Every finding on record at Forest Home Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/24/25. Standard level deficiencies cited.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct staff training relative to the Agency's Emergency Preparedness plan for 5 of 7 employees (E# 1, 4, 5, 6,and 7). Findings include: 1. The Emergency Preparedness plan was reviewed on 09/24/25 and included documentation of in-service training related to Agency’s Emergency Preparedness Plan on 05/01/23 and 03/13/24. As of 09/24/25, the Agency’s Emergency Preparedness Plan lacked documentation of Emergency Preparedness training for the following employees: E#1 (Administrator/Hire date 01/01/15) – lacked training in 2024 E#4 (Registered Nurse/Hire date 04/19/22) – lacked training in 2023 E#5 (Registered Nurse/Hire date 01/19/22) – lacked training in 2023 and 2024 E#6 (Home Health Aide/Hire date 06/17/22) – lacked training 2023 E#7 (Registered Nurse/Hire date 07/31/25) – lacked training in 2025 2. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 at 3:35 PM, the Agency Supervisor confirmed the Agency was unable to provide documentation that employees received 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 a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. Findings include: 1. The Emergency Preparedness Plan was reviewed on 09/24/25. The Plan contained documentation that the Agency conducted table-top exercises on 04/14/23, 09/11/24 and 03/03/25. The Plan lacked documenation that the Agency activated the Emergency Preparedness Plan and/ or participated in a full scalle or facility-based exercise. 2. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 at 3:35 PM, the Agency Supervisor confimred that the Agency did not activate and document an actual Emergency Plan activation nor participate in a full-scale or facility-based exercise.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 09/24/25. Standard level deficiencies cited. Abbreviations: E = Employee VAD = Vascular Access Device > = more than SN = Skilled Nurse POC/PsOC = Plan of Care / Plans of Care Pt./Pts. = Patient/Patients AM = morning PM = afternoon % = percent OASIS = Outcome Assessment and Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined that in 220 of 327 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 08/01/24 to 09/12/25 (12 months), was reviewed on 09/24/25. The report included a warning for Error # -3330. The Error included 220 (67.28 %) of 327 assessments that were submitted late. 2. During staff interview with the Agency Supervisor, on 09/24/25 at 1:00 PM, the Agency Supervisor confirmed the above findings. .

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 review of the Agency's Pt. admission folder, observations during home visits, review of clinical records, and staff interviews, in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The Agency's Pt. admission folder was reviewed on 09/23/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 09/23/25, and 09/24/25. Pt. #1. SOC 09/04/25 Pt. #2. SOC 07/03/25 Pt. #3. SOC 08/28/25 During the home visits, the Pt. admission folder was observed, and lacked the name and contact information of the Administrator. 3. The clinical records of the following Pts. were reviewed from 9/23/25 to 9/24/25: Pt. #1 SOC: 09/04/25 Pt. #2 SOC: 07/03/25 Pt. #3 SOC: 08/28/25 Pt. #4 SOC: 08/26/25 Pt. #5 SOC: 03/21/25 Pt. #6 SOC: 12/30/24 Pt. #7 SOC: 04/23/25 The clinical records reviewed lacked documentation that the Pt./patient’s representative was provided the name and contact of the new Administrator to file a complaint or grievance. 4. During an interview with the Agency Supervisor on 09/24/25 at 1:00 PM, the Agency Supervisor confirmed the Agency failed to provide the Pt./patient's representative with the Administrator's name and contact information.