Every finding on record at Healthy Health Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/09/26. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 04/09/26. Standard level deficiencies cited. Abbreviations: Pt./Pts. = patient/patients # = number AM = morning PM = afternoon SN = Skilled Nurse SOC = Start of Care POC = Plan of Care PsOC = Plans of Care

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interviews, 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 Agency’s Pt. admission folder was reviewed on 04/06/26. The folder lacked documentation of the Agency's transfer and discharge policies. 2. The following home visits were conducted on 04/06/26 and 04/07/26. Pt. #1. SOC 01/17/26. Pt. #2. SOC 03/21/26. Pt. #3. SOC 02/09/26. During the home visits, the Pt. admission folders were observed, and lacked documentation of the Agency's transfer and discharge policies. 3. The following clinical records were reviewed on 04/06/26 and 04/07/26: Pt. #1. SOC 01/17/26. Pt. #2. SOC 03/21/26. Pt. #3. SOC 02/09/26. Pt. #4. SOC 03/15/26. Pt. #5. SOC 03/16/26. Pt. #6. SOC 10/16/25. Pt. #7. SOC 12/08/25. The records lacked documentation the Agency provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 4. During the interview with the Agency Supervisor, on 04/09/26 at 9:45 AM, it was confirmed the Pt. Admission folder reviewed was used for all Pts. admitted to this Agency, and the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the Patient's Admission Folder, clinical record review, and staff interview, the Agency failed to ensure Pts. were provided with the correct information to file a concern or complaint with the Illinois Department of Public Health. This was found in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6, and 7). Findings include: 1. The Patient's Admission folder was reviewed on 04/06/26 at 11:00 AM. The folder included a document with the following information regarding filing a complaint. “You have the right to complain to us and to the United States Secretary of Health and Human Services if you believe we have violated your privacy rights. There is no risk in filing a complaint. To file a complaint with us contact us by mail at: Our Designee: Nursing Supervisor, RN. 4747 Lincoln Mall Drive Suite 260, Telephone No (708) 283-0202.” “To file a complaint with the United States Secretary of Health and Human Services. Send your complaint to the Secretary at: Office of Civil Rights, U.S. Department of Health and Human Services: 200 Independence Ave SW. Washington, DC 20201.” The above address is inaccurate. The Agency failed to provide the Pts. and/or the patients' representatives the State of Illinois' toll free home health telephone hot line purpose and its contact information. 2. During an interview with the Agency Supervisor on 04/09/26 at 9:45 AM, the above findings were confirmed.

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 observation and interviews during home visits, clinical record review and staff interviews, for 3 of 7 Pts (Pts. #1, 6 and 7), the Agency failed to ensure that the PsOC included all the requirements. Findings include: 2. Pt. #6 was admitted to home health services on 10/16/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 04/08/26 and included a POC for the certification period of 12/15/25 to 02/12/26. The POC required, “SN assess patient on diabetic status…identify any signs and symptoms of hyper/hypoglycemia and report significant changes to physician…” The POC lacked documentation of blood glucose monitoring parameters to be reported to the physician. 3. Pt. #7 was admitted to home health services on 12/08/25 with the diagnoses of but not limited to Atherosclerosis of native arteries of the left leg with ulceration of other part of foot, Type 2 Diabetes Mellitus with hypoglycemia without coma and End Stage Renal Disease. The clinical record was reviewed on 04/09/26 and included a POC for the certification period of 12/08/25 to 02/05/26. The POC required “(Blood glucose checks) three times daily before meal…” The POC lacked documentation of blood glucose monitoring parameters to be reported to the physician. During an interview with the Agency Supervisor on 04/09/26 at 10:30 AM, it was confirmed the Pt. had dialysis treatments 3 times a week and that the dialysis access site should be inspected. The POC lacked documentation of the care of the dialysis access site and supplies used. 4. During an interview with the Agency Supervisor on 04/09/26 from 10:00 Am to 11:00 AM, the above findings were confirmed. 1. Pt. #1 was admitted to Home Health services on 01/17/26 with the diagnosis of Non pressure chronic ulcer of an unspecified part of the lower leg with unspecified severity. The clinical record was reviewed on 04/06/26. The POC for period of 03/18/26 to 05/16/6 has an order to apply negative pressure wound vac twice weekly on Mondays, then Thursdays by wound clinic. The order lacked a description of the directions for the application of the wound vac, a description of equipment used, and instructions to Pt. or caregiver regarding care and application of wound vac therapy. The SN notes dated, 02/09/26, 02/16/26, 02/23/26, 03/02/26 03/09/26, 03/23/26 and 03/30/26 documents the same entry “negative pressure wound vac was applied” during every visit where treatment was completed by SN.

