Every finding on record at Holy Name Home Care, Inc

On 2/28/23 through 3/1/23, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Holy Name Home Care was found to be non-compliant with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness. The following condition level deficiency was identified: 42 CFR §484.102 Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to develop an Emergency Preparedness plan that must be reviewed and updated, including guidance for the Covid-19 pandemic, resulting in lack of direction for Agency personnel (See E 0004); failed to develop an Emergency Preparedness plan that must be reviewed and updated at least every 2 years that included guidance for the Covid-19 pandemic and strategies based on documented facility and community based risk assessments from an all hazards approach (See E 0006); failed to develop written Emergency Preparedness policies and procedures that were based on an Emergency Preparedness plan, risk assessment, and communication plan (See E0013); failed to develop and maintain a Communication Plan for an Emergency Preparedness plan which is updated every 2 years that included a facility and community based risk-assessment, policies and procedures, and included guidance for the COVID-19 pandemic (See E 0029); failed to show evidence the Emergency Preparedness training and testing program is based on the emergency plan, risk assessment, policies, procedures, and the communication plan (See E0036); and failed to perform testing of their Emergency Preparedness program as required (See E 0039). The cumulative effect of these systemic problems could potentially have a negative effect on all patients serviced by the agency in the event staff is not properly prepared for an emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.

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), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that must be reviewed and updated to include strategies to address the Covid-19 global pandemic, resulting in no directions for Agency personnel in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all patients serviced by this agency in the event of an emergency or disaster. Findings include: Agency Policy: "Emergency Operations Plan and Policies" 2.1.1 (Revised January 2020) stated, "The Agency has established and maintains an emergency preparedness program that meets all requirements. The Agency complies with all applicable Federal, State, and local emergency preparedness requirements." On 2/28/23 at 1:45 PM., review of the Agency's Emergency Preparedness (EP) binder revealed no evidence of active participation since 11/23/2018. At 2:10 PM., a request was made to the Chief Executive Officer (CEO#1) to review the Governing Board's (GB) review and approval of the Agency's EP program. The last documented GB meeting minutes was dated 12/28/2018. CEO#1 was asked if there were any additional GB meeting minutes approving the Agency's EP program. CEO#1 replied, "No, we haven't had any patients since then (2018)." Documentation of the annual review of all Agency Policies and Procedures which included the EP program, was approved on 12/26/22. However, no explanation was offered when CEO#1 was questioned how the EP program's Policy and Procedure could be reviewed and approved when there was no evidence of active participation since 2018. Further review of the EP binder found no documentation that the Agency had developed an EP plan that acknowledged and incorporated strategies how to optimize patient care concerning the Covid-19 pandemic for the last three years. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:06 AM.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop an Emergency Preparedness Plan that was based on both a facility-based and community-based all-hazards risk assessment, resulting in the potential for being unprepared to respond effectively in the event of an emergency. This deficient practice could negatively affect the health and safety of all patients serviced by this Agency in the event of an emergency or disaster. Findings include: On 2/28/23 at 1:50 PM., review of the Agency's Emergency Preparedness (EP) binder revealed no evidence of that the Agency had assessed and updated its facility and community-based risk assessment since 11/23/2018. Findings of collaborative efforts with other entities within the community to promote an integrated response were not evidenced. No documentation was found in the all-hazards risk assessment that identified and incorporated strategies to address the Covid-19 pandemic of the last three years. The Agency failed to develop a risk assessment that was comprehensive, which identified the likeliness of emergencies that would endanger patient care within the Agency and the community itself. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:07 AM.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop and update Emergency Preparedness (EP) policies and procedures that were based on an EP plan, risk assessment, and communication plan, resulting in the Agency's inability to implement appropriate emergency actions which could negatively affect the health and safety of all patients serviced by the Agency. Findings include: On 2/28/23 at 1:55 PM., the Agency's Emergency Preparedness (EP) documentation was reviewed. It was noted that the EP's plan and policies were last reviewed and approved on 12/26/22. However, no explanation was offered when CEO#1 was questioned how the EP program's Policy and Procedure could be reviewed and approved when there was no evidence of active participation since 2018. Further review of the EP binder found no documentation that the Agency had developed an EP plan that acknowledged and incorporated strategies how to optimize patient care concerning the Covid-19 pandemic for the last three years. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:09 AM.

