Every finding on record at Dinamic Health Care, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, 3/15/24. Standard level deficiencies cited. Abbreviations: # = number E = Employee Pts. = Patients PT = Physical Therapy

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: Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to complete an all-hazards risk assessment. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. On 3/13/24, the Agency's Emergency Preparedness plan was reviewed. The Emergency Preparedness plan last updated on 3/17/23 lacked a facility and community-based risk assessment, using an all-hazards approach. 2. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the above findings.

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 Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the communication plan included a complete list of employees, contracted providers, Pt. Physicians and their contact information. Findings include: 1. The Emergency Preparedness plan last updated on 3/17/23 was reviewed on 3/13/24. The communication plan contained an employee list which lacked the names and contact information of employees active as of 3/17/23 (E #2, E #3, E #5, E #7, E #8, E #9 and E #10); entities providing service under a contractual agreement for PT, occupational therapy, speech therapy, medical social services; and Pt. Physicians. The communication plan lacked current contacts when it was reviewed and revised on 3/17/23. The communication plan contained the name of E #11 as the Administrator. During the entrance interview with the Agency's Administrator (E #5) on 3/11/24, E #5 stated she had been the Administrator for the past 3 to 4 years. The communication plan lacked accurate information when it was reviewed and revised on 3/17/23. 2. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the communication plan lacked a current list of employees, contracted providers, Pt. Physicians and their contact information.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined in 10 of 10 employees (E#1, E #2, E #3, E #4, E #5, E #6, E #7, E #8, E #9 and E #10), the Agency failed to conduct employee training relative to its Emergency Preparedness plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Emergency Preparedness plan last updated on 3/17/23 was reviewed on 3/13/24. As of 3/13/24, the Agency lacked documentation the employees (E#1, E #2, E #3, E #4, E #5, E #6, E #7, E #8, E #9 and E #10) received any training in 2021, 2022 and 2023, pertaining to the Agency's Emergency Preparedness plan. 2. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the Agency failed to provide employee training relative to the Agency's Emergency Preparedness plan.

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 review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct Emergency Preparedness exercises as required. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan last updated on 3/17/23 was reviewed on 3/13/24. The plan lacked documentation that the Agency conducted Emergency Preparedness exercises in 2021 and 2022. 2. The Emergency Preparedness plan last updated on 3/17/23 contained documentation that a table top exercise was conducted on 3/17/23, and included a sign-in sheet that 2 employees (E #4 and E #5) had attended. The Agency lacked documentation that the other employees (E #1, E #2, E #3, E #6, E #7, and E #9) participated in any exercises in 2023. 3. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the Agency failed to conduct Emergency Preparedness exercises as required.

A recertification was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 3/15/24. Standard level deficiencies cited. Abbreviations: w/wk = week Pt./Pts. = Patient/patients # = number SOC = Start of Care POC/PsOC = Plan of care/Plans of Care ml = milliliters MG = milligrans PO = by mouth PT = Physical Therapy/Physical Therapist PTA = Physical Therapy Assistant % = percent $ = dollar RN = Registered Nurse SN = Skilled Nurse

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 a review of the Agency's Pt. admission folder, clinical record review, observation and interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. Findings include: 1. The Patient's admission folder was reviewed on 3/11/24 and lacked documentation of the Agency's transfer and discharge policies. 2. The following clinical records were reviewed from 3/12/23 to 3/13/24: Pt. #1. SOC 1/30/22. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22. Pt. #4. SOC 10/19/23. Pt. #5. SOC 1/26/24. Pt. #6. SOC 7/3/23. Pt. #7. SOC 12/6/22. The records lacked documentation the Agency provided Pts./patient's representative information regarding the Agency's transfer and discharge policies. 3. The following home visits were conducted on 3/12/24: Patient #1. SOC 1/30/22. Patient #2. SOC 6/8/22. Patient #3. SOC 1/30/22. During the home visits of Pts. #1 and #2, the patient's admission folder was observed, and lacked documentation the Agency had provided Pts./patient's representative information regarding the Agency's transfer and discharge policies. During the home visit of Pt. #3, the Pt./family were unable to locate the patient's admission folder, an interview was conducted with the Pt. and family, that stated they were unaware of the Agency's transfer and discharge policies. 4. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the Agency failed to provide Pts. information pertaining to the Agency's transfer and discharge policies.