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, in 3 of 7 (Pts. #1, 2 and 5) clinical records reviewed, the Agency failed to ensure the PsOC were followed. Findings include: 1. Pt. #1 was admitted to home health services on 09/04/25 with the diagnosis of Encounter for Surgical aftercare following surgery of the Digestive System and Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 09/23/25. The clinical record included a POC effective 09/04/25 to 11/02/25, required: “…Order: Observe and Assessment Surgical incision/suture…SN to assess…weight….SN to evaluate patient’s current blood glucose levels….” The clinical record included the following SN visit notes and lacked assessments as ordered in the PsOC: SN visit note dated 09/04/25, lacked a blood glucose assessment. SN visit notes dated (SOC) 09/04/25, 09/11/25, 09/16/25 and 09/23/25, lacked surgical incision/suture assessment. SN visit notes dated 09/11/25, 09/16/25 and 09/23/25, lacked weight assessments. 2. Pt. #2 was admitted to home health services on 07/03/25 with the diagnosis of Unspecified Cirrhosis of the Liver and Encounter for change or removal of drains. The clinical record was reviewed on 09/23/25. The clinical record included PsOC effective 07/03/25 to 08/31/25 and 09/01/25 to 10/30/25, that required: “Skilled Nursing Orders:…. Parameters to Notify Physician:….Temperature….Respirations….Blood Pressure Systolic….Blood Pressure Diastolic….Pulse Rate....Pleurx Abdominal Drainage Order….Skilled Nurse to change insertion site dressing after each drainage and as needed. Skilled Nurse to document….color of the drainage fluid….” The clinical record included the following SN visit notes and lacked assessments as ordered in the PsOC: SN visit notes dated 07/28/25, 08/04/25, 08/20/25, 08/25/25, 09/01/25, 09/03/25, 09/12/25, 09/17/25 lacked documentation of color of the drainage fluid. SN visit notes dated 09/01/25, 09/03/25, 09/05/25, lacked documentation of Temperature, respirations, Blood pressure and Pulse. 3. Pt. #5 was admitted to home health services on 03/21/25 with the diagnosis of Acute on Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 09/23/25. The clinical record included the POC effective 07/19/25 to 09/16/25, that required: “…. Skilled Nursing Orders:….Parameters to Notify Physician:….Blood Pressure Systolic > 180 100 < 60….Pulse Rate….Observation and Assessment of Cardiovascular Status….” The clinical record contained the following SN visit notes and lacked documentation of assessment of Cardiovascular status, and Physician Notification, as ordered: SN visit note dated 07/28/25, included a Blood Pressure of 89/66, lacked Physician notification SN visit note dated 07/28/25, 08/11/25, 08/25/25, 09/01/25, 09/08/25 lacked documentation of weight assessments. SN visit note dated 08/25/25 – lacked documentation of Blood Pressure and Pulse assessment. SN visit note dated 09/01/25, 09/08/25 lacked documentation of Blood Pressure assessments. 4. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 from 1:55 PM to 3:35 PM, the Agency Supervisor stated that confirmed that weight assessments are included in a cardiovascular assessment. During the same interview, the Agency Supervisor confirmed 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 clinical record review and staff interview, in 3 of 7 (Pts. #1, 2 and 5) clinical records reviewed, the Agency failed to ensure the PsOC included Pt. specific required elements. Findings include: 1. Pt. #1 was admitted for home health services on 09/04/25 with the diagnosis of Encounter for Surgical aftercare following surgery of the Digestive System and Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 09/23/25. The clinical record included a POC effective 09/04/25 to 11/02/25, that lacked orders for frequency of Skilled Nursing services and Home Health Aide services. 2. Pt. #2 was admitted for home health services on 07/03/25 with the diagnosis of Unspecified Cirrhosis of the Liver and Encounter for change or removal of drains. The clinical record was reviewed on 09/23/25. The clinical record included PsOC effective 07/03/25 to 08/31/25 and 09/01/25 to 10/30/25, that lacked Pt. specific orders for dressing change of abdominal drainage insertion site. The clinical record included a POC effective 09/01/25 to 10/30/25, that lacked orders for frequency of Skilled Nursing services. 3. Pt. #5 was admitted for home health services on 03/21/25 with the diagnosis of Acute on Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 09/23/25. The clinical record included the POC effective 07/19/25 to 09/16/25, that lacked Pt. specific weight parameters to report to the Physician. 4. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 from 1:55 PM to 3:35 PM, the Agency Supervisor confirmed the above findings.