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), §485.542(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: Based on record review and interview, the Agency failed to 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, resulting in the Agency's inability to ensure the coordination of patient care in the event of an actual emergency. These practices could negatively affect the health and safety of all patients serviced by this Agency. Findings included: On 2/28/23 at 2:00 PM., the Agency's Emergency Preparedness (EP) documentation was reviewed which revealed no evidence of active participation since 11/23/2018. Further review noted that the employee contact list consisted of names and phone numbers for Agency staff that are no longer employed. Prominent staff such as the Agency's Administrator were not updated in the Communication Plan. Instead, the previous Administrator who has not been employed since 1/13/2022, was listed. No evidence was found which detailed by name and title, how the Agency would interact and coordinate with staff, patients, and emergency management agencies of how to protect patient health and safety in the event of a disaster. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:11 AM.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies/procedures, and communication plan, which must be reviewed and updated at least every two years. This deficient practice could affect the health and safety of all patients and staff in the event of an actual emergency. Findings included: On 2/28/23 at 2:05 PM., review of the Agency's Emergency Preparedness binder revealed the Agency had failed to perform any training or testing of its staff since 11/23/2018, at both the Agency and community-based levels. In addition, no training/testing of strategies to address the Covid-19 pandemic of the last three years were evidenced. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:12 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), §485.542(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 record review and interview, the Agency failed to provide documentation that it had conducted exercises to test its emergency plan annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the full-scale exercise, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 2/28/23 at 2:10 PM., review of the Agency's Emergency Preparedness binder found no evidence the Agency had conducted the required full-scale community-based exercise every two years. Additionally, no evidence was noted of an additional testing exercise scheduled every two years opposite of the full-scale exercise noted above. No documentation of an actual emergency or event that could be substituted for an exercise was evidenced. No communication or effort was noted by the Agency in reaching out to the local incident command center to participate in the community-based exercise. The last documented Agency involvement concerning Emergency Preparedness was dated 11/23/2018. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:13 AM.

The following standard and condition level deficiencies were noted during the Medicare recertification survey conducted on 2/28/23 through 3/1/23 by the Michigan Department of Licensing and Regulatory Affairs at: Holy Name Home Care, Inc. 30700 Telegraph Rd., Suite 2560-B Bingham Farms, MI 48025 At the time of the survey, the Agency did not operate any branch offices or subunits. The services the agency provides are: Skilled Nursing (SN). Clinical records reviewed for this survey: None, the Agency has had zero patients since the last deemed-status survey on 6/6/2019. Condition level deficiencies were identified at: 42 CFR §484.102 Emergency Preparedness42 CFR §484.65 Quality Assessment/Performance Improvement 42 CFR §484.70 Infection Prevention and Control 42 CFR §484.65 Quality Assessment/Performance Improvement 42 CFR §484.105 Organization and Administration of Services 42 CFR §484.115 Personnel Qualifications As a result of the Condition level noncompliance identified on 3/1/2023, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