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, clinical records, observation during home visits and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. 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's admission folder was reviewed on 3/11/24 and contained the form titled, "Authorization and Agreement for Home Health Services". The Agency requires the SN to complete the Agreement form during the SOC visit. The form includes a section that includes all the services the Agency's offers, the RN is required to indicate the discipline(s) to provide service and their frequency of their visits. 2. The following clinical records were reviewed on 3/12/23 and 3/13/24: Pt. #1. SOC 1/30/22.. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22 Pt. #4. SOC 10/19/23. Pt. #5. SOC 1/26/24. Pt. #6. SOC 7/3/23 Pt. #7. SOC 112/6/22. The records contained the form titled, " Authorization and Agreement for Home Health Services" completed by the RN, signed by the Pt./patient's representative, RN and dated with the SOC date. The section indicating the disciplines to provide care/service and their proposed frequency was left blank. 3. Home visits were conducted on the following Pts. on 3/13/24: Pt. #1. SOC 1/30/22.. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22 During the home visits of Pts. #1 and #2 , the Pt. admission folder was observed and lacked a signed "Authorization and Agreement for Home Health Services " form. During the home visit of Pt. #3, the Pt./and or family were unable to locate the Pt. admission folder. 4. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the Agency failed to ensure Pts./Pt. Representatives were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, clinical records, observation during home visits and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. are advised of the extent of their financial liability for services before care is initiated. Findings include: 1. The Patient's admission folder was reviewed on 3/11/24 and contained the form titled, "Authorization and Agreement for Home Health Services". The Agency required the SN to complete the Agreement form during the SOC visit. The form contained a section that include all the services the Agency offer, the RN was required to indicate the discipline(s) to provide service, the "Amount Insurance Pays (% or $), Co-Payment (% or $), Charge(% or $)". 2. The following clinical records were reviewed on 3/12/23 and 3/13/24: Pt. #1. SOC 1/30/22. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22. Pt. #4. SOC 10/19/23. Pt. #5. SOC 1/26/24. Pt. #6. SOC 7/3/23. Pt. #7. SOC 12/6/22. The records contained the form titled, " Authorization and Agreement for Home Health Services" signed by the Pt./Patient's Representative, the RN and dated with the SOC date. The section that includes: "Amount Insurance Pays (% or $), Co-Payment (% or $), Charge(% or $)" were left blank. 3. Home visits were conducted on the following Pts. on 3/13/24: Pt. #1. SOC 1/30/22. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22. During the home visits of Pts. #1 and #2, the Pt. admission folder was observed and lacked a signed "Authorization and Agreement for Home Health Services " form. During the home visit of Pt. #3, the Pt./and or family were unable to locate the Pt. admission folder. 4. During an interview with the Director of Nursing on 3/13/24 at 11:27 AM, the Director of Nursing confirmed the Agency failed to ensure Pts. were advised of the extent of their financial liability for services before care is initiated.

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 a review of clinical records and staff interview, it was determined in 6 of 7 (Pts. #1, 2, 3, 4, 5 and 7) clinical records reviewed, the Agency failed to obtain or secure referral information to ensure the initial assessment visits were conducted within 48 hours upon receiving the referral or inpatient discharge. Findings include: 1. The following clinical records were reviewed on 3/12/24 and 3/13/24: Pt. #1. SOC 1/30/22.. Pt. #2. SOC 6/8/22. Pt. #3. SOC 1/30/22 Pt. #4. SOC 10/19/23. Pt. #5. SOC 1/26/24. Pt. #7. SOC 112/6/22. The records contained a SOC comprehensive assessment form completed by the RN and dated with each patient's SOC date. As of 3/12/24, the record lacked a referral or Physician's order to indicate that service was initiated within the required time frame. 2. During interviews with the Administrator and Director of Nursing on 3/13/24 at 11:27 AM and 2:00 PM, both confirmed the above findings.

