Every finding on record at Critical Care Visiting Nurses

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 05/27/25 to 05/29/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 05/27/25 to 05/29/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

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 document review and interview, the Home Health Agency (HHA) failed to electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments (a comprehensive patient assessment) to the Centers for Medicare and Medicaid Services (CMS) system within 30 days after completing the assessment. This failure had the potential to affect funding for the agency. Findings include: Review of the CMS OASIS assessment reference manual, effective 01/01/23 and located at https://www.cms.gov/files/document/oasis-e-guidance-manual51622.pdf, directed that the OASIS assessments be transmitted to CMS within 30 days of completion. Review of the Transmission Summary Report provided by the facility, revealed OASIS assessments were submitted to CMS greater than the 30 days after the completion of the assessment for 65 assessments submitted for 2023 Quarter (Q) 1, 57 assessments submitted for 2023 Q2, 32 assessments submitted for 2023 Q3, 39 assessments submitted for 2023 Q4, 35 assessments submitted for 2024 Q1, 36 assessments submitted for 2024 Q2, 31assessments submitted for 2024 Q3, 33 assessments submitted for Q4, and 37 assessments submitted for 2025 Q1. During an interview on 05/28/25 at 2:30 PM, the Director of Clinical Services (DCS) and Administrator stated the HHA used the CMS manual for the completion and transmission instructions for the completion and submission of the patients' OASIS assessments. The DCS and Administrator confirmed the HHA had failed to submit OASIS assessments within 30 days of completion. The DCS and Administrator also stated that OASIS assessments were delayed in being submitted due to HHA's process for completing the OASIS for transmission. The DCS and Administrator stated that the Registered Nurse or Physical Therapist performed the assessment, and it was available to the HHA’s office. The DCS and Administrator stated the assessment information was then sent to a third party affiliated with the software vendor for coding with the patient’s diagnoses. The DCS and Administrator stated after the third-party contactor completed the coding, the assessment was returned to the HHA for corrections, if needed and acknowledged OASIS assessments were submitted more than 30 days after the completion of the assessment.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) 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. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to provide information on its discharge and transfer policies in advance of furnishing care for seven out of seven sampled patients (Patients (P) 1, P2, P3, P4, P5, P6, and P7). This had the potential to affect the patient's knowledge of the agency's discharge or transfer criteria before provision of care. Findings include: Review of the agency's current undated admission packet provided by the agency revealed it did not include information on the agency discharge or transfer policies. A review of an agency's policy titled, Patient Admission Criteria, dated February 2024, revealed it included a list of items provided to the patient at the initial visit. The list did not include information about the agency discharge or transfer policies. During an interview on 05/27/25 at 2:30 PM, the Administrator confirmed that information about the agency discharge and transfer policies was not included in the admission packet or provided to the patient prior to furnishing care.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on document review, interviews, and policy review, the Home Health Agency (HHA) failed to provide the name and contact information for the Administrator for two of two patients (Patient (P) 1 and P3) reviewed during home visit observations. This failure had the potential to deter the patient or caregiver from verbalizing a complaint or concern due to the lack of direct contact information. Findings include:that the name of the Administrator was not included in the information provided to the patient/caregiver. The documentation revealed to call the "Administrator" and provided the main phone number for the agency. During an interview on 05/27/25 at 12:50 PM, Family (F) 1 confirmed that there was no information provided that included the name of the Administrator. 2. Review of documentation included in the home health folder provided to P3 during a home visit observation on 05/28/25 at 1:15 PM, revealed the name of the Administrator was not included in the information provided to the patient/caregiver. The documentation revealed to call the Administrator and provided the main phone number for the agency. During an interview on 05/28/25 at 1:25 PM, P3 confirmed that there was no information received from the agency other than what was included in the admission packet. During an interview on 05/29/25 at 10:40 AM, the Administrator stated, "The staff are supposed to bring the agency brochure along with my business card attached to it."