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: Based on review of clinical records, policy review and staff interviews, in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7) the Agency failed to conduct complete assessments for Pts. for influenza and pneumonia vaccine status. Findings include: 1. The following clinical records were reviewed on 09/23/25 and 09/24/25. The records lacked documentation of assessment and/or dates when the influenza and/or pneumonia vaccines were received by Pts. Pt. #1 SOC: 09/04/25 - lacked influenza date and lacked pneumonia assessment. Pt. #2 SOC: 07/03/25 – lacked influenza and pneumonia assessment. Pt. #3 SOC: 08/28/25 – lacked influenza date and lacked pneumonia assessment. Pt. #4 SOC: 08/26/25- lacked influenza and pneumonia dates. Pt. #5 SOC: 03/21/25 – lacked influenza and pneumonia dates. Pt. #6 SOC: 12/30/24 – lacked influenza and pneumonia assessments. Pt. #7 SOC: 04/23/25 – lacked influenza and pneumonia assessments. 2. The policies titled, “Vaccination (Influenza) and (Pneumonia) Policy, was reviewed on 9/24/25 and required: "7. -8. The following should be considered to be documentation approaches that meet the requirements of Section 6.5 (a) of the Act: 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.” b. Standardized check off form recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow up activities.” 3. During an interview with the Agency Supervisor on 09/24/25 at 1:00 PM and at 3:35 PM, the above findings were confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews and staff interviews, the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor and their contact information in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 09/23/25. The folder lacked the name and information to contact the Agency Supervisor. 2. The following home visits were conducted on 09/23/25, and 09/24/25. Pt. #1. SOC: 09/04/25 Pt. #2. SOC: 07/03/25 Pt. #3. SOC: 08/28/25 During the home visits, the Pt. admission folder was observed, and lacked documentation of the Agency Supervisor. 3. The clinical records of the following Pts. were reviewed from 9/23/25 to 9/24/25: Pt. #1 SOC: 09/04/25 Pt. #2 SOC: 07/03/25 Pt. #3 SOC: 08/28/25 Pt. #4 SOC: 08/26/25 Pt. #5 SOC: 03/21/25 Pt. #6 SOC: 12/30/24 Pt. #7 SOC: 04/23/25 The clinical records reviewed lacked information identifying the Agency Supervisor name and contact information. 4. During a staff interview with the Agency Supervisor, on 09/24/25 at 1:00 PM, it was confirmed the same admission folder is given to all Pts. The Agency Supervisor confirmed the Agency failed to identify the Agency Supervisor.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interview, in 1 of 3 (Pt. #1) clinical records reviewed with Home Health Aide services, the Agency failed to ensure that the written patient care instructions were individualized. Findings include: 1. Pt. #1 was admitted for home health services on 09/04/25 with the diagnosis of Encounter for Surgical aftercare following surgery of the Digestive System. The clinical record was reviewed on 09/23/25. The clinical record included an Aide Plan for Care effective 09/04/25, that required Aide to assess for Blood pressure and Pulse rate weekly and lacked parameters for Blood pressure and Pulse rate for the Aide to notify case manager. 2. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 at 3:35 PM, the Agency Supervisor confirmed the above findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, in 2 of 3 (Pts. #1 and 5) clinical records reviewed with Home Health Aide services, the Agency failed to ensure that Aide provided services, as ordered and included in the POC. Findings include: 1. Pt. #1 was admitted for home health services on 09/04/25 with the diagnosis of Encounter for Surgical aftercare following surgery of the Digestive System and Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 09/23/25. The clinical record included an Aide Plan of Care effective 09/04/25, which required Shower, weekly check of Pressure Points and ROM (Range of Motion) exercise for PT/OT (Physical Therapy/Occupational Therapy, each visit. The clinical record included the following Aide visit notes dated 09/05/25, 09/08/25, 09/12/25, 09/15/25, 09/19/25 and 09/22/25, that documented "N/A"(Not Applicable) for Shower, check pressure points and ROM exercises for PT/OT, each visit, as ordered. 2. Pt. #5 was admitted for home health services on 03/21/25 with the diagnosis of Acute on Chronic Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 09/23/25. The clinical record included an Aide Plan of Care effective 07/19/25, which required Shower weekly and check for Pressure points weekly. The clinical record included the following Aide visit notes dated 08/01/25, 08/04/25, 08/08/25, 08/11/25, 08/25/25 and 09/08/25, that documented "N/A"(Not Applicable) for Shower, check pressure points and ROM exercises for PT/OT, each visit, as ordered. The same Aide Plan of Care, included parameters to notify Case Manager: “….Blood Pressure > 180/90 110 09/15/25 BP – 89/61, and lacked documentation that the Case Manager was notified for parameters falling outside of range. 3. During an interview with the Administrator Back Up and Agency Supervisor on 09/24/25 at 3:35 PM, the Agency Supervisor confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, in 2 of 2 (Pts. #6 and #7) discharge records reviewed, the Agency failed to ensure a discharge summary was sent to the Physician. 1. Pt. #7 was admitted for home health services on 04/23/25 with the diagnosis of Encounter for adjustment and management of (VAD) Vascular Access Devices. The closed clinical record was reviewed on 9/24/25. The record included the discharge summary completed by the SN and dated 06/19/25. The record lacked documentation that a copy of the summary was sent to the Physician. 2. During staff interview with the Agency Supervisor on 9/24/25 at 1:00 PM, the Agency Supervisor confirmed the Agency failed to send a copy of the discharge summary to the Physician. Findings include: 1.Pt. #6 was admitted for home health services on 12/30/24 with the diagnosis of Encounter for Adjustment and Management of VAD. The clinical record was reviewed on 09/24/25. The clinical record included a Discharge Summary, with a discharge date of 02/01/25. The record lacked documentation that a copy of the summary was sent to the Physician.

