stated, "It was not done." 2. During a review of the agency's "Emergency Preparedness Program on February 11, 2022 at 2 PM with the Director Of Nursing Services (DNS), there was no documented evidence to a policy and procedure has been developed for the contacting off duty staff during an emergency and procedures to use staff from other facilities and state or federally-designated health professionals. During an interview with the DNS on February 11, 2022 at 2:50 PM, the DNS confirmed there was no documented evidence to show the contacting off duty staff during an emergency and procedures to use staff from other facilities and state or federally designated health professionals. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for the use of volunteer support and contacting off duty staff and the use of staff from other facilities and state or federally-designated health professionals. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures for a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 2 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show policies and procedures for a written emergency communication plan that contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. During an interview with the DNS on February 11, 2022 at 2:50 PM, the DNS confirmed there was no documented for a written emergency communication plan. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for written emergency communication plan. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have a communication plan with names and contact information for Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 2:45 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show a communication plan with names and contact information for Staff, Entities providing services under arrangement, Patients’ physicians and Volunteers had be developed. During an interview with the DNS on February 11, 2022 at 2:50 PM, the DNS confirmed there was no documented evidence to show a communication plan with names and contact information has been developed. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for developing a communication plan with names and contact information. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have an emergency preparedness plan which included contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 3 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance had been developed. During an interview with the DNS on February 11, 2022 at 3:10 PM, the DNS confirmed there was no documented evidence in the emergency preparedness program to show contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance had been developed. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for developing an emergency preparedness plan to include contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance had been developed. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have an emergency preparedness plan to include a Primary and alternate means for communicating with Facility staff and Federal, State, tribal, regional, and local emergency management agencies. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 3:20 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show a primary and alternative means for communicating with facility staff and federal, state, tribal, regional, and local emergency management agencies had been developed. During an interview with the DNS on February 11, 2022 at 3:30 PM, the DNS confirmed there was no documented evidence in the emergency preparedness program to show to a primary and alternative means for communicating with facility staff and federal, state, tribal, regional, and local emergency management agencies had been developed. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for developing an emergency preparedness plan to include contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 3:40 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show a policy and procedure had been developed for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care during an emergency. During an interview with the DNS on February 11, 2022 at 3:50 PM, the DNS confirmed there was no documented evidence in the emergency preparedness program for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care during an emergency. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for sharing information and medical documentation for patients under the agency care with other health providers to maintain the continuity of care The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop policies and procedures for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee during an emergency. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 4 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show a policy and procedure had been developed for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee in the event of an emergency. During an interview with the DNS on February 11, 2022 at 4:10 PM, the DNS confirmed there was no documented evidence in the emergency preparedness program for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for providing information about the agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop and maintain an emergency preparedness training and testing program. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 4:15 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show an emergency preparedness training and testing program had been developed and maintain. During an interview with the DNS on February 11, 2022 at 4:20 PM, the DNS confirmed there was no documented evidence to show an emergency preparedness training and testing program had been developed and maintain. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for emergency preparedness training and testing. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles and provide emergency preparedness training at least every 2 years. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 4:45 PM with the Director Of Nursing Services (DNS), there was no documented evidence to show to 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 provide emergency preparedness training at least every 2 years. During an interview with the DNS on February 11, 2022 at 4:20 PM, the DNS confirmed there was no documented evidence to show an to 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 provide emergency preparedness training at least every 2 years. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for 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 provide emergency preparedness training at least every 2 years. The facility did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the agency's, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to participate in a community based, full-scale exercise, conduct an annual individual, facility-based functional exercise, conduct a mock disaster drill, and conduct a tabletop exercise. This failure had the potential to place the agency's patients at risk when the agency was not prepared to respond in an emergency. Findings: During a review of the agency's Emergency Preparedness Program on February 11, 2022 at 4:20 PM with the Director Of Nursing Services (DNS), there was no documented evidence the agency participated in a community based full scale exercise, conduct an annual individual, facility based functional exercise, conduct a mock disaster drill, and conduct a tabletop exercise. During an interview with the DNS on February 11, 2022 at 4:20 PM, the DNS confirmed there was no documented evidence to show the agency participated in a community based full-scale exercise, conduct an annual individual, facility-based functional exercise, conduct a mock disaster drill, and conduct a tabletop exercise. The DNS stated, "It was not done." A request was made for the agency's policy and procedure for participating in a community based full scale exercise, conduct an annual individual, facility based functional exercise, conduct a mock disaster drill, and conduct a tabletop exercise. The agency did not provide a policy and procedure. The DNS stated, "I don't have that." During a review of the policy and procedure, "Emergency Management Plan," revised November 2018, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations."

