Every finding on record at Caring Touch, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 05/07/26. Standard deficiencies cited.

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), §485.542(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 review of the Emergency Preparedness Binder and staff interview, the Agency failed to include names and contact information for contracted staff, entities providing services under arrangement, and patients' physicians in the emergency preparedness communication plan. This has a potential to affect all staff and patients receiving services. Findings include: 1.The Emergency Preparedness binder was reviewed on 05/05/26. The binder lacked documentation of contact information for contracted staff, entities providing services under arrangement, and patient’s physicians. 2.During an interview with the Administrator and the Agency Supervisor / Director of Nursing on 05/06/26 at 4:00 PM, the Administrator and the Agency Supervisor / Director of Nursing confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to conduct a full-scale exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings include: 1.The Agency's Emergency Preparedness Plan was reviewed on 05/05/26. The Emergency Preparedness Plan lacked documentation indicating the Agency conducted any full-scale exercise or implemented the Emergency Preparedness Plan since 2023. 2. During an interview with the Administrator and the Agency Supervisor / Director of Nursing on 05/06/26 at 4:00 PM, the Administrator and Agency Supervisor / Director of Nursing confirmed the above finding.

A recertification survey was conducted in conjunction with the evaluation of the Emergency Preparedness requirements, on 05/07/26. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse RN = Registered Nurse POC = Plan of Care PsOC = Plans of Care Pt. / Pts. = Patient / Patients AM = morning PM = afternoon SOC = Start of Care OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report for the last 12 months and staff interviews, the Agency failed to submit 349 of 908 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 04/01/25 to 04/29/26, was reviewed on 05/06/26. The report documented 349 of 908 (38.44%) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM, the administrative team confirmed the above finding.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, a review of the clinical records, observation during home visits, and staff interviews, in 6 of 7 (Pts. #1, 2, 3, 4, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. and/or patients’ representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. Findings include: 1. The patient admission folder was reviewed on 05/05/26 and included the form titled, "Admission Consents/Service Agreement”. The Agency required the SN to complete the Agreement form during the SOC visit. The form lacked a section that includes the disciplines to provide services and the frequency of their visits. 2. The clinical records were reviewed from 05/05/26 to 05/06/26, and included documentation that the following services were provided: Pt. #1. SOC 02/04/26. SN, HHA, PT and OT. Pt. #2. SOC 02/19/26. SN and PT. Pt. #3. SOC 04/21/26. SN, PT and OT. Pt. #4. SOC. 03/28/26. SN, PT and OT. Pt. #6. SOC 02/12/225. SN. Pt. #7. SOC 09/03/25. SN and PT. The records included the form titled, "Admission Consents/Service Agreement” completed by the RN, signed by the Pt./patient's representative, and dated with the SOC date. The records lacked documentation that the Pt. or Pt.'s representative was notified of each discipline providing services and frequency of visits, prior to when Pt. care and services were provided. 3. Home visits were conducted on the following Pts. on 05/04/26 and 05/05/26: Pt. #1. SOC 02/04/26. Pt. #2. SOC 02/19/26. Pt. #3. SOC 04/21/26. During the home visits, the patient's admission folder was reviewed and lacked discipline and the frequency of the services to be provided. 4. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM and 4:00 PM, the administrative team confirmed the above findings.

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 clinical record review and staff interviews, in 4 of 7 (Pts. #4, 2, 3, and 7) clinical records reviewed the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for home health care services. 2. Pt. #2 was admitted for home health services on 02/19/26 with diagnosis of Essential (primary) hypertension. The clinical record was reviewed on 05/05/26. The referral for home health services was faxed to agency on 02/12/26. As of 05/07/25, the record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #3 was admitted for home health services on 04/21/26 with diagnosis of Pneumonia, unspecified organism. The clinical record was reviewed on 05/05/26. The referral for home health services was faxed to agency on 04/16/26. As of 05/07/25, the record lacked documentation the Agency initiated service within the required time frame. 4. Pt. #7 was admitted for home health services on 09/03/25 with diagnosis of Essential (primary) hypertension. The clinical record was reviewed on 05/05/26. The referral for home health services was faxed to agency on 08/27/25. As of 05/07/25, the record lacked documentation the Agency initiated service within the required time frame. 5. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM and 4:00 PM, the administrative team confirmed the above findings. Finding include: Pt. #4 was admitted to home health services on 03/28/26 with a diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 05/05/26. The referral for home health services was faxed to the Agency on 03/19/26. As of 05/07/26, the record lacked documentation the Agency initiated service within the required time frame.