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 record review and interview, the Agency failed to include full contact information for the Home Health Agency's Administrator in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 2/28/23 at 10:50 AM., the Agency's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice, patient rights and responsibilities forms and Emergency Preparedness documents. However, it was noted the contact information for the Agency's Administrator was inaccurate, having listed the previous Administrator not employed since 1/13/2022. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:03 AM.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on record review and interview it was determined that the Agency failed to inform patients how to access auxiliary aids and language services, resulting in the potential for unmet patient care needs for all patients serviced by this Agency. Findings include: On 2/28/23 at 10:54 AM., review of the Agency's admission packet under Patient Rights utilized at the start of care, found no evidence concerning how patients would be able to access auxiliary aids and language services as needed. The above findings were reviewed with and acknowledged by the Chief Executive Officer (CEO#1) during an interview on 3/1/23 at 10:02 AM.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Quality Assurance and Performance Improvement (QAPI) program that measured, tracked, and analyzed its quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the Agency (See G 642); failed to provide data collected which monitored the QAPI program to determine the effectiveness, safety of services, and quality of care to identify opportunities for improvement (See G 644); failed to document any quality improvement projects for 2019 through 2023 to date, and document the reasons for conducting these projects and the measurable progress achieved each year (See G 658); and failed to ensure the Governing Body had appropriate over-sight that ensured an effective means to comprehensively evaluate the Agency's QAPI program (See G 660). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care for all the patients the Home Health Agency has served for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all patients serviced by the Agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: Agency Policy: "Quality Assessment and Performance Improvement (QAPI) Plan and Program" 10.1.1 (Revised February 2021) stated, "The Agency will establish an ongoing, Agency-wide, data-driven program of quality assessment and performance improvement and maintain documentary evidence of its program." The Agency's QAPI documentation binder was reviewed on 2/28/23. During review, documentation to support the Agency's performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes was not found. The QAPI binder contained documentation and instructions for a QAPI program but had no additional documentation or data since 2018. At 12:55 PM., the Chief Executive Officer (CEO#1) was queried if there was any documentation to support that the Agency had utilized any aspects of QAPI since 2018. CEO#1 replied, "No, we haven't had any patients since then (2018)." The Agency failed to ensure their QAPI program had working processes in place that showed measurable improvements in indicators to address any aspects concerning patient care, including the last three years of the Pandemic.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement (QAPI) program, which had the potential to negatively affect all patients serviced by this Agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: On 2/28/23, during review of the Agency's QAPI program activities for 2019, 2020, 2021, and 2022 to date, it was noted that the Agency failed to produce any data that could be measured, tracked, or analyzed. There was no evidence the Agency's Governing Body had recognized and acknowledged the need for data collection within the QAPI program. The Chief Executive Officer (CEO#1) was queried on 2/28/23 at 12:55 PM., if there was any documentation to support that the Agency had utilized any aspects of QAPI since 2018. CEO#1 replied, "No, we haven't had any patients since then (2018)."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual performance improvement projects, and the reasons for conducting these projects with measurable progress achieved, resulting in the Agency's inability to show improvement in areas concerning quality of patient care, health outcomes, and patient safety. Findings include: On 2/28/23, review of the Agency's QAPI program activities 2019, 2020, 2021, and 2022 to date, it was noted that the Agency failed to produce any data that could be measured, tracked, or analyzed. There was no evidence the Agency's Governing Body had recognized and acknowledged the need to establish any performance improvement projects (PIP) concerning the Agency or patient care related items. The Chief Executive Officer (CEO#1) was queried on 2/28/23 at 12:56 PM., if there was any documentation to support that the Agency had proposed and utilized any PIP's related to the QAPI program since 2018. CEO#1 replied, "No, we haven't had any patients since then (2018)."

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all patients serviced by this Agency. Findings include: On 2/28/23, a request was made to review the Agency's QAPI report and Governing Body (GB) meeting minutes for 2019, 2020, 2021 and 2022 to date. Upon receipt and review of the Agency's QAPI binder and all GB documentation, no evidence was found that affirmed the GB's oversight of the QAPI program since 2018. The Chief Executive Officer (CEO#1) was queried on 2/28/23 at 12:57 PM., if there was any documentation to support any input or involvement by the Agency's executive GB concerning the QAPI program since 2018. CEO#1 replied, "No, we haven't had any patients since then (2018)."

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure effective infection prevention and control measures were utilized (G-682); failed to maintain an Agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases that was incorporated into the Quality Assessment/Performance Improvement program (G-684); and failed to provide any documented evidence that infection control education, including Covid-19, was provided to staff employed by the Agency (G-686). The cumulative effects of these systemic problems resulted in the Agency's inability to ensure the provision of safe health care for the condition of participation of 42 CFR§484.70 Infection Prevention and Control.