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted February 7, 2022 through February 11, 2022. Representing the Department of Public Health: Surveyors: 33786 41459 Census: 84 Unduplicated Admissions: 411 Home Visits with Record Review: 3 Record Reviews without Home Visits: 7 Sample Size: 10 The following Conditions of Participation were not met: G 510 484.55 Comprehensive Assessments of Patients G 640 484.65 Quality assessment/performance improvement

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: The agency failed to provide the names, addresses, and telephone numbers of federally and state-funded entities for one of 10 Sampled Patients (Patient 4) This failure resulted in Patient 4 not having the names, addresses, and telephone numbers of federally and state-funded entities available for use in case of an emergency. Findings: During a home visit on February 10, 2022, at 3:15 PM with Patient 4, he was sitting in the recliner. The agency's admission packet was on top of the table. During a review of Patient 4's admission packet, the admission packet did not contain the names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. During an interview with Patient 4 on February 10, 2022, at 3:30 PM, Client stated, "I do not know of any telephone numbers." During an interview with the Director Of Nursing Services, (DNS 1) on February 11, 2022, at 9:45 AM, DNS 1 confirmed client 4 did not have a list of names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The Director of Nursing Services (DNS 1) stated, "I did not know the clients needed a list of names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. We have not been doing that. I will fix it right away." During a review of the Patient 4's face sheet (a document which contains basic information about the client) was admitted on February 3, 2022, with diagnoses which included high blood pressure, difficulty walking, and dementia (a disease of the brain which causes memory loss). A request was made for the agency's policy and procedure concerning the names, addresses, and telephone numbers of Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The agency did not provide a policy and procedure.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: The agency failed to ensure the Condition of Participation: G510 484.55 Comprehensive Assessment of Patients was in compliance when: Based on interview and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for two of ten sampled patients (Patient's 3 and 4) when: a. For Patient 3, four medications on the medication profile (MP- a current list of all medications prescribed for a specific patient), indicated a wrong dosage, five medications, five medications the patient was taking had a wrong frequency, seven medications the patient was taking had been discontinued, and eleven of the medications the patient was taking were not indicated on the MP. b. For Patient 4, all the medications were in a locked black box which prevented a medication review. (Refer G 536) The cumulative effect of these systemic practices resulted in the potential to cause: Patients to suffer ineffective drug therapy, significant side effects and unaddressed noncompliance with drug therapy. -

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure a review of the medications was conducted for patients in the home for two of nine sampled patients (Patients 3 and 4) when: 1. For Patient 3, four medications on the medication profile (MP – a current list of all medications prescribed for a specific patient), indicated a wrong dosage, five medications the patient was taking had a wrong frequency, seven medications the patient was taking had been discontinued, and eleven of the medications the patient was taking were not indicated on the MP. 2. For Patient 4, all the medications were in a locked black box which prevented a medication review. This failure had the potential to came ineffective drug therapy, significant side effects and non- compliance with drug therapy. [BA1]That was locked. Findings: 1. A review of Patient 3’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care from 9/30/2021, with a certification period of 1/28/2022 to 3/28/2022. Patient 3 had diagnoses that included Osteoporosis and Difficulty in Walking. During a home visit at an assisted living facility on February 9, 2022 with an Occupational Therapist (OT – treat, injured, ill, or disabled patients through the therapeutic use of everyday activities) in the presence of the assisted living facility medication technician (Med Tech-works under a licensed individual dispensing medications to residents who need them), an observation was made of Patient 3’s MP. During an observation and interview with the Medication Technician on February 9, 2022, at 2:50 PM, the Medication Technician stated the facility receives new orders from the doctor’s office, they then for Patient 3 anytime they need to. During an interview with the DON from the home health agency, she was shown the medication profile from the home health agency and the medication profile from the assisted living facility, The DON stated, “These look like two different patients. During a continued observation and interview with the Medication Technician, the Medication Technician provided the following medication cards for Patient 3: a. Acetaminophen (treats minor aches and pains and reduces fever), 325mg (milligrams – a unit of measure) take two tablets (650mg), three times daily. The medication order date is from October 6, 2021. The home health agency had the medication as Acetaminophen ER, 650mg, daily, with an order date of September 30, 2021. b. Alendronate (used to prevent and treat certain types of bone loss in adults), 70mg, take one tablet once a week before breakfast with eight oz (ounces – a unit of weight) of water, remain upright for thirty min (minutes – a period of time equal to sixty seconds) Wednesdays. The medication order date is from April 19, 2021. The home health agency had the medication as Alendronate, 70mg, take one tablet daily, with an order date of September 30, 2021 c. Amlodipine (widens blood vessels and improves blood flow and treats chest pain), 2.5mg, take one tablet daily. The medication order date is from April 12, 2021. The home health agency had the medication as Amlodipine