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: A. Based on review of the Emergency Management Plan and staff interview, it was determined the Agency failed to review and update the Emergency Management Plan and policies every 2 years. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's undated “Emergency Management Plan” was reviewed on 7/13/22 at 10:00 AM. The Plan lacked documentation indicating when the Agency last reviewed and revised the Plan. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the above finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Management Plan and staff interview, it was determined the Agency failed to ensure the Plan was based on a facility and community risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's undated "Emergency Management Plan" was reviewed on 7/13/22 at 10:00 AM. The Plan lacked a facility and community-based risk assessment, using an all hazards approach. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the Plan was not based on a risk assessment.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: A. Based on a review of the Emergency Management Plan and staff interview, it was determined the Agency failed to ensure the Plan included, procedures for communicating with emergency preparedness officials for the purpose of Pt. evacuations. This has a potential to affect all services provided by the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 7/13/22 at 10:00 AM. The Plan lacked documentation of a method or process to contact State and local emergency preparedness officials, in the event of an emergency that required Pts. to vacate their home. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the Agency failed to establish a method of communicating with emergency preparedness officials for the purpose of Pt. evacuations.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Management Plan and staff interview, it was determined the Agency failed to review and update its Communication Plan and policies every 2 years. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's undated “Emergency Management Plan” was reviewed on 7/13/22 at 10:00 AM. The Plan lacked documentation indicating when the Agency last reviewed and revised the Communication Plan. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the above finding.

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: A. Based on review of the Agency's Emergency Management Plan and staff interview, it was determined the Agency failed to ensure the Communication Plan was complete. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's undated "Emergency Management Plan" was reviewed on 7/13/22 at 10:00 AM, which contained the Communication Plan. This plan lacked the names and contact information of the staff, contract agencies and the patient's Physicians. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the communication Plan was incomplete.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Management Plan and staff interview, it was determined the Agency failed to conduct staff training relative to the Agency's Emergency Preparedness Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's undated "Emergency Management Plan" was reviewed on 7/13/22 at 10:00 AM. As of 7/13/22, the Agency lacked documentation the Agency conducted staff training in 2019, 2020 and 2021 and 2022 pertaining to the Emergency Management Plan. 2. During an interview with the Administrator on 7/13/22 at 1:59 PM, the Administrator confirmed the Agency failed to provide staff training regarding the Agency's "Emergency Management Plan".