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: Based on record review and interview, the Agency failed to develop and update an Infection Control Program which incorporated policies and procedures within accepted standards of practice to prevent the transmission of infections and communicable diseases, including Covid-19. This deficient practice resulted in the increased potential for the transmission of infectious agents to all Agency staff and patients. Findings include: The Agency's infection prevention documentation binder was reviewed on 2/28/23. There was no evidence found of any active involvement by the Agency concerning the education, in-services, surveillance, screening, and the appropriate use of PPE (Personal Protective Equipment) concerning the containment of Covid-19 and/or other infectious diseases from 2019 through 2023 to date. At 1:10 PM., the Chief Executive Officer (CEO#1) was queried if there was any documentation to support if the Agency had utilized any aspects of infection prevention (hand washing, environmental disinfection, PPE, minimizing potential exposures, etc.) with emphasis on Covid-19. CEO#1 replied, "No, we haven't had any patients since Covid started." The Agency failed to ensure accepted standards of practice were utilized concerning infection prevention, including the last three years of the Covid-19 pandemic.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; failed to develop a method to screen visitors and agency staff prior to providing clinical services, and failed to develop an infection control program that is incorporated into the Agency's QAPI (Quality Assurance & Performance Improvement) program in order to track and trend the risk factors focused on the containment of Covid-19 and other communicable diseases, resulting in the potential development and spread of a contagious viral infection between Agency staff and all patients serviced by the Agency. Findings included: Agency Policy: "Infection Control Committee" 5.13.1 (Revised March 2018) stated, "The committee will meet annually. Reports from meetings will be forwarded to the QAPI Committee, Administrator and Governing Body." The Agency's infection control program was reviewed on 2/28/23. No evidence was found that indicated any active involvement by the Agency concerning the surveillance, identification, prevention, and control of infectious diseases, including Covid-19 since 2018. No screening procedures to mitigate the spread of Covid-19 and other infectious diseases were noted for clinical staff and visitors. In addition, there was no documented evidence the Agency's QAPI program included the surveillance, identification, prevention, or control of Covid-19 and other infectious diseases since 2018. On 3/1/23 at 10:19 AM., the Chief Executive Officer (CEO#1) acknowledged the Agency had failed to perform any of the above measures for over three years concerning infection control.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the agency failed to provide evidence of infection control education concerning Covid-19 and other communicable disease was provided to any staff employed by the agency, resulting in the potential for the development and spread of the Covid-19 and other infectious agents to staff and all patients serviced by the agency. Findings include: The agency's infection control program was reviewed on 2/28/23. No evidence was found that indicated any education concerning infection control had been provided since 2018. On 2/28/23 at 10:20 AM., the Chief Executive Officer (CEO#1) was queried if there was any documentation of staff training, education, and in-services regarding infection control/Covid-19. CEO#1 replied, "No, we haven't had any patients since the last survey (2018). CEO#1 on 3/1/23 at 10:20 AM., acknowledged the agency had failed to follow its policy, "Employee Infection Control Training" 5.4A.5 (Revised March 2019) stated, "Employees will receive education and training...at least annually." The agency failed to ensure annual infection control education was provided to all staff employed or contracted by the agency.

