Every finding on record at Horizon Home Health, Inc.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf the State of New Mexico, Department of Health. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 08/09/23 to 08/11/23 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102 and the following standard-level deficiencies listed below. The agency's Administrator was informed on 08/10/23 at 3:50 PM that an Immediate Jeopardy (IJ) existed in that the agency failed to establish and maintain a Comprehensive Emergency Preparedness Program, to ensure the safety of patients receiving home health services. The agency's Administrator was informed that Immediate Jeopardy was still present and ongoing at the time of exit from the survey on 08/11/23 at 4:40 PM. See findings in Tags E0004, E0006, E0007, E0009, E0013, E0017, E0019, E0021, E0023, E0024, E0029, E0030, E0031, E0032, E0033, E0034, E0036, E0037, and E0039, The facility provided an IJ Removal Plan on 8/11/2023 at 4:40 PM. The IJ Removal Plan was approved on 09/05/2023 at 1:45 PM.

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 review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to establish a Comprehensive Emergency Preparedness Program that complied with all applicable Federal, State, and Local Emergency Preparedness requirements that was based off the HHA's Risk Assessment and patient population it serves. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2, The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained an undated "Emergency Preparedness Plan Policy:" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including the Emergency Preparedness Conditions of Participation, or a policy based on the HHA's risk assessment and patient population. (See findings in Tags E0004, E0006, E0007, E0009, E0013, E0017, E0019, E0021, E0023, E0024, E0029, E0030, E0031, E0032, E0033, E0034, E0036, E0037, and E0039, During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Comprehensive Emergency Preparedness Plan and Policy, including the Emergency Preparedness Conditions of Participation were not developed based on the HHA's risk factors and patient population.

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 review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop and maintain an Emergency Preparedness Plan that must be reviewed and updated every two years. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan which must be reviewed and updated every two years. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Comprehensive Emergency Preparedness Plan had not been established.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to have an Emergency Plan (EP) that was based on a facility-based and community-based Risk Assessment that included strategies for addressing emergency events identified by the Risk Assessment. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a facility and/or community-based risk assessment or strategies for addressing emergency events identified by the Risk Assessment. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a facility-based and community-based Risk Assessment had not been performed and/or strategies for addressing emergency events had not been developed.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop an Emergency Preparedness Plan based on the HHA's patient population and failed to determine the services that the HHA would be able to provide during an emergency. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including the incorporation of the HHA's patient population and services that the HHA would be able to provide during an emergency based on the patient population, including delegations of authority and succession plans. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that the HHA's patient population and services that the HHA would be able to provide during an emergency were not addressed in an Emergency Preparedness Plan.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop an Emergency Preparedness Plan including a process for collaboration and cooperation with local, tribal, regional, State, and Federal emergency preparedness officials. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including collaboration and coordination with local, tribal, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or an emergency situation. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that he/she did not collaborate and coordinate with local, tribal, regional, State, and Federal emergency preparedness officials for development of an Emergency Preparedness Plan.

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 review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop Comprehensive Emergency Preparedness policies and procedures based on the HHA's Risk Assessment that must be reviewed and updated every two years. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain policies and procedures based on the HHA's Risk Assessment. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that he/she did not perform a Risk Assessment or develop policies and procedures based on the Risk Assessment.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder and staff interview, the HHA failed to include plans for patients during a natural or man-made disaster as part of the comprehensive assessment. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" The policy did not address the HHA's procedure for providing an emergency plan to each patient during the comprehensive assessment. Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the policy did not include a procedure for providing an Emergency Plan to each patient during the Comprehensive Assessment. During an interview 08/10/23 at 8:50 AM, the Administrator confirmed that he/she did not develop a procedure for providing an Emergency Plan for each patient during the Comprehensive Assessment.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including policies and procedures of the Risk Assessment to inform State and local emergency preparedness officials about patient's needing evacuation. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including procedures to inform State and local emergency preparedness officials about patient's needing evacuation due to an emergency situation based on the patient's medical and psychiatric condition and home environment. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a procedure to inform State and local emergency preparedness officials about patient's needing evacuation was not developed.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including policies and procedures on follow-up with on-duty staff and patients in the event there is an interruption of service during or due to an emergency. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the agency's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including policies and procedures on follow-up with on-duty staff and patients in the event there was an interruption of service. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that policies and procedures to follow-up with on-duty staff and patients in the event there was an interruption of service was not developed.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including policies and procedures for medical documents. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the agency's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including policies and procedures to ensure a secure system of documentation preserving patient information and protecting patients' confidentiality and secures and maintains availability of records. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that policies and procedures to ensure a secure system of documentation preserving patient information and protecting patients' confidentiality were not developed.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including policies and procedures to incorporate the use of volunteers. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including policies and procedures to incorporate the use of volunteers or other emergency staffing strategies in an emergency. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that policies and procedures to incorporate the use of volunteers or other emergency staffing strategies in an emergency were not developed.

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 review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan that complied with Federal, State, and Local Laws, which must be reviewed and updated every two years. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan that complied with Federal, State, and local laws was not developed.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan containing list of names with contact information. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else include in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan containing contact information for staff, entities providing services under arrangement, physicians, and volunteers. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan containing contact information for staff, entities providing services under arrangement, physicians, and volunteers was not developed.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan that included emergency officials contact information. This deficient practice had the potential to affect all patients receiving services at the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan containing contact information for Federal, State, tribal, regional, local emergency preparedness staff, as well as other sources of assistance. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan containing contact information for Federal, State, Tribal, regional, local emergency preparedness staff, as well as other sources of assistance was not developed.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan containing primary and alternate means for communication. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else include in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan containing primary and alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency management agencies. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan containing primary and alternate means for communicating was not developed.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan containing a method for sharing patient information to other health care providers to maintain continuity of care. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan containing a method for sharing patient information and medical documentation for patients under the HHA care, as necessary, with other health providers to maintain the continuity of care, or a means of providing information about the general condition and location of patients under the HHA's care as permitted. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan containing a method for sharing patient information to other health care providers to maintain continuity of care was not developed.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including a Communication Plan containing a method for sharing information on occupancy and needs. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including a Communication Plan containing a method for providing information about the agency's needs and the ability to aid the Incident Command Center. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a Communication Plan containing a method for providing information about the agency's needs and the ability to aid the Incident Command Center was not developed.

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 review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including maintaining an emergency preparedness training and testing program. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including maintaining an emergency preparedness training and testing program. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a plan maintaining an emergency preparedness training and testing program was not developed.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA's) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including training new and existing staff every two years on the Emergency Preparedness Policy. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the HHA's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including training new and existing staff every two years on the Emergency Preparedness Policy. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a training program for new and existing staff members on emergency preparedness had not been developed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's (HHA) policy, review of the HHA's "Emergency Preparedness" binder, and staff interview, the HHA failed to develop a Comprehensive Emergency Preparedness Plan including emergency preparedness testing requirements. This deficient practice had the potential to affect all patients receiving services from the HHA. Review of the agency's undated policy titled "Emergency Preparedness Plan Policy