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times wk = week % = percent # = number eff = effective AM = morning GM = gram(s) MG = Milligram(s) SN = Skilled Nurse JP = Jackson Pratt POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients ADL = Activities of Daily Living VAD = Vascular Access Device PT = Physical Therapy/Therapist PICC = Peripherally Inserted Central Catheter

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to inform Pts. of each discipline's frequency of visits. This was found in 7 of 7 (Pts. 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 7/11/22 (2:40 PM) to 7/12/22 (3:15 PM): Pt. #1. SOC 4/12/22. Pt. #2. SOC 2/8/22. Pt. #3. SOC 3/11/22. Pt. #4. SOC 6/6/22. Pt. #5. SOC 6/2/22. Pt. #6. SOC 4/27/22. Pt. #7. SOC 9/25/21. The records lacked documentation the above Pts./patient's legal representative consented to the frequency of visits to be provided by each discipline at the SOC. 2. During interviews with the Administrator on 7/13/22 at 11:00 AM and 1:59 PM, the Administrator confirmed that the above records lacked documentation the Pt./patient's legal representative consented to the frequency of visits at the SOC.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service and/or treatment, as indicated in the POC. This was found in 2 of 7 (Pts. #2 and 4) clinical records reviewed. Findings include: 1. Pt. #2. SOC 2/8/22. Diagnoses: Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene and Encounter for Adjustment and Management of VAD. The clinical record was reviewed on 7/12/22 at 3:15 PM. The record contained the POC effective 6/8/22 requiring, "PT to assess/eval and treat eff: 06/08/2022". As of 7/12/22, the record lacked documentation the PT assess/eval the Pt. The POC for the certification period of 4/9/22 to 6/7/22 included: “Home Health Aide Orders…5 visits per 60 days from 04/09/22 through 06/07/2022 ADL assistance”. The record lacked documentation the Home Health Aide provided any service from 4/9/22 to 6/7/22. 2. Pt. #4. SOC 6/6/22. Primary Diagnosis: Malignant Neoplasm of Unspecified Site of Left Female Breast. The clinical record was reviewed on 7/12/22 at 1:30 PM. The record contained the POC effective 6/6/22 requiring: Home Health Aide Orders...3 visits/week From 06/06/2022..." As of 7/12/22, the record lacked documentation the Home Health Aide provided any service effective 6/6/22. The POC effective 6/6/22 also required the SN to provide service "2 visits/week". As of 7/12/22, the record lacked documentation the SN provided any service during the weeks of 6/12/22 to 6/18/22 and 6/19/22 to 6/25/22. 3. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator confirmed the services were not provided as indicated above, and the POC was not updated to cancel these services.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC was complete and/or accurate. This was found in 3 of 7 (Pts. #2, 3 and 4) clinical records reviewed. Findings include: 1. Pt. #2. SOC 2/8/22. Diagnoses: Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene and Encounter for Adjustment and Management of VAD. The clinical record was reviewed on 7/12/22 at 3:15 PM. The record contained the SN visit notes dated 5/16/22 to 7/8/22 indicating the SN performed a "Line Flush...Dressing Change" to "PICC Line". The PsOC for the certification period of 4/9/22 to 6/7/22, and effective 6/8/22 lacked instructions for PICC line care and maintenance, including a frequency for the SN to change the dressing. The SN visit notes dated 5/16/22 to 7/8/22 included documentation the SN provided wound care during each visit. The PsOC for the certification period of 4/9/22 to 6/7/22, and effective 6/8/22 lacked instructions for wound care and the location of the wound. The POC effective 6/8/22 included: "SN to maintain and instruct the patient on JP drain care." During a home visit on 7/13/22 at 12:00 PM, a JP drain was not observed. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator stated "the Pt. doesn't have a JP drain..." 2. Pt. #3. SOC 3/11/22. Primary Diagnosis: Pressure Ulcer of Contiguous Site of Back, Buttock and Hip, Stage 4. The clinical record was reviewed on 7/12/22 at 10:45 AM. The record contained the SN visit notes for 2 to 3 times a week from 5/11/22 to 6/1/22 and 6/13/22 to 7/1/22, which included documentation the SN provided wound care to the sacrum, left plantar foot, left calf and right heel; assessed the Foley catheter and provided PICC line dressing changes and maintenance. The POC effective 5/10/22 lacked instructions for wound care, care and maintenance of the Foley catheter and PICC line. 3. Pt. #4. SOC 6/6/22. Primary Diagnosis: Malignant Neoplasm of Unspecified Site of Left Female Breast. The clinical record was reviewed on 7/12/22 at 1:30 PM. The record contained the SOC comprehensive assessment dated 6/6/22; SN visit notes dated 6/7/22, 6/9/22, 6/26/22 and 6/28/22, indicating the Pt. had a JP drain. The POC effective 6/6/22 lacked instructions on care and maintenance of the JP drain. 4. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator confirmed the POC indicated above were incomplete and/or inaccurate.