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: Based on record review and interview, it was determined the Home Health Agency failed to ensure the Governing Body consisted of more than one person which assumed full legal authority and responsibility in hiring a qualified Administrator to provide appropriate oversight concerning the Agency's overall management and operation, and its quality assessment and performance improvement program (See G0942); and failed to ensure that a qualified alternate administrator was authorized in writing by the administrator and the governing body to function in the administrator's absence (See G-954). The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care for the condition of participation of 42 CFR §484.105 Organization and Administration of Services.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined Agency failed to ensure the Governing Body consisted of more than one individual which assumed full legal authority in hiring a qualified Administrator to provide appropriate oversight concerning the Agency's overall management and operation and failed to review its quality assurance and performance improvement (QAPI) program since 2018, resulting in the potential for provision of substandard or unsafe care for patients serviced by the agency. Findings include: On 2/28/23 at 2:40 PM, the Governing Body (GB) meeting minutes were requested for review. Upon review of the meeting minutes, it was noted that the last meeting was held on 12/28/18. The agency's Chief Executive Officer (CEO#1) was queried if there was any further documentation of the GB meeting to discuss and strategize on pertinent topics such as Covid-19 or any review of its QAPI program since 2018. CEO#1 replied, "No, we haven't had any patients since before Covid started." Additional review noted documentation that the Agency had appointed a new Administrator (Adm#1). CEO#1 then submitted upon request, the written authorization which appointed Adm#1. Review of this document noted the authorization was approved and signed by one individual: "(CEO#1)/Governing Body" effective 1/3/23. No other "designated persons" other than CEO#1 were found representing the agency's GB. CEO#1 was further queried at 2:52 PM., what the administrative background was concerning Adm#1. CEO#1 replied, " She is our Director of Nursing and our only current employee." When asked what experience Adm#1 has had, CEO#1 stated, "She was just hired and is new to the role." On 3/1/23 at 10AM., a phone interview was conducted with Adm#1, who confirmed she had no previous administration experience prior to accepting the role on 1/3/23. Adm#1 was then questioned about administrative duties needed to effectively manage and provide oversight of the Agency's services and how compliance with the Conditions of Participation would be upheld. Adm#1 was found to be unfamiliar with topics such as: CMS (Centers for Medicare & Medicaid Services) Conditions of Participation regulations, QAPI (Quality Assurance Performance Improvement), Emergency Preparedness training and testing requirements, and other administrative duties. During an interview on 3/1/23 at 10:14 AM., CEO#1 reviewed and acknowledged the above findings. The agency's Governing Body failed to be comprised of more than one individual, failed to responsibly hire an appropriate administrator, and failed to ensure its the QAPI program was reviewed as required since 2018.

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: Based on record review interview, the Agency failed to ensure a qualified alternate administrator, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in a lack of organization and direction of the Agency's ongoing functions to assure the availability and provision of care and services. Findings include: On 2/28/23, documentation review revealed the Agency had a newly appointed Administrator (Adm#1), effective 1/3/23. During a follow-up interview on 2/28/23 at 12:10 PM., the agency's Chief Executive Officer (CEO#1) was queried as to the administrative background of the Adm#1. CEO#1 replied, "She is our Director of Nursing (DON) and our only current employee." CEO#1 was then asked who the alternate Administrator is when Adm#1 is not available. CEO#1 responded, "We don't have one yet." CEO#1 acknowledged at 12:12 PM., that the agency failed to have an alternate Administrator as required.

Personnel qualifications CFR(s): 484.115 Condition of participation: Personnel qualifications. HHA staff are required to meet the following standards: This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the current Administrator possessed the necessary training and experience required to be qualified to work as an Administrator of a home health agency, which has the potential to affect all patients serviced by the agency (See G 1052). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.115 Personnel Qualifications.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the current Administrator did not have the training and experience required to be qualified to work as an Administrator of a home health agency, which has the potential to affect all patients serviced by the agency, resulting in the potential for patients to receive services that are unsafe or substandard. Findings include: On 2/28/23, at 2:52 PM., an interview was conducted with the Agency's Chief Executive Officer (CEO#1) to ascertain the background of the newly appointed Administrator effective 1/3/23. CEO#1 replied, "She is our Director of Nursing (DON) and our only current employee." When asked what experience Adm#1 has had, CEO#1 stated, "She was just hired and is new to the role." Additional review noted Adm#1 is still serving as the Agency's DON, with the clinical experience of managing 0 patients 2018; as the agency has been essentially non-operational since then. A follow-up phone interview on 3/1/23 at 10:06 AM., was performed with Adm#1 to ascertain the current level of competence needed to comprehensively perform home health administrative duties. During the interview, Adm#1 was queried and found to be unfamiliar with essentials such as: QAPI (Quality Assurance Performance Improvement), EP (Emergency Preparedness), and other administrative duties. Although Adm#1 was available by phone at 10:06 AM., no physical presence was noted by Adm#1 at any time during the re-certification survey 2/28/23 through 3.1.23. During an interview on 3/1/23 at 10:20 AM., the above findings were reviewed with and acknowledged by CEO#1. The agency failed to ensure the Administrator was appropriately qualified to provide oversight of the agency's day to day operations to effectively manage and safeguard the provision of quality care to all patients serviced.