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 a review of clinical records, observation and interview during a home visit and staff interview, it was determined in 2 of 7 (Pts. #2 and 1) clinical records reviewed, the Agency failed to ensure the PsOC contain correct and accurate medications and interventions. Findings include: 1. Pt. #2 was admitted to Home Health services on 6/8/22 with diagnosis of Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 3/12/24. The record contained the PsOC dated 11/30/23 to 1/28/24 and effective 1/29/24 that required: "Notify Physician of... Blood Sugar, Fasting: Greater Than (>) 200 Less than () 250 Less Than ( The signed PsOC dated 11/21/23 to 1/19/24 and 1/20/24 to 3/19/24 contained the following medications” “….Tyvaso Kit Powder 64 mg inhalation solution 1 puff inhale 4 times daily inhaled (INH) N….Tyvaso 0.6 mg/ml inhalation solution inhale 0.09 ml 4 times daily Inhaled (INH) N….Sildenafil 20 mg oral 1 tablet three times daily By mouth (PO) N….Sildenafil 20 mg oral 1 tab 3 times daily By mouth….Insulin Glargine 100 units/ml solution 22 units bedtime subcutaneous (SQ)….Insulin Glargine 100 units/ml subcutaneous solution 18 units bedtime subcutaneous (SQ)….” The PsOC contained an inaccurate list of medications. 3. During interview with the Administrator and Director of Nursing on 3/13/24 from 2:00 PM to 3:30 PM, the Director of Nursing confirmed that the medications listed on PsOC were duplicated and inaccurate. During interviews with the Director of Nursing on 3/13/24 at 11:27 AM and with the Administrator and Director of Nursing from 2:00 PM to 3:30 PM, the above findings were confirmed.