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on document review and staff interview, the Home Health Agency (HHA) failed to provide the OASIS (Outcome and Assessment Information Set) notice of privacy to eight of eight sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, and P8) reviewed for admission to the HHA for care and services. The HHA’s failure to inform patient of their right regarding OASIS privacy may violate the patient’s right to information privacy. Findings include: Review of the HHA’s policy titled, OASIS Statement of Patient Privacy Rights, revised 03/19, documented "Prior to furnishing care during initial evaluation visit, each non-maternal patient over the age of 18 will be informed verbally and in writing of their rights concerning OASIS data collection." During an interview on 05/28/25 at 1:45 PM, the Administrator confirmed the HHA was not providing services to patients under the age of 18 nor maternal health patients. The Administrator also confirmed the HHA failed to provide the OASIS "Statement of Patient Privacy Rights" as required.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to complete the patient comprehensive admission assessment within five calendar days after the start of care for three of five patients (Patients (P) 1, P4, and P5) reviewed for the completion of records. The failure to complete the Comprehensive Assessment in a timely manner has the potential to delay implementation of an effective plan of care. Findings include: Review of the agency's policy titled, Initial Assessment/Comprehensive Assessment, dated February 2024, revealed "Completion of the Comprehensive Assessment …The start of care date is the first visit where the Agency actually provides hands on, direct care services or treatment to the patient … Must be completed in a timely manner consistent with the patient’s needs, but no later than 30 calendar days after the start of care." The policy failed to identify the Comprehensive Assessment must be completed in five calendar days. Review of P1's Comprehensive Assessment revealed the Start of Care (SOC) date was 04/22/25 and the Comprehensive Assessment was completed on 05/01/25 which was 10 days after the SOC. Review of P4's Comprehensive Assessment revealed the SOC date was 12/27/24 and the Comprehensive Assessment was completed on 01/06/25 which was 10 days after the SOC. Review of P5's Comprehensive Assessment revealed the SOC date was 02/20/25 and the Comprehensive Assessment was completed on 03/06/25 which was 14 days after the SOC. During an interview on 05/27/29 at 2:30 PM, the Administrator stated, "We give them until Friday to complete documentation or the following Friday if the visit was on a Friday, but the nurses are late. We have done training and are working on it."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on document review, interviews, and policy review, the Home Health Agency (HHA) failed to provide the patient or caregiver with a written schedule of medications. for two of two patients (Patient (P) 1 and P3) reviewed during home visit observations. This failure had the potential to result in medication errors. Findings include: Review of the agency's policy titled, Patient Admission Criteria, dated February 2024, revealed "Develop a written medication schedule/instruction including: medication name, dosage, route and frequency and which medications will be administered by the agency staff." 1.Review of documentation included in the home health folder provided to P1 during a home visit observation on 05/27/25 at 12:30 PM, revealed the lack of a medication list including the name of the medication, dosage, and frequency. During an interview on 05/27/25 at 12:50 PM, Family (F) 1 confirmed the lack of a medication list provided by the agency. 2. Review of documentation included in the home health folder provided to P3 during a home visit observation on 05/28/25 at 1:15 PM, revealed the lack of a medication list including the name of the medication, dosage, and frequency. During an interview on 05/28/25 at 1:25 PM, P3 confirmed the lack of a medication list provided by the agency. During an interview on 05/29/25 at 10:40 AM, the Director of Clinical Services (DCS) stated, "The nurse is expected to print the medication list and bring it to the patient at the next visit."

If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This ELEMENT is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to complete an in person on-site home health aide supervisory visit every 14 days for one of two patients (Patient (P) 1) reviewed for home health aide services. This failure had the potential to result in unidentified patient or caregiver concerns or care not being provided as written in the home health aide care plan. Findings include: Review of the agency's policy titled, Home Health Aide Supervision, dated February 2024, revealed "The Agency will conduct the 14-day supervisory visit during and on-site, in person visit." Review of P1's nursing notes indicated the Director of Clinical Services (DCS) documented a home health aide supervisory visit on 05/06/25 and 05/20/25. During an interview on 05/27/25 at 4:00 PM, the DCS stated he/she has "not done in person supervisory visits for this patient" and that he/she called on the phone to inquire about the home health aide care being provided.