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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Transfer Summary. This was found in 1 of 2 (Pt. # 6) discharged clinical records reviewed. 1. Pt. #6 was admitted for home health services on 10/16/25 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The record included a transfer assessment, indicating that Pt. #6 was transferred to an in-patient facility on 12/24/25. As of the date of the clinical record review on 04/08/26, the record lacked documentation that a complete copy of the transfer summary was sent to the physician and the hospital. 2. During an interview with the Director of Nursing on 04/09/26 at 11:00 AM, the above findings were confirmed.

A Recertification survey was conducted on 01/06/23. A Determination has been made that this Agency is not in compliance with the Condition of Participation for: 42 CFR 484.105 Organization and Administration of Services. The Agency is precluded from conducting Aide training and/or competency evaluations for 24 months effective 01/06/23. This applies even if the Agency is not currently conducting Aide training and/or competency. Abbreviations EP =Emergency Preparedness LPN = Licensed Practical Nurse RN = Registered Nurse SOC = Start of Care SN = Skilled Nurse POC = Plan of Care 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), §485.625(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 the Agency's Emergency Preparedness Plan review and staff interview it was determined that Agency failed to develop the vulnerability / risk assessment based on a facility-based and or community-based risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/06/23 at 9:30 AM. The Emergency Plan lacked a vulnerability risk assessment using an all-hazards approach. 2. The Agency's Emergency Preparedness not having a vulnerability risk assessment was confirmed during an interview with Administrator on 01/06/23 at 11:00 AM.

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 the Agency's Emergency Preparedness Plan review and staff interview it was determined that Agency failed to develop a communication plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/06/23 at 9:30 AM. The Emergency Plan lacked a current communication plan that included the contact information for staff, entities providing services under arrangement and patients' physicians and volunteers. 2. The Agency's Emergency Preparedness not having a current communication plan was confirmed during an interview with Administrator on 01/06/23 at 11:00 AM.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Plan and staff interview it as determined that the Agency failed to conduct a full-scale testing of the Emergency Preparedness plan using a community-based exercise since 2018. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/06/23 at 9:30 AM. The Emergency Plan lacked documentation of Agency implementing or conducting testing of the Emergency Preparedness Plan since 2018. 2. The Agency's Emergency Preparedness not conducting a full-scale testing of the Emergency Preparedness plan was confirmed during an interview with the Administrator on 01/06/23 at 11:00 AM.

A Recertification survey was conducted on 01/06/23. A Determination has been made that this Agency is not in compliance with the Condition of Participation for: 42 CFR 484.105 Organization and Administration of Services. The Agency is precluded from conducting Aide training and/or competency evaluations for 24 months effective 01/06/23. This applies even if the Agency is not currently conducting Aide training and/or competency. Abbreviations EP =Emergency Preparedness LPN = Licensed Practical Nurse RN = Registered Nurse SOC = Start of Care SN = Skilled Nurse POC = Plan of Care PT = Physical Therapy