Besylate– Benazepril HCL 5mg – 20mg take one capsule daily, order date is from September 30, 2021. d. Atorvastatin (used to lower the amount of cholesterol [a waxy, fat like substance that’s found in all the cells your body] in the blood), 40mg, take one tablet daily, the medication order date is March 15, 2021. The home health agency had the medication as Atorvastatin 80mg, take one tablet daily, order date is from September 20, 2021. e. Benazepril HCL (blocks a substance in the body that causes blood vessels to tighten), 20mg, take one tablet daily, the medication order date is April 15, 2021. The home health agency had the medication as Amlodipine Besy – Benazepril HCL 5mg -20mg take one capsule daily, order date is from September 30 2021. f. Daily -Vite Tab (used to treat and prevent vitamin deficiency due to poor diet), take one tablet daily, the medication order date is April 13, 2021. The home health agency has no record of this medication on the medication profile. g. Exemestane (used to treat early breast cancer in women who have experienced menopause [change of life; end of monthly menstrual periods]), 25mg, take one tablet daily, the medication order date is August 16, 2021. The home health agency has no record of this medication on the medication profile. h. Ferrous Sulfate (used to treat iron deficiency anemia [too few healthy red blood cells in the body] ), 325mg, take one tablet daily, the medication order date is April 13, 2021. The home health agency has no record of this medication on the medication profile. i. Hydrochlorothiazide (reduces extra fluid in the body by making more urine), 25mg, take one tablet daily, the medication order date is March 11, 2021. The home health agency has no record of this medication on the medication profile. k. Lidocaine 5% Patch (used to relieve pain), apply two patches topically to left lower back daily, on in morning and remove at bedtime, the medication order date is May 20, 2021. The home health the medication as Lidocaine 5% Patch, apply one patch every twelve hours daily, the order date is from September 30, 2021. l. Metoprolol Tartrate (used to treat high blood pressure and chronic chest pain), 25mg, take one tablet two times daily, the medication order date is April 13, 2021. The home health agency order reads: Metoprolol Tartrate, 25mg, take one tablet daily, medication order date is from September 30, 2021. k. Oysco 500-Vit D3 200 (calcium helps prevent osteoporosis [weak or brittle bones], vitamin D helps your body use the calcium, calcium and vit D are [minerals that your body needs to work properly]), take one tablet daily. The home health agency order reads: Calcium-Carbonate- Vitamin D (Liquid Calcium/Vitamin D)600-200mg unit, take one capsule daily, medication order date is from September 30, 2021. l. Pantoproazole (it works as decreasing the amount of acid you stomach makes), 20mg, take one tablet daily, the medication order date is March 11, 2021. The home health agency has no record of the order. m. Polethylene Glycol 3350 powder( increases the amount of water in the intestinal tract to stimulate bowel movements), take 8.5 grams(unit of weight), in water daily, medication order date is January 10, 2022. The home health agency order read: Polyethylene Glycol 3350, take 17 grams daily, the medication order was dated September 30, 2021. n. Sertraline HCL (used to treat depression and obsessive compulsive disorder [bothersome thoughts that won’t go away and the need to perform certain actions over and over), 50mg, take one tablet daily, medication ordered January 10, 2022. The home health agency did not have a record of this medication. o. Vitamin B12 (maintains good health and wellbeing) 1000mg, take one tablet daily, medication ordered April 13, 2021. The home health agency did not have a record of this medication in the medication profile. p. Vitamin D3 ( maintains good health and wellbeing), 2,000units, take one capsule daily, medication order date is April 13, 2021. The home health agency had no record of this medication in the medication profile. q. Bisacodyl (medication that can help you empty your bowels), 10mg suppository (another way to deliver a drug), insert one suppository rectally daily as needed, medication ordered March 8, 2021. The home health agency had no record of this medication in the medication profile. r. Hydrocodone/APAP (used to relieve moderate to severe pain), 5/325mg, take one tablet every six hours as needed, medication order date September 14, 2021. The home health agency order reads: Hydrocodone-Acetaminophen, 5-325mg, take 1 tablet 2 times a day, the order date is from September 30, 2021. s. Aspirin (can treat pain, fever, headache and inflammation), 81mg, take 1 tablet daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders nor was there a medication card available. t. Isosorbide Mononitrate ER (prevent angina [chest pain] caused by coronary artery disease [heart disease]), 30mg, take one tablet daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders, nor was there a medication card available. u. Misc Natural Products (for joint health), take on capsule daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders, nor was there a medication card available. v. Omega 3 Fatty Acids (supplements that build and maintain a healthy body), 1200mg, take one capsule daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders, nor was there a medication available. w. Multiple Vitamins – Minerals (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses or during pregnancy), take one tablet daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders, nor was there a medication available. x. Cyanocobalamin (used to treat vitamin B12 deficiency), 1500mg, take one tablet daily, medication order dated September 30, 2021. The assisted living facility medication profile did not have this medication listed on their doctor orders, nor was there a medication available. 