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 review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the Pneumonia and/or the Influenza vaccination policy was followed. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 7/11/22 (2:40 PM) to 7/12/22 (2:15 PM) and lacked documentation the SN assessed whether the Pt. required the Influenza and Pneumococcal vaccines during the SOC, as required by the Agency: Pt. #1. SOC 4/12/22. Pt. #2. SOC 2/8/22. Pt. #3. SOC 3/11/22. Pt. #4. SOC 6/6/22. Pt. #5. SOC 6/2/22. Pt. #6. SOC 4/27/22. Pt. #7. SOC 9/25/21. 2. The Agency policy titled; "Vaccination (influenza) Policy and Vaccination (pneumonia) Policy" was reviewed on 7/13/22 at 2:00 PM. The policies included: “7. For all clients/patients who are provided services between November 1 and February 28, the home health agency shall document in the client’s/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. 3. Home health agency shall document in each client’s /patient’s medical record that a vaccination against pneumococcal pneumonia was offered and was administered, arranged, refused, or medically contraindicated or that the client/patient is not a member of a vaccination priority population.” 4. During the entrance interview with the Administrator on 7/11/22 at 10:09 AM, the Administrator stated the SN is required to assess the patient's Influenza and Pneumococcal Pneumonia status at the SOC, and this information is documented in the SOC comprehensive assessment. 5. During interviews with the Administrator on 7/13/22 at 11:00 AM and 2:15 PM, it was confirmed that the records lacked documentation of patients' vaccine status for Influenza and Pneumonia.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on observations during home visits, Agency policy review and staff interview, it was determined the Agency failed to ensure staff provide services in accordance with the Agency's Infection Control Standards of Practice, while providing service. This was observed in 2 of 3 (Pts. #1 and #2) home visits conducted. 2. Pt. #2. SOC 2/8/22. Diagnoses: Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene and Encounter for Adjustment and Management of VAD. The clinical record was reviewed on 7/12/22 at 3:15 PM. A home visit was conducted on 7/13/22 at 12:00 PM with Employee #2, during the home visit observed Employee #2 remove a blood pressure machine from the nursing bag, used the equipment on the patient's arm, after removing the equipment from the Pt., Employee #2 returned the blood pressure machine into the nursing bag without cleaning the equipment. 3. The Agency's policy titled, "Nursing Bag" was reviewed on 7/13/22 at 2:40 PM. The policy required: "GUIDELINES The inside of the bag and its contents are considered clean. Therefore...All items removed from the bag should be cleaned before returning to the bag..." 4. During an interview with Administrator on 7/13/22 at 11:00 AM and 2:15 PM, the Administrator confirmed staff failed to comply with the Agency's Infection Control Standards of Practice . Findings include: 1. Pt. #1. SOC date 4/12/22. Diagnosis: Malignant neoplasm of the brain. A home visit was conducted with Staff #1 on 7/12/22 at 12:00 PM. During the home visit, Staff #1 placed a bag containing gloves, blood pressure machine and supplies on top of the patient’s bed and then on the floor. Staff #1 also placed all the supplies needed for the PICC line dressing change on top of the patients’ bed and then transferred them to a bedside table next to patient. Staff #1 never use a barrier for the bag or the supplies during the home visit.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. This was found in 1 of 1 (Pt. #3) clinical records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #3. SOC 3/11/22. Primary Diagnosis: Pressure Ulcer of Contiguous Site of Back, Buttock and Hip, Stage 4. The clinical record was reviewed on 7/12/22 at 10:45 AM. The record contained Home Health Aide visit notes, indicating service was provided 1 to 3 times a week from 5/10/22 to 7/2/22. As of 7/12/22, the record lacked any documentation the RN supervised the Home Health Aide from 5/10/22 to 7/2/22. 2. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator confirmed the RN failed to supervise the Home Health Aide as indicated above.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: A. Based on staff interview, review of a designation letter, personnel file review and review of the Illinois Administrative Code, it was determined the Agency failed to ensure a qualified designated alternate was appointed, in the absence of the Agency Supervisor. This has the potential to affect all services provided by the Agency. Findings include: 1. The entrance interview was conducted on 7/11/22 at 10:09 AM, the Administrator was present. The Agency Supervisor was not present. During an interview with the Administrator on 7/12/22 at 3:45 PM, the Administrator stated the Agency Supervisor was "not available" during the survey conducted from 7/11/22 to 7/14/22. 