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: Based on a review of clinical records and staff interview, it was determined in 4 of 7 (Pts. #3, 7, 1 and 5) clinical records reviewed, the Agency failed to ensure staff provide service, as ordered by the Physician and indicated in the POC. Findings include: 1. Pt. #3 was admitted to Home Health services on 1/30/22 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/12/24. The record contained the POC for the certification period of 1/20/24 to 3/19/24 that required, "SN Frequency: 1wk9". The record lacked documentation the SN provided service during the week of 2/16/24. 2. Pt. #7 was admitted to Home Health services on 12/6/22 with diagnosis of Unspecified Hyperparathyroidism. The clinical record was reviewed on 3/13/24. The record contained the POC for the certification period of 8/3/23 to 10/1/23 that required, "SN Frequency: 1wk9... perform finger stick for blood glucose analysis..." The SN visit notes dated 8/15/23, 8/29/23, 9/5/23 and 9/12/23 lacked documentation the SN performed finger stick for blood glucose analysis. 3. Pt. #1 was admitted to Home Health services on 1/30/22 with diagnosis of Hypertensive Heart disease without Heart Failure. The clinical record was reviewed on 3/12/24. The signed POC for episode of 1/20/24 to 3/19/24, required SN frequency 1 time a week for 9 weeks. The clinical record lacked an SN visit for the week of 1/28/24 to 2/3/24 as ordered in the plan of care. 4. Pt. #5 was admitted to Home Health services on 1/26/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 3/13/24. The signed POC for episode of 1/16/24 to 3/25/24, required PT frequency of 1 time a week for 1 week, then 2 times a weeks for 7 weeks start 2/2/24. The clinical record lacked 2 PT visits for week of 2/4/24 to 2/10/24 and a second PT visit for week of 2/11/24 to 2/17/24 as ordered in the plan of care. 5. During interviews with the Director of Nursing on 03/13/24 at 11:27 AM and with the Administrator and Director of Nursing from 2:00 PM to 3:00 PM, the above findings were confirmed.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on a review of clinical records, Agency policy and staff interview, it was determined in 3 of 3 (Pts. #2, 3 and 5) clinical records reviewed, wherein PTA services were provided, the Agency failed to ensure the PT supervised the PTA. Findings include: 1. Pt. #2 was admitted to Home Health services on 6/8/22 with the diagnosis of Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 3/12/24. The record contained PTA visit notes 1 to 2 times a week from 2/8/24 to 2/27/24. The record included a form titled, "PTA Supervisory Visit" dated 3/1/24, this form was left blank. As of 3/12/24, the record lacked documentation the PT supervised the PTA in February 2024. 2. Pt. #3 was admitted to Home Health services on 1/30/22 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/12/24. The record contained the PTA visit notes 1 to 2 times a week from 2/1/24 to 2/27/24. The record included a form titled, "PTA Supervisory Visit" dated 3/1/24, this form was left blank. As of 3/12/24, the record lacked documentation the PT supervised the PTA in February 2024. 3. Pt. #5 was admitted to Home Health services on 1/26/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 3/13/24. The clinical record included orders for Physical Therapy services 1 time a week for 1 week, then 2 times a weeks for 7 weeks start 2/2/24. The Physical Therapist conducted the evaluation on 2/2/24. The record contained PTA visit notes 1 to 2 times a week from 2/16/24 to 2/26/24. The record lacked documentation that the PT supervised the PTA in February 2024. 4. Therapy Services policy was reviewed on 03/14/24. The policy required: "....9. Therapy Assistant may provide services under supervision of the licensed therapist....a. Supervision by the licensed must be made to patients home monthly, with or without therapy assistant...." 5. During interviews with the Director of Nursing on 03/13/24 at 11:27 AM and with the Administrator and Director of Nursing from 2:00 PM to 3:00 PM, the Director of Nursing stated that physical therapy assistant supervision is done every 30 days. During the same interviews, the Director of Nursing confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 2 of 3 (Pts. #2 and 4) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #2 was admitted to Home Health services on 6/8/22 with the diagnosis of Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 3/12/24. The record contained the Home Health Aide visit notes, 1 to 2 times a week from 1/19/24 to 2/5/24. As of 3/12/24, the record lacked documentation of Home Health Aide supervision by the RN from 1/19/24 to 2/5/24. 2. Pt. # 4 was admitted to Home Health services on 10/19/23 with Diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/13/24. The signed PsOC for episode of 12/18/23 to 2/15/24 and 2/16/24 to 4/15/24, required Home Health Aide services frequency of 2 times a week for 9 weeks. The clinical record contained Home Health Aide supervision dated 2/5/24 and 2/26/24 (more than 14 days). 3. During interview with the Director of Nursing on 3/13/24 at 11:27 AM and with the Administrator and Director of Nursing from 2:00 PM to 3:00 PM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 3 of 7 (Pts. #3, 1 and 5) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical record was complete. Findings include: 1. Pt. #3 was admitted to Home Health services on 1/30/22 with diagnosis of Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/12/24. The record contained the SN visit notes dated 3/1/24 and 3/9/24 that lacked the name of the SN, and date the SN completed the visit notes. 2. Pt. #1 was admitted to Home Health services on 1/30/22 with Diagnosis of Hypertensive Heart disease without Heart Failure. The clinical record was reviewed on 3/12/24. The clinical record contained an “Authorization and Agreement for Home Health Services” signed by Patient #1 and was undated. The section on Advance Directives, required the SN to indicated whether the Pt. chooses to formulate an Advance directive or not, this section was left blank. 3. Pt. #5 was admitted to Home Health services on 1/26/24 with Diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 3/13/24. The form titled: “Beneficiary Elected Transfer”, signed by the Pt and dated, lacked the patient’s Medicare number and the name of the previous Agency that provided service, as required by the Agency’s form. 4. During interviews with the Director of Nursing on 3/13/24 at 11:27 AM and with the Administrator and Director of Nursing from 2:00 PM to 3:00 PM, the above findings were confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Emergency Preparedness Program and Plan, and staff interview, it was determined the Agency failed to ensure the Agency had conducted Agency and community exercises and table top exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. This has the potential to affect all patients receiving Home Health Care services. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 3/24/21 at 11:15 AM. The plan lacked documentation of community based and tabletop exercises for the years 2018, 2019 and 2020. 2. An interview was conducted with the Director of Nursing on 3/24/21 at 1:30 PM. The Administrator confirmed the Agency did not conduct any drills to test the Emergency Preparedness Plan, nor participate in any community exercises for the years 2018, 2019 and 2020.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 3/25/2021. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: wk = week AM= Morning PM= Afternoon Pt./Pts. = Patient/Patients POC= Plan of Care SOC= Start of Care PT = Physical Therapy