2. A review of Patient 4’s facesheet, undated, indicated a start of care date 2/3/22, with a certification period of 2/3/22 to 4/3/22. Patient 4 had diagnoses that included: generalized arthritis, difficulty in walking, and vascular dementia without behavioral disturbance. During a home visit on February 9, 2022, with the Physical Therapist (PT – movement experts who improve quality of life through prescribed exercise, hands on care, and patient education). The PT was asked to review Patient 4 medication bottles with the medication profile. During an interview with the PT on February 9, 2022 at 3:30 PM he stated, Patient 4 does not have his medication bottles in the home, his son places the medications in a locked black box, dispensing the pills in to a weekly pill organizer. Patient 4 has a caregiver that comes into the home daily in order to give Patient 4 his medications. The PT did not know how Patient 4 gets his medications in case of an emergency. During an interview with the DON on February 10, 2022 at 10:00 AM, she stated Patient 4 has a caregiver, that lives in the same gated community, that comes into the home three times a day in order to give Patient 4 his medications, the family is also involved with his care. The son and caregiver are the only individuals who have the combination to the locked black box. The DON saw the medication bottles at start of care otherwise wasn’t sure about how to do a medication reconciliation during home visits unless the son met at Patient 4 home during each home visit. During a record review of the agency policy and procedure, titled, “Medication Profile”, revised November 2018, indicated the following: “Purpose: To define the use of the medication profile in evaluating a patient’s medication regimen, Policy: Patients receiving medications will have a current, accurate medication profile in the clinical record, Medication profiles will be updated for each chane to reflect current medications and new and/or discontinued medications, Procedure: 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization. A comparison of the medications ordered for the patient while under the organization’s care will be made to those on the list, 2. The admitting nurse will initiate a medication profile to document the current medication regimen, including name, strength, dose, route, frequency, date and time of administration and a diagnosis, condition, or indication for use for each medication ordered, A. In rehabilitation therapy-only cases, the patient’s therapist must submit a list of patient medications to a registered nurse for review, 3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after a patient has been placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy omissions and unclear information, 4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting, B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications, C. Using the medication profile as a communication tool for other clinicians involved in care, 7. The medication profile and other relevant data will be available to all clinicians providing care. 11. When the patient leaves the organization’s care, the current list of reconciled medication will be provided and explained to the patient and, as needed, the family/caregiver. Importance of managing medication will also be explained (e.g. keeping a current list of their medications up-to-date, giving the primary care physician a copy of the list and carrying medication information at all time in the event of emergency situations.) The clinician will document this interaction..."

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review of skilled nursing visits, the agency failed to provide skilled nursing visits for 5 days during the week of (12/27/21 to 1/2/22) in one of nine sampled patients. (Patient 1) This failure had the potential to cause the patient harm due to lack of care. Findings: During a record review of Patient 1’s face sheet (a document that gives a summary of patient information), undated, it indicated Patient 1 had a start of care date of 12/10/2021, with a certification period of 12/10/2021 through 2/7/2022. Patient 1 had diagnoses that included: Cellulitis (a skin infection treated with antibiotics) of unspecified part of limb, Peripheral vascular disease (a slow and progressive circulation disorder), and Methicillin Resistant Staphylococcus Aureus (MRSA) infection (staphylococcus [bacterium found in upper respiratory infections and the skin] infection that is difficult to treat because of resistance to some antibiotics. During a record review of Patient 1’s certification period (a period of time a patient can be active before the next renewal is due) was reviewed, dates December 10, 2021 through February 7, 2021. The Plan of Care (POC – Physicians Orders) indicated the frequency for the Skilled Nursing (SN – either a Registered Nurse or Licensed Vocational Nurse – provides assessment, teaching, and reviews medications) visits was one time a day for sixty days. A review of the visits for Patient 1 indicated: During the week of December 29, 2021, Patient 1 received no SN visit on December 28, 2021. During the week of December 29, 2021, Patient 1 received no SN visit on December 30, 2021, During the week of December 29, 2021, Patient 1 received no SN visit on December 31, 2021. During the week of December 29, 2021, Patient 1 received no SN visit on January 1, 2022. During the week of December 29, 2021, Patient 1 received no SN visit on January 2, 2022. There was no order received at anytime to decrease the number of SN visits. The DON confirmed that the schedule shows that the Licensed Vocational Nurse (LVN – an entry level health care provider who is responsible for rendering basic nursing care.) did miss home visits on the dates stated. The DON stated, the agency does not have any orders sent to the physician on why there were missed visits on those dates. During a record review of the agency policy and procedure, “Missing Visits”, revised November 2018, indicated the following: Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the clinical supervisory and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. 1. Patient name, 2. Date and type of visit that was missed, 3. Reason for the missed visits, 4. Description of any unmet needs and how the patient’s needs were met, 5. Physician notification including date, time, physician name, method of notification, and the staff reporting the information, 6. Any other follow-up needed, 7. Other person(s) that were notified of the missed visit, 8. Signature of staff member reporting the information, 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits..."