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 clinical record review and staff interview on 05/06/26, in 2 of 7 (Pts. #6 & 2) clinical records, the Agency failed to ensure clinical interventions are documented in the POCs. 2. Pt. #2 was admitted to home health services on 02/19/26 with diagnosis of Essential (primary) hypertension. The clinical record was reviewed on 05/05/26. The record included the POC’s for the certification periods of 02/19/26 to 04/19/26 that required SN to assess the patient: 1 time per week for 1 time, 2 times per week for 2 weeks and 1 time per week for 6 weeks and for 04/20/26 to 06/18/26 the POC required SN to assess the patient 1 time per week for 9 weeks. The POC lacked the orders for the Right big toe abscess… “cleanse with wound wash spray, gently pat dry with gauze, paint with povidone iodine, cover with bordered gauze.” 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM and 4:00 PM, the administrative team confirmed the above findings. Findings include: Pt. #6 was admitted to home health services on 02/12/25 with a diagnosis of Burn of second-degree right thigh, Burn of second-degree of left lower leg, and chronic ulcer right lower leg. The clinical record was reviewed on 05/06/26. The record included orders on 02/12/25 for wound care interventions for left hip, RLE lateral, and right inner thigh ... "cleanse with NS, pat dry, apply Calcium alginate dressing." and for LLE ... "cleanse with NS, pat dry, apply Betadine and leave open to air." The POC for a certification period of 02/12/25 to 04/12/25 lacked documentation of the wound care interventions.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and staff interviews, in 7 of 7(Pts #1, 2, 3, 4, 5, 6 and 7) the Agency failed to provide information regarding the Agency Supervisor/Director of Nursing (DON), and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 05/04/26. The folder lacked information identifying the Agency Supervisor's name and contact information. 2. The clinical records of the following Pts. were reviewed from 05/5/26 to 05/06/26. Pt. #1 SOC 02/04/26. Pt. #2 SOC 02/19/26. Pt. #3 SOC 04/21/26. Pt. #4 SOC 03/28/26. Pt. #5 SOC 04/14/26. Pt. #6 SOC 02/12/25. Pt. #7 SOC 09/03/25. The clinical records reviewed lacked information identifying the Agency Supervisor's name and contact information. 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

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 clinical records review and staff interview, in 2 of 2 (Pt. #6 & 7) closed clinical records the Agency failed to complete and send a discharge summary to the Physician. Findings include: 2. Pt. #7 was admitted for home health services on 09/03/25 with the diagnosis of Essential (primary) hypertension. The clinical record was reviewed on 05/05/26. The record included the discharge summary completed by the SN dated 10/08/25. The record lacked documentation on the date that a copy of the summary was sent to the Physician. 3. During an interview with the Administrator and Agency Supervisor/Director of Nursing (DON) on 05/06/26 at 3:15 PM and 4:00 PM, the administrative team confirmed the above findings. Findings include: Pt. #6 was admitted to home health services on 02/12/25 with a diagnosis of Burn of second-degree right thigh. The clinical record was reviewed on 05/06/26. The clinical record lacked evidence that a discharge summary had been completed and sent to the physician.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC = Plan of Care Pt./Pts. = Patient/Patients SN = Skilled Nurse SOC = Start of Care

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/01/23 at 11:15 AM. The plan lacked documentation of a Hazard Vulnerability Risk Assessment for the years 2021 and 2022. 2. During an interview with the Administrator and Director of Nursing on 02/01/23 at 11:35 AM, the above finding was confirmed.