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on the review/observation of vaccination records, Staff interviews, policy review and review of CMS rules, it was determined the Agency failed to ensure a complete vaccination policy. Findings include: 1. On 01/06/23 at 10:30 AM, the Agency’s policy titled “Infection Control Policy: Guidance for Home Health Agencies on Care For COVID-19 and Potential COVID-19 Patients” was reviewed and was incomplete. The policy lacked the required processes for the documentation and tracking of the vaccinated Staff. The policy also lacked the contingency plans for staff who are not fully vaccinated for COVID-19. 2. On 01/06/23 at 10:30 AM, the CMS rule was reviewed and expects “all providers’ and suppliers’ staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute noncompliance under the rule.” 3. On 01/06/23 at 10:30 AM, during the interview with the Administrator, it was confirmed the above policy was incomplete and lacked the Mandatory vaccination policy.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: A. Based on the Staff interview and on-site observations, it was determined the Agency failed to have administrative and supervisory oversight of the Agency. This has the potential to affect all patients being served by the agency. Findings include: 1. The Agency failed to ensure the day to day operations (G948). 2.The Agency failed to ensure a Clinical Manager was available (G950). 3. The Agency failed to ensure a written designee was available (G954). 4. The Agency failed to ensure an available designee for the Administrator (G956). 5. The Agency failed to ensure administrative oversight for all patient care. (G958). The cumulative effect of these systemic practices resulted in the Agency's inability to provide care effectively.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: A. Based on observation and Staff interview, it was determined that the Agency failed to ensure day to day operations. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. On 01/03/2023 at 9:05 AM, it was observed that there were no administrative staff to assist with the survey. The Receptionist stated the Administrator is out of town and he will text her if needed. No Alternate Administrator, Agency Supervisor and Alternate Agency Supervisor were available. 2. On 01/03/2023 during the operating hours, the Surveyors could not access the clinical records, personnel files, in-services or the policies / procedures for: COVID-19, Emergency Procedures, Clinical Records, Criminal Background checks, etc. 3.On 01/04/2023 and 01/05/2023 the Agency's personnel files, in-services, policies and procedures were not available or accessible. 4. The Agency's policies/ procedures, in-services and personnel files were requested on 01/03/23 at 9:45 AM and were not accessible/ available until 01/06/2023 at 10:00 AM. 5. The above findings were confirmed with the Administrator on 01/06/23 at 10:40 AM.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: A. Based on observation and Staff interview, it was determined that the Agency lacked an available Clinical Manager during Agency’s hours of operation. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. On 01/03/2023 at 9:05 AM, it was observed that there was no Clinical Manager present at the Agency. The Receptionist was not successful with a telephone call to the Administrator and received a text from the Administrator at 9:45 AM, that the Field RN will come to the office. 2. It was observed the Clinical Manager or qualified alternate was not available 01/03/2023 through 01/06/2023. 3. On 01/03/2023 at 9:05 AM, it was confirmed with the Receptionist that the Clinical Manager or qualified designee were unavailable.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: A. Based on on-site observations and Staff interviews, it was determined the Agency failed to establish in writing, a qualified pre designated Alternate Administrator to serve in the absence of the Administrator. Findings include: On 01/03/2023 at 10:00 AM, it was observed the Administrator did not ensure an Alternate Administrator was available to assist the Agency in her absence. The Agency was unable to provide documentation establishing a qualified pre-designated alternate administrator. 2. During interviews with the Field Nurse on 01/03/2023 at 3:00PM and the Receptionist on 01/05/2023 at 10:00 AM, the above findings were confirmed.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: A. Based on observation and Staff interview, it was determined that the Agency failed to ensure that the Administrator or pre-designated Alternate is available during operating hours. This has potential to affect all patients receiving Home Health services. Findings include: 1. On 01/03/2023 at 10:00 AM, the Administrator’s son arrived and stated that both the Administrator and her designee were not available today. It was observed that the Agency failed to ensure the qualified pre-designated person, was available, during the operating hours. The Agency did not have any written pre-designated authorizations for review. 2. On 01/03/2023 at 10:00 AM, it was confirmed, during the onsite interview with the Administrator’s son, that the Administrator and Alternate Administrator were out of town and unavailable to be onsite.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: A. Based on the on-site observations and a Staff interview, it was determined the Agency failed to ensure the administrative oversight for all the patient care. Findings include: 1. On 01/03/23 at 10:30 AM, during the telephone interview with the Administrator, it was stated that the Agency has 10 patients and 2 Nurses (1-RN and 1- LPN). It was stated the Agency’s RN will arrive to assist with the survey and the Administrator will return 01/06/2023. 2. On 01/03/23 through 01/05/23, it was observed that the Clinical Manager or designee was not available to ensure the administrative oversight for the patient care. 3. The above findings were confirmed by telephone with the Administrator and the Administrator’s Son on 01/03/2023 at 10:40 AM and on 01/05/23 with the Receptionist.

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 review of clinical records, home visit patient interview and Staff interview, it was determined that the Agency failed to ensure the staff documented all interventions/ services and responses to those intervention/ services. This was found in 2 of 7 (Pts. # 2 and 3) clinical records reviewed. 4. Pt. #2 SOC 10/06/22 Primary Diagnosis: Hypertension. The clinical record was reviewed on 01/04/23 at 11:00 AM. The clinical record contained a POC for certification period 12/05/22 to 02/02/23 that required SN frequency 1 time a week for 9 weeks. The clinical record contained SN visit notes dated 12/06,12/10, 12/13, 12/20 and 12/27/23 that lacked documentation for vital signs. 5. Pt. #3 SOC 11/28/22 Primary Diagnosis: Hypertension. The clinical record was reviewed on 01/05/23 at 12:00 PM. The clinical record contained a POC for certification period 11/28/22 to 01/26/23 that required PT frequency of 2 times a week for 5 weeks beginning week 11/28/22. The clinical record did not contain any PT visit notes. During a SN home visit on 01/05/23 the patient stated that PT has been visiting patient 2 times a week since the beginning of home care services. Findings include: 1.Pt. #4 SOC 10/25/22 Primary Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 01/04/23 at 1:30 PM. The RN failed to document the vital signs evaluation on 11/29/22 and 12/06/22. 2.Pt. #5 SOC 09/08/22 Primary Diagnosis: Bilateral Osteoarthritis of Knee. The clinical record was reviewed on 01/04/23 at 12:30 PM. The RN failed to document the vital signs evaluation on 12/06/22 and the patient/family responses. During the interview with the RN, it was stated this is due to the new soft ware. 3.The above findings were confirmed during the interview with the Field Nurse (RN) on 01/03/2023 at 3:00 PM.