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: This Condition is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G640 484.65 Quality Assessment and Performance Improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to track, measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services and operations for ten of ten sampled patients (Patients1,2,3,4,5,6,7,8,9, and 10) (Refer to G 642) 2. Based on interview and record review, the agency failed to use quality indicator data to improve the quality of the agency’s services. And the agency’s Governing Body (GB) failed to approve the frequency and detail of the Quality Assessment and Performance Improvement (QAPI) program’s data collection, for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 644) 3. Based on interview and record review, the agency failed to ensure opportunities for improvement addressing gaps in systems or processes by developing and implementing an improvement or corrective plan and continuously monitoring plan for effectiveness of intervention for ten of ten sampled patients (1,2,3,4,5,6,7,8,9 and 10) (Refer to G 646) 4. Based on interview and record review, the agency failed to focus on high risk, high volume, problem-prone areas, or adverse patient events for the Quality Assessment and Performance Improvement (QAPI) program for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 648) 5. Based on interview and record review, the agency failed to consider incidence, prevalence, and severity of problems in areas and other events which are negative and unexpected impacting the patients plan of care for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 550) 6. Based on interview and record review, the agency failed to provide Quality Assessment and Performance Improvement (QAPI) program which would lead to an immediate correction of any identified problem and directly or potentially threatened the health and safety of patients for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 552) 7. Based on interview and record review, the agency failed to provide Quality Assessment and Performance Improvement (QAPI) program which would initiate performance improvement activities that must track adverse patient events, analyze their causes, and implement preventive actions for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 6554) 8. Based on interview and record review, the agency failed to provide Quality Assessment and Performance Improvement (QAPI) program which could take action aimed at performance improvement, and after implementing those actions, the Home Health Agency must measure its success and track performance to ensure that improvements are sustained for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) (Refer to G 656) 9. Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP – a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10)(Refer to G 658) 10. Based on interview and record review, the agency’s Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) program was implemented, maintained and evaluated for effectiveness for ten of ten sampled patients (1,2,3,4,5,6,7,8,9 and 10) (Refer to G 660) The cumulative effect of these systemic practices resulted in the potential to cause problems in health outcomes, patient safety and quality of care to go unrecognized and unresolved. -

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to track, measure and analyze quality indicators (a measurable element of the agency’s practice that can be used to assess the quality of care provided) in order to assess the agency’s processes of care, services and operations for 10 of 10 sampled patients (1,2,3,4,5,6,7,8,9 and 10) in a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unrecognized and unaddressed. Findings: A review of the agency’s Quality Assessment and Performance Improvement plan consisted of a stapled policy and procedure with the title, “Quality Assessment and Performance Improvement (QAPI) Plan. A governing body minutes from January 19, 2022, which did not pertain to (QAPI), a form titled, “QAA/QAPI Meeting Agenda”, which was from January 19, 2022, and a Transfer to Hospital List from 11/19/21 to 1/19/22. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, “Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systematic organization -wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required time frames, meets quarterly..."

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data to improve the quality of the agency’s services. And the agency’s Governing Body (GB) failed to approve the frequency and detail of the Quality Assessment Performance Improvement (QAPI) program’s data collection for ten of ten sampled patients (1,2,3,4,5,6,7,8,9 and 10) in a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unrecognized and unaddressed. Findings: A review of the agency’s Quality Assessment and Performance Improvement plan consisted of a stapled policy and procedure with the title, “Quality Assessment and Performance Improvement (QAPI) Plan. A governing body minutes from January 19, 2022, which did not pertain to (QAPI), a form titled, “QAA/QAPI Meeting Agenda”, which was from January 19, 2022, and a Transfer to Hospital List from 11/19/21 to 1/19/22. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, “Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systematic organization -wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required time frames, meets quarterly..."

