Every finding on record at Citywide Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/28/25. Standard level deficiencies cited.

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 the review of the Agency’s documents and Staff interview, it was determined that the Agency failed to conduct and document community drills for the years of 2022 to 2025 related to the Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 05/28/25 at 10:00AM. The Agency’s documents included annual table tops for 2022 to 2025 and lacked documentation of any live activations or community drills, as required. 2. During an interview with the Administrator and Director of Nursing/ Clinical Manager on 05/28/25 at 10:30 AM, the Administrative Staff confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/28/25. Standard level deficiencies cited. Abbreviations: / = per x= times # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care RN = Registered Nurse PM = afternoon/evening Pt./ Pts.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission binder, observation during home visits, and Staff interview, it was determined in 3 of 3 (Pts. #1, 2, and 3) home visits conducted, the Agency failed to provide the Pt./patient's representative written information regarding the Agency's transfer and discharge policies. Findings include: 1. The Pt. admission binder was reviewed on 05/27/25. The binder included a form that contained a statement that the Agency provides information regarding the Agency’s transfer and discharge policies. However, the binder lacked any documentation regarding the Agency’s transfer and discharge policies. 2. The following home visits were conducted on 05/27/25 and 05/28/25: Pt. #1. SOC 04/19/25. Pt. #2. SOC 01/06/25. Pt. #3. SOC 01/11/25. During the home visits, the Pt. admission binder was observed and contained a form that staff provided the Pt. information of the Agency's transfer and discharge policies. However, the binder lacked any information pertaining to the Agency’s transfer and discharge policies. 3. During an interview with the Administrator, Director of Nursing, and the Nurse Case Manager on 05/28/25 at 12:47 PM, the Administrator confirmed that the Agency failed to provide written information regarding transfer and discharge policies.

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 the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #4 and 7) clinical records reviewed, the patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 04/19/25 with the diagnoses of Hemiplegia following Cerebral Infarct Affecting Right Dominant Side and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. The clinical record was reviewed on 05/27/25. The clinical record contained a POC dated 04/19/25, that required the SN to assess the diabetic status, and instruct on diabetic footcare,1 time a week for 9 weeks. As of 05/27/25, the SN did not document assessment of the footcare or the blood glucose. 2. Pt. #7 was admitted to the Home Health Services on 01/21/25 with the diagnoses of Encounter for Change or Removal of Surgical Wound Dressing and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/27/25. The clinical record contained a POC dated 01/21/25, that required the SN to notify the Physician if the heart rate was greater than 100. The SN failed to notify the Physician of the heart rate of 102 on 02/28/25. The same POC required the SN to assess the blood glucose, and instruct on diabetic footcare,2 times a week for 4 weeks and 1 time a week for 5 weeks. As of 05/27/25, the SN did not document assessment of the footcare or the blood glucose. 3. The findings were confirmed during the interview with the Administrator and Clinical Manager on 05/28/25 between 9:45 AM and 10:30 AM.

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 a review of the Agency's Pt. admission binder, observation during home visits, clinical record reviews, and Staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Director of Nursing/Clinical Manager. Findings include: 1. The Agency’s Pt. admission binder was reviewed on 05/27/25. The binder lacked the name and information to contact the Director of Nursing/Clinical Manager. 2. The following home visits were conducted on 05/27/25 and 05/28/25: Pt. #1. SOC 04/19/25. Pt. #2. SOC 01/06/25. Pt. #3. SOC 01/11/25. During the home visits, the Pt. admission binder was observed, and lacked the name and contact information of the Director of Nursing/Clinical Manager. 3. The following clinical records were reviewed on 05/27/25 and 05/28/25: Pt. #1. SOC 04/19/25. Pt. #2. SOC 01/06/25. Pt. #3. SOC 01/11/25. Pt. #4. SOC 04/23/25. Pt. #5. SOC 05/15/25. Pt. #6. SOC 06/26/25. Pt. #7. SOC 01/21/25. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Director of Nursing/Clinical Manager. 4. During an interview with the Administrator, Director of Nursing, and the Nurse Case Manager on 05/28/25 at 12:47 PM, the Administrator confirmed the Agency failed to provide Pts. information regarding the Director of Nursing/Clinical Manager.

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: 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 a 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 3/8/22 at 1:30 PM. The plan lacked a facility and community-based risk assessment, using an all-hazards approach. 2. During an interview conducted with the Back-up Administrator/RN, the Agency Supervisor and the Visiting Nurse/LPN/Assistant Administrator/Quality Assurance on 3/9/22 at 11:00 AM, the above finding was confirmed.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC = Start of Care HHA = Home Health Aide Pt./Pts. = Patient/Patients AM = Morning PM = Afternoon, Evening RN = Registered Nurse LPN= Licensed Practical Nurse

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that the written Pt. care instructions provided to the HHA were based on Pt. care needs. This was found in 1 of 3 (Pt. #3) clinical records reviewed, wherein the Pt. received HHA services. Findings include: 1. Pt. #3. SOC 2/15/22. Principal Diagnosis: Acute Pain Due to Trauma. A home visit was conducted with the Visiting Nurse/LPN/Assistant Administrator on 3/8/22 and an interview was conducted with Pt. #3 during the visit. Pt. #3 stated the HHA gives a full sponge bath, which the Pt. also prefers, because the shower has been leaking, and cannot be used. The clinical record was reviewed on 3/9/22 at 9:40 AM. The record contained a “HHA Care Plan" completed by the RN and dated 9/29/21. The Plan required the HHA to provide the following personal care every visit: "Assist with Chair Bath, Tub Bath, Shower, Shower w/ Chair." The Plan lacked to specify the type of bath based on Pt. needs. Pt. #3’s HHA notes dated 2/19/22, 2/23/22, 2/26/22 and 3/4/22 included documentation that HHA had been providing Pt. #3 with a “…full sponge bath.” 2. During an interview conducted with the Back-up Administrator/RN, Agency Supervisor and Visiting Nurse LPN/Assistant Administrator/Quality Assurance on 3/10/22 at 10:30 AM, the above findings were confirmed.