2. On 7/13/22 at 3:10 PM, the Administrator presented an undated letter/document titled, "Agency Supervisor Backup" which contained documentation that in the absence of the Agency Supervisor, Employee #6 was the designated alternate. 3. The personnel file of Employee #6 was reviewed on 7/13/22 at 3:15 PM which contained, Employee #6's job application with work history that included employment in a long term care facility since 2016 to the present (this was the only employment history indicated on application). 4. 77 Illinois Administrative Code 245, 245.30d) 2) B) i-ii) require: "e) Agency Supervision - Home Health Agencies... 2) The home health agency shall designate an agency supervisor with one of the following sets of qualifications to supervise the provision of home health services...B) A registered nurse who does not have a baccalaureate degree, but who has at least three years of nursing experience that meets the following requirements: i) At least two years of the nursing experience must have been in: a home health agency; a community health program that included care of the sick; or a generalized family-centered nursing program in a community health agency. ii) At least two years of the three years nursing experience must have been obtained within five years prior to current employment with the home health agency." 4. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator confirmed Employee #6 received an Associate Degree in Nursing, and the work history on the job application was complete and accurate. Employee #6 lack the required work experience to fulfill role of the designated alternate for the Agency Supervisor.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, observations and interviews during home visits, Agency policy review and staff interview, it was determined the Agency failed to ensure the interventions and medications entered into the clinical record are complete and/or accurate. This was found in 2 of 7 (Pts. #2 and 3) clinical records reviewed. Findings include: 1. Pt. #2. SOC 2/8/22. Diagnoses: Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene and Encounter for Adjustment and Management of VAD. The clinical record was reviewed on 7/12/22 at 3:15 PM. The record contained the SN visit notes indicating service was provided 1 to 4 times a week from 5/16/22 to 7/8/22, and during those visits the SN changed the dressing to the "PICC" line. A home visit was conducted on 7/13/22 at 12:00 PM with the SN, during the home visit an interview was conducted with the SN that stated: "I change the PICC dressing once a week, every Monday". The SN visit notes were inaccurate to contain the SN changed the dressing to the "PICC" every visit. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator stated PICC line dressings are changed once a week, and confirmed the SN documented inaccurately. During the home visit conducted on 7/13/22 at 12:00 PM, the patient’s medications were observed which included: “Docusate SOD 100 MG capsules Take 1 capsule by mouth twice daily”, the prescription bottle was labeled 5/9/22. During an interview with the Pt. it was stated he began taking the Docusate SOD “a few months ago”. The “Medication Profile” form last updated by the RN on 7/11/22 lacked Docusate SOD. The “Medication Profile” form dated 7/11/22 also included: “Dakins (1/4 strength) External Solution 0.125% 1 Application Daily Topically” and “Santyl External Ointment 250 UNIT/GM Topical”. During an interview with the Administrator on 7/13/22, the Administrator stated these medications were discontinued on 6/1/22. 2. Pt. #3. SOC 3/11/22. Primary Diagnosis: Pressure Ulcer of Contiguous Site of Back, Buttock and Hip, Stage 4. A home visit was conducted on 7/12/22 at 9:00 AM, during the visit the medications were observed. Finasteride 5 MG Tablet Take one tablet my mouth daily, the prescription bottle was dated 4/7/22, the caregiver stated the Pt. began taking the Finasteride before April 2022, "its been awhile"; Carvedilol 6.25 MG Tablet Take 1 table by mouth every 12 hours, prescription bottle was dated 6/7/22, the caregiver stated "he's been taking it for a while, the dose has been changed..."; and Amlodipine Besylate 10 MG Tab Take 1 tablet by mouth every day, prescription bottle was dated 6/20/22, the caregiver stated "He's been taking this for a couple of months". The clinical record was reviewed on 7/12/22 at 10:45 AM ,and included the "Medication Profile" form last updated by the RN on 7/7/22 which lacked the Finasteride, Carvedilol and Amlodipine Besylate. As of 7/12/22, the Medication Profile was inaccurate. 3. The Agency's policy titled, "Clinical Documentation Policy" was reviewed on 7/13/22 at 3:50 PM. The policy required: "...Purpose To ensure there is an accurate record of the services provided..." 4. The Agency's policy titled, "Medication Profile Policy" was reviewed on 7/14/22 at 1:15 PM. The policy required: "...The profile will be reviewed and updated as needed to reflect current medications the Patient is taking..." 5. During an interview with the Administrator on 7/13/22 at 2:15 PM, the Administrator confirmed the interventions and medications entered into the clinical records were incomplete and/or inaccurate.