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on interview and record review the agency’s Governing Body (GB) failed to ensure opportunities for improvement addressing gaps in systems or processes by developing and implementing an improvement or corrective plan and continuously monitoring plan for effectiveness of interventions for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care, to go unrecognized and unaddressed. Findings: During a review of the agency’s QAPI Plan the agency did not have any data related to performance improvement activities. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON went on to state, we do not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, “Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to focus on high risk, high volume, problem -prone areas, or Adverse patient events by the Quality Assessment and Performance Improvement (QAPI) program for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: A review of the agency’s Quality Assessment and Performance Improvement (QAPI) Plan there is no documented evidence to show a Performance Improvement Project (PIP – a concentrated effort on a particular problem in one area of the agency or agency wide, it involves gathering information systematically to clarify issues or problems, and intervening for improvements) had been identified, developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated,” Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to consider incidence, prevalence, and severity of problems in areas and other events which are negative and unexpected impacting the patient’s plan of care for ten of ten sampled patients (1,2,3,4,5,6,7,8,9, and 10) for a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unrecognized and unaddressed. Findings: A review of the agency’s Quality Assessment and Performance Improvement (QAPI) Plan there is no documented evidence to show a Performance Improvement Project (PIP – a concentrated effort on a particular problem in one area of the agency or agency wide, it involves gathering information systematically to clarify issues or problems, and intervening for improvements) had been identified, developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated,” Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..." '

Activities lead to an immediate correction CFR(s): 484.65(c)(1)(iii) (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide a Quality Assessment and Performance Improvement (QAPI) program which would lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of patients for ten of ten sampled patients (Patient 1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unrecognized and unaddressed. Findings: During a record review of the agency’s QAPI plan, the agency had no documented evidence to show a Performance Improvement Project (PIP) had been identified, developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide Quality Assessment and Improvement (QAPI) program which would lead to an immediate correction of any identified problem that directly or potentially threatened the health and safety of patients for ten of ten sampled patients (Patient 1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients. This failure had the potential to cause problems with health outcomes, patient safety and quality of care to go unrecognized and unaddressed. Findings: During a record review of the agency’s QAPI program, the agency had no documented evidence to show a Performance Improvement Project (PIP) had been identified developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to conduct and document Performance Improvement Projects (PIP), the agency could not provide data giving the reasons for conducting the PIP and measurable goals to show progress achieved for ten of ten patients (Patient 1,2,3,4,5,6,7,8,9, and 10) in a universe of 84 patients . The failure had the potential to cause problems in health outcomes, patient safety, and quality of care to go unrecognized and unaddressed. Findings: During a record review of the agency’s QAPI plan there is no documented evidence to show a Performance Improvement Project (PIP) had been identified, developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency’s Governing Body (GB) failed to ensure a QAPI plan was implemented maintained and evaluated for effectiveness, for ten of ten patients (Patient 1,2,3,4,5,6,7,8,9, and 10) for a universe of 84 patients. This failure had the potential to cause problems in health outcomes, patient safety, and quality of care, to go unrecognized and unresolved. Findings: During a record review of the agency’s QAPI plan there was no documented evidence to show a Performance Improvement Program (PIP) had been identified, developed or conducted. During an interview with the Director of Nursing (DON) on February 11, 2022, at 11:00 AM, she stated, “this is the first year doing QAPI.” The DON agreed that the agency does not have a full QAPI plan in place. A review of the agency’s policy and procedure titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, Revised November 2018, indicated, Mission: All QAPI activities must support and be aligned with the mission of the organization. The mission of the home health is to provide compassionate, high-quality healthcare for the best value, one person at a time, in their home setting. To carry out this mission, the home health provides: A holistic program for the patient and family, caring for the physical, psychological and rehabilitative needs, A dedicated team of health care professionals and staff who are qualified by experience and education, Education to families, caregivers, and the community at large in the area’s healthcare and chronic disease management in the home setting. Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systemic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations. Objectives: To show measurable improvement in indicators that demonstrate an improvement in patient outcomes, To measure , analyze and track quality indicators, including advisers events, to enable the assessments of processes of care, home health services and operations, To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement, To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that is tis sustained, To document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects, To keep current with monitoring of required quality measures, submit reports in mandated format within required timeframes, Meets quarterly..."