A Medicare recertification survey including a review of the Emergency Preparedness Program was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of health and Human Services. The survey conducted from 03/03/2021 to 03/04/2021 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every 2 years. This failure had the potential to affect 96 patients receiving home health services and hindered the facility's abilities to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: The administrator provided emergency preparedness information dated 2018. A review of Emergency Preparedness Packet for Home Health Agencies revealed an undated All-Hazard Emergency Preparedness Policy with examples of various types of incidents, definitional terms, and examples of what could potentially be considered natural disasters, and man-made disasters. During an interview on 03/04/2021 at 9:45 AM, the administrator revealed the agency had not updated their policies. We got an Emergency Preparedness Packet for Home Health Agencies in 2018 and that was the most updated policies. The agency was in the process of reviewing old policies and it was a work in progress. We do have policies that need to be updated, but we have not got to update them yet.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every 2 years. The facility failed to ensure the EPP was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach. This failure had the potential to affect 96 patients currently receiving home health services and hindered the agency's ability to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies lacked documentation of a facility-based and community-based risk assessment was conducted, utilizing an all-hazards approach. The Emergency Preparedness information dated 2018 contained no documentation of a facility-based or community-based risk assessment was conducted. There was no documented evidence of any hazard risk assessments, hazard vulnerability assessments completed or evaluated to determine any natural disasters, geographical, environmental disasters, manmade disasters, or operational disasters as part of the agency's EPP plan. Review of the agency policy titled Emergency Preparedness Guidance Home Health and Hospice Policy dated July 19, 2017 indicated, "The providers/suppliers are required to meet four core elements (with specific requirements adjusted based on the individual characteristics of each provider and supplier): Emergency plan- Develop an emergency plan based on a risk assessment and using an all hazards approach, which will provide an integrated system for emergency planning that focuses on capacities and capabilities." During an interview on 03/04/2021 at 9:45 AM, the administrator indicated the agency did not have a documented facility-based and community-based risk assessment. The administrator indicated the agency obtain an Emergency Preparedness Book in 2018 and this was the most updated policy.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least every 2 years. The facility failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials, and did not include documentation of the facility's efforts to contact such officials. This failure had the potential to affect 96 patients receiving home health services and hindered the facility's abilities to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies lacked documentation of a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials. There was no evidence of documentation to include the facility's efforts to contact such officials. Review of Emergency Preparedness information dated 2018 indicated, "Communication Elements-Home health organizations are required to develop an emergency preparedness communication plan for communicating with local, state, tribal, regional, and national emergency management organizations. This plan must comply with federal, state, and local laws. In addition, the plan must be reviewed and updated at least every two years ...Documentation of the coordination and interaction procedures must be kept for tribal, local, regional, state and national emergency management agencies." During an interview on 03/04/2021 at 9:45 AM, the facility administrator confirmed the agency lacked documented evidence of contact with local, regional, state, or federal officials.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and implement emergency preparedness policies and procedures based on the facility and community-based risk assessments that was reviewed and updated every two years. This failure had the potential to affect 96 patients receiving home health services and hindered the facility's abilities to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies lacked documentation of when the EPP plan was developed, reviewed, and updated. The Emergency Preparedness information dated 2018 lacked documentation to indicate any facility-based risk assessments, community-based risk assessments, all-hazard risk assessments, or hazard vulnerability assessments were completed or evaluated as part of the facility's EPP plan. During an interview on 03/04/2021 at 9:45 AM, the administrator confirmed the agency lacked documented evidence a facility-based risk assessment, an all-hazard risk assessment, or a hazard vulnerability assessment had been conducted to assist with the development of emergency preparedness policies and procedures.