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT 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 Patients are advised of the extent of their financial liability for care, and/or services before care is initiated. This was found in 7 of 7 (Pts. #1 to 7) clinical records reviewed. Findings include: 1. The clinical records of the Patients listed below were reviewed on 3/23/21 at 9:45 AM to 3/24/21 at 11:44 AM. All of the records contained a form, which was signed by the Pt at the SOC titled: "Authorization and Agreement for Home Health Services" with the section titled: "Notification of Financial Liability." The section lacked documentation indicating the patient's financial responsibility. All of the records also contained a form, which was signed by the Pt. at the SOC titled: "Advance Beneficiary Notice of Non-Coverage (ABN)" with the section titled: "G. Options: Check only one box..." The section, "Option 1." is checked, which indicates, "I want D. (blank) listed above" but lacked documentation on what the items were, the reason Medicare may not pay and estimated cost. Pt. #1 SOC: 11/20/20 Pt. #2 SOC: 1/20/21 Pt. #3 SOC: 3/5/21 Pt. #4 SOC: 7/30/20 Pt. #5 SOC: 11/19/20 Pt. #6 SOC: 6/12/20 Pt. #7 SOC: 1/27/20 2. The above findings were confirmed during an interview with the Director of Nursing on 3/24/21 at 1:30 PM, 2:15 PM and 3:00 PM.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure Pts. were assessed for the status of the influenza and/or pneumococcal vaccine at the SOC per Agency policy. This was found in 2 of 7 (Pt. # 2 and 4) records reviewed. Findings include: 1. Pt. #2 SOC 1/20/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 3/23/21 at 9:45 AM. The record lacked documentation Pt. #2 was assessed for the influenza and pneumococcal vaccines. 2. Pt. #4 SOC 7/30/2020. Primary Diagnosis: Type 2 Diabetes with chronic kidney disease. The clinical record was reviewed on 3/23/21 at 11:00 AM. The record lacked documentation that Pt. #4 was assessed for influenza vaccine. 3. The Agency policy titled, "Pneumococcal Pneumonia," was reviewed on 3/24/2021 at 1:00 PM. The policy required: "...Special Instruction letter D. 4. The following shall be considered to be documentation... A. Individual client/patient record entries identifying the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow up activities..." 4. The Agency policy titled, "Influenza," was reviewed on 3/24/2021 at 1:30 PM. The policy required:: "...Special Instruction... 4. For all clients/patients who are provided services between November 1 and February 28, the home health agency shall document in the clients/patient's medical record that an annual vaccination against influenza was administered, arranged, refused, or medically contraindicated or that the client/patient is not a member of a vaccination priority population..." 5. During an interview with the Director of Nursing on 3/24/2021 at 2:15 PM and 2:30 PM, the above findings were confirmed. The Director of Nursing stated that patients should be assessed for the vaccines at SOC and documented in the patient's clinical record.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to provide services as ordered in the POC. This was found in 1 of 3 Pts. (Pt. #5) for whom PT services were ordered by the Physician. Findings include: 1. Pt. #5 SOC 11/19/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 3/23/21 at 11:30 AM. The record included the POC effective 1/18/21 through 3/18/21. This POC included the Physician order "PT Frequency: 2 wk 9." The record lacked documentation PT services were provided during this time period. The record also lacked documentation of a Physician's order to discontinue PT services. 2. The Agency policy titled "Plan of Care" was reviewed on 3/24/21 at 1:00 PM. The policy required: "..Home health services from members of the Agency staff as well as those under contractual arrangements shall be given in accordance with the plan of treatment and Patient care plan..." 3. During an interview with the Director of Nursing on 3/24/21 at 2:30 PM, the Director of Nursing confirmed PT services were not provided to Pt. #5, as indicated in the POC.