Inservice training supervised by RN CFR(s): 484.80(d)(1) In-service training may be offered by any organization and must be supervised by a registered nurse. This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to implement their performance policy and procedure for a Licensed Vocational Nurse (LVN 1) when LVN 1 did not received her annual performance evaluation for 2021. This failure had the potential not to identify areas requiring performance improvements when delivering patient care. Finding: During a review of Licensed Vocational Nurse (LVN 1) employee file on February 8, 2022, at 3 PM with Human Resources (HR), the HR did not have documented evidence LVN 1 received her annual performance evaluation for the year 2021. During an interview with HR on February 8, 2022, at 4PM, HR confirmed LVN 1 did not received her annual performance evaluation for the year 2021. The HR stated, "The LVN should have received their annual performance. It should be in their employee file." During an interview with the office manager (OM) on February 8, 2022, at 4:15 PM, she stated, "I am in charge of their annual performance." The OM further stated, "I have not done their annual performance." During a review of the agency’s policy and procedure, titled, “Performance Evaluation,” dated November 2018, indicated, “All staff will be evaluated at periodic intervals based on the appropriate job description to determine strengths and areas requiring performance improvement.”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure that the Home Health Aide/Licensed Vocational Nurse was following the Home Health/Home Care – Aide Assignment Sheet prepared by the Registered Nurse for one of ten sampled patients (Patient 1). This failure had the potential to cause the Based on interview and record review the agency failed to ensure that the Home Health Aide/Licensed Vocational Nurse was following the Home Health/Home Care – Aide Assignment Sheet prepared by the Registered Nurse for one of ten sampled patients (Patient 1). This failure had the potential to cause the patients harm due to lack of care. Findings: During a review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of 12/10/2021, with a certification period of 12/10/2021 through 2/7/2022. Patient 1 had diagnoses that included Cellulitis (a skin infection treated with antibiotics) of unspecified part of limb, Peripheral vascular disease (a slow and progressive circulation disorder), and Methicillin resistant Staphylococcus aureus infection (staphylococcus [bacterium found in upper respiratory infections and the skin] infection that is difficult to treat because of resistance to some antibiotics. During a record review of the Home Health/Home Care Assignment Sheet prepared by the Registered Nurse indicated the nursing staff (home health aide/licensed vocational nurse) caring for Patient 1 was given the assignment to perform the following tasks at each home visit: Bath via tub, Personal Care, Assist with dressing, Hair Care (brush, shampoo), Skin Care (food care, hygiene), Check Pressure Areas, Shave, Groom, Deodorant, Nail Hygiene (clean, file, report), Oral Care (brush), Ambulation Assist with Walker, Mobility Assist (bed, tub), Active Range of Motion to arms and legs bilaterally, Positioning (Assist to turn every 1-2 hours), Exercise (Physical Therapy, Occupational Therapy), Diet Order, Light Housekeeping (bedroom, bathroom), Equipment Care. Temperature, Pulse, Respirations, Blood Pressure. A review of the Home Health Aide Note for December 21, 2021, indicated, activities performed: Assist Bath- Chair, check pressure sores, Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after services. A review of the Home Health Aide Note for December 23, 2021, indicated, activities performed: Assist Bath- Chair, check pressure sores, Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after services. A review of the Home Health Aide Note for December 28, 2021, indicated, activities performed: Assist Bath-chair, Personal Care, assist with dressing, Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after Services. A review of another Home Health Aide Note for December 28, 2021, indicated Assist -Chair, assist with dressing, Hair Care (brush, shampoo), Skin Care/Foot Care (Hygiene), Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after Services. A review of the Home Health Aide Note for December 30, 2021, indicated, Assist Bath – Chair, Temperature, Pulse, Respirations, Blood Pressure, and Wash hands before and after Services. A review of another Home Health Aide Note for December 30, 2021, indicated, Assist Bath – Chair, Shave/Groom/Deodorant, Temperature, Pulse, Respirations, Blood Pressure, and Washing hands before and after Services. A review of the Home Health Aide Note for December 31, 2021, indicated, Assist Bath- Chair, Temperature, Pulse, Respirations, Blood Pressure, and Washing hands before and after Services. A review of the Home Health Aide Note for January 1, 2022, indicated, Assist Bath- Chair, Temperature, Pulse, Respirations, Blood Pressure, and Washing hands before and after Services. A review of the Home Health Aide Note for January 5, 2022, indicated, Bed Bath – Partial/Complete, Skin Care/Foot Care (Hygiene), Check pressure areas, Temperature, Pulse, Respirations, Blood Pressure, Mobility Assist, Washing hands before and after Services. A review of the Home Health Aide Note for January 6, 2022, indicated, Assist Bath – Chair, Personal Care, assist with dressing, check pressure areas, Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after Service. A review of the Home Health Aide Note for January 12, 2022, indicated, Bed Bath – Partial/Complete, Assist Bath – Chair, Personal Care, assist with dressing, Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after Services. A review of the Home Health Aide Note for January 14, 2022, indicated, Assist Bath – Chair, Personal Care, assist with dressing, Hair Care (brush, shampoo), Temperature, Pulse, Respirations, Blood Pressure, Washing hands before and after Services. During an interview with the Director of Nursing (DON) on February 10, 2022, at 10:00 AM, she stated she wasn’t aware that the Home Health Aide (HHA) needed to follow the Home Health/Home Care Aide Assignment Sheet exactly as written by the Registered Nurse. During a record review of the policy and procedure titled, “Orientation of Assigned Personnel”, revised November 2018, indicated the following: “Purpose: To define the process for the communication of patient information and