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to develop and implement policies and procedures to address a system of medical documentation that preserves patient information, protects confidentiality or patient information, and secures and maintains availability of records. This failure had the potential to affect 96 patients currently receiving home health services and hindered the facility's ability to prepare for potential emergency situations and keep patient medical records and patient information safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies lacked documentation on how the facility would protect the confidentiality of patient information and secure and maintain patient medical records in the event of an emergency. The Emergency Preparedness information dated 2018 revealed a policy and procedure dated 2018 which indicated, "Determining the location of patients ...can be time consuming when an organization has not implemented a tracking and monitoring system ...Patient Tracking Form: Use this form to maintain updated contact information for each patient ...check your patient electronic health record software's capability to print a tracking form." Review of the Patient Tracking Form dated 2018 being used as a sample document was blank. There was no evidence in place to determine how the facility was protecting the confidentiality of patient information and securing and maintaining patient medical records. During an interview on 03/04/2021 at 9:45 AM, the administrator revealed the agency had updated the policies. The Emergency Preparedness Packet for Home Health Agencies dated 2018 was most updated policies. The agency was in the process of reviewing old policies and it was a work in progress. The administrator revealed patients were educated to keep everything with them. Everything was in our software and our nurses were educated on confidentiality of records. Our office was locked and under a security system.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to ensure the communication plan included names and contact information for staff and for entities providing services under arrangement, patient's physicians, and volunteers. This failure had the potential to affect 96 patients currently receiving home health services and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies identified a phone tree which listed the administrator, two chief executive officers, one office staff, then clinicians however there was no contact information or phone numbers listed for any of the telephone tree contacts, or any staff. The Emergency Preparedness binder lacked documented evidence of emergency contact information for staff, patient's physicians, or volunteers. The Emergency Preparedness information dated 2018 indicated, "Identifying the individuals who are responsible for activating the Emergency Preparedness Plan, the roles and responsibilities of these individuals, along with their primary and alternative contact information, is essential to ensuring your organization's policies and procedures are followed in a timely and appropriate manner." During an interview on 03/04/2021 at 9:45 AM, the administrator provided a list of hospital numbers and fax numbers. The administrator revealed it was an updated list of hospital phone numbers, but no contact information for staff and/or emergency personnel. The administrator revealed the agency had references for the Federal Emergency Management Agency (FEMA), and the Red Cross but do not have anything in writing for every contact. All we have was an office staff roster with telephone numbers.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility communication plan failed to have contact information for Federal, State, Regional, and local emergency preparedness staff. This failure had the potential to affect 96 patients currently receiving home health services and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Plan lacked a communication plan that had contact information for Federal, State, Regional emergency preparedness staff which was reviewed and updated at least every 2 years. During an interview on 03/04/2021 at 9:45 AM, the administrator was unable to provide contact information for the Federal Emergency Management Agency (FEMA), Red Cross or any Federal, State or Regional emergency preparedness personnel.

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 review of the facility's Emergency Preparedness Plan (EPP), the facility failed to conduct an exercise to test the emergency plan annually. This failure had the potential to affect all 96 patients currently receiving home health services and hindered the facility's ability to prepare for potential emergency situations and keep patients safe during an emergency event. Findings include: Review of the facility's undated Emergency Preparedness Packet for Home Health Agencies and the Emergency Preparedness packet dated 2018 lacked documented evidence the agency participated in a full-scale exercise that was community-based, or a second full-scale exercise that was community based. The agency lacked documented evidence of a tabletop exercise that included a discussion of these drills, a mock disaster drill conducted, a tabletop exercise or workshop led by a facilitator, or group discussion, an analysis of the facility's response to the emergency events, or any revisions the agency's emergency plan, as needed. During an interview on 03/04/2021 at 9:45 AM, the administrator revealed the agency had not participated in a tabletop or a full-scale community exercise.

A Medicare Recertification and Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey was conducted from 03/03/2021 to 03/0420/21 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C.