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), §485.542(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: A. Based on the review of the Agency's Emergency Preparedness Plan, policy review, and Staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/01/23 at 11:15 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, Patients' Physicians and entities providing service under contract. 2. The Agency’s policy titled, “All Hazard Emergency Preparedness" was reviewed on 02/01/23 at 11:15 AM. The policy required: "Planning: Each office will keep and maintain a current list of contract information for staff, staff members, vendors, emergency services, hospitals and other appropriate community resources. Said list should include phone numbers, alternate phone numbers, emails and text capabilities…” 3. During an interview with the Administrator and Director of Nursing on 02/01/23 at 11:35 AM, the above finding was confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC = Plan of Care Pt./Pts. = Patient/Patients PT = Physical Therapy SN = Skilled Nurse SOC = Start of Care

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on the clinical record review and Staff interview, it was determined the Agency Staff did not conform to the Physician’s orders. This was found in 3 of 7 (Pts. # 2, 4 and 6) records reviewed. Findings include: 1. Pt. #2 SOC 11/28/22 Diagnoses: Other Sequelae of Cerebral Infarction and Muscle Weakness. The clinical record was reviewed on 01/31/23 at 3:00 PM. The Plan of Care (POC) dated 11/28/22 included orders for the SN to assess the patient 2 times a week for 2 weeks and 1 time a week for 8 weeks. The SN did not visit/assess the patient the weeks of 12/05/22 (week #2), 12/26/22 (week #5) and 01/09/23 (week #7) and the POC was not modified. 2. Pt. #4 SOC 10/30/22 Diagnoses: Heart failure, Unspecified and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 01/31/23 at 2:00 PM. The POC dated 12/29/22 included orders for the SN: 1 time a week for 9 weeks to assess the oxygen saturation. The SN did not assess the oxygen saturation 01/07/23 (week #1), 01/13/23 (week #2) and 01/27/23 (week #4). The same POC required the SN to assess the blood glucose every visit. The SN did not assess the blood glucose on 01/13/23 (week #2). The POC also required the SN to notify the physician of weight gain greater than 215lbs or less than 205 lbs. The SN did not weigh the patient during the month of January 2023 (weeks # 1-4) and the POC was not modified. 3. Pt. #6 SOC 12/24/22 Diagnoses: “Infect/ Inflm reaction due to Periton Dialysis Catheter subs” and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 01/31/23 at 12:00 PM. The Plan of Care (POC) dated 12/24/22 included orders for the SN to assess the patient: 1 time a week for 1 week and 2 times a week for 1 week and 1 time a week for 6 weeks and notify the physician of blood sugar greater than 300 or below 60. The SN did not assess the patient’s blood glucose 12/24/22, 12/29/22 and 12/31/22 and the POC was not modified. The same POC required the PT to evaluate the patient. The PT evaluation was not conducted and the POC was not modified. 4. The above findings were confirmed, during interview with the Administrator and Director of Nursing on 02/02/23 between 9:30AM and 10:00 AM.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: A. Based on the on-site observations and Staff interview, it was determined that the Agency failed to ensure that the Administrator or pre-designated person is available during all operating hours. This has potential to affect all patients receiving Home Health services. Findings include: 1. On 01/31/23 at 9:00 AM, it was observed that there were no employees available at the Agency. A telephone call was attempted several times with no answer. 2. On 01/31/23, the Administrator arrived approximately 9:55 AM. During the entrance interview with the Administrator, it was stated that the agency calls are forwarded to his telephone. He further stated, his phone was in driving mode and he was not able to answer the phone. It was observed no designated person covered the Administrator, during that time. 3. The above findings were confirmed, during interview with the Administrator on 01/31/23 at 10:30 AM.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: A. Based on the on-site observations and a Staff interview, it was determined the Agency failed to ensure a qualified person for the administrative oversight for all the patient care. Findings include: 1. On 01/31/23 at 10:30 AM, during the entrance interview with the Administrator (LPN), it was stated that the Agency has 15 patients and several part time Registered Nurses. It was stated the Clinical Manager/Agency’s Supervisor (RN) was out of town and will return: 02/01/2023. 2. On 01/31/23 , it was observed that the Clinical Manager (RN/Employee #5) and the designated RN to act (Employee #3) were not available on 01/31/23 during the operating hours to ensure the administrative oversight for the patient care. 3. On 01/31/23 , it was observed that the Agency’s oversight was covered on 01/31/23 by the Administrator (LPN/Employee #9) and the Administrator’s designee (PTA/Employee #10) which were not Registered Nurses (RN). 4. The above findings were confirmed with the Administrator, on 01/31/2023 at 3:45 PM and with the Director of Nursing/Clinical Manager on 02/01/23 at 12:45 PM.