assignment of responsibilities to personnel caring for the patient. Policy: When making patient care assignments, consideration will be given to the needs of the patient, personnel’s responsibilities, and the specific care to be provided. All organization personnel will receive patient information prior to caring for the patient. This will include information about the unique physical, psychosocial, and environmental aspects of the care. Patient care communication may include verbal or written instruction and demonstration. Communication about assigned responsibilities may include on-site orientation when appropriate, and at the very least, telephone contact prior to caring for the patient. Procedure: Home Health Aide – 1. Personal care and support services provided will be based on the initial and ongoing assessments of patient needs, as conducted by a nurse or therapist in the patient’s home. A. The nurse or therapist will be responsible for the initial assessment and assignment of the home health aide. Assessments are updated every 60 days, and as the patient’s condition changes, 2. The home health aide will review the duties to be performed and the arrangements for providing services, as stated in the plan of care, and he/she will discuss this with the supervising nurse or therapist. B. A home health aide assignment sheet is completed, reviewed with the home health aide, and signed by either the nurse or therapist and the home health aide. Return demonstration will be requested, as needed. 3. Each patient receives care in accordance with the written plan of care and related instructions. A. The home health aide assignment sheet correlates with the orders on the plan of care (485)..." During a record review of the policy and procedure titled, “Home Health Aide Supervisory Visits”, revised November 2018, indicated the following: “Purpose: To establish guidelines for the responsibilities and the frequency of supervisory visits for home health aides. Policy: Skilled nursing personnel or other appropriate skilled professionals, as appropriate, must be available to the home health aide for consultation at all times during the aide’s working hours. The registered nurse or other appropriate skilled professional that is familiar with the patient, the patient’s plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. Procedure: 5. Supervisory visits will be documented on a supervisory visit form. A. Each supervisory visit shall contain documentation to ensure that the aide is furnishing care in a safe and effective manner, including, but not limited to, the following elements: 1. Following patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or another appropriate skilled professional. B. Ongoing supervision will be documented within the plan of care, home health aide assignment sheet, and clinical notes..."

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency Licensed Vocational Nurse ( LVN -responsible for rendering basic nursing care) providing the skills of the home health aide (HHA- provides basic personal care to patients) missed four SN need for care or treatment that can only be performed by a licensed nurse) visits, not turning in four skilled nursing notes. The LVN provided four extra HHA visits, not following physician orders for one of ten sampled patients (Patient 1). This failure had the potential to cause the patients harm due to lack of care with lack of skilled nursing visits. Findings: During a review of the clinical record for Patient 1, certification period (the period of time a patient can be active before the next renewal is due) dates reviewed from December 10, 2021 through February 7, 2022. The Plan of Care (POC – Physician Order) indicated the frequency for the Skilled Nurse visits was one time a day, and the frequency for the HHA visits was two times a week as of December 19, 2021. A review of the visits for Patient 1 indicated: During the week of December 27, 2021, Patient 1 was missing four SN visits. During the week of December 27, 2021, Patient 1 had four extra HHA visits. During an interview on February 10, 2022 at 10:10 AM, with the Director of Nursing (DON – responsible for leading and supervising a nursing unit), she confirmed the four missing SN visits and the four extra HHA visits, with no physicians order changing the visit frequency. The DON confirmed that the HHA didn’t have any missing notes and there was no evidence the physician had been notified regarding the visit discrepancies. During a record review of the policy and procedure titled, “Missing Visits”, revised November 2018, indicated the following: “Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Procedure: 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit, B. Document in the patient’s clinical record the following information: 1. Patient name, 2. Date and type of visit that was missed, 3. Reason for the missed visit, 4. Description of any unmet needs and how the patient’s needs were met, 5. Physician notification, date, time, physician name, method of notification and the staff reporting the information, 6. Any other follow up needed, 7. Other person(s) that were notified of the missed visit, 8. Signature of staff member reporting the information, 4. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits..." During a record review of the policy and procedure titled, “Care Planning Process”, revised November 2018, indicated the following: “Purpose: To provide clinical direction to clinicians providing direct patient care. Policy: A written plan of care will be initiated within (5) days of start of care and undated at least every 60 days, or as patient’s condition warrants. The patient plan of care will be developed or revised with in (5) working days of initiation of each service or of the reassessment of the patients. All clinicians including the physician involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The patient and family/caregiver will participate in decisions regrading the plan of care whenever possible. The care planning process will be documented on the plan of care, individualized discipline-specific care plans, clinical notes, medication profiles, care conference/summary forms, and discharge/clinical summaries. Procedure: 5. The plan of care will be based upon the physicians orders and will encompass the equipment, supplies and services required to meet the patient’s needs, 10. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. Change must be written, dated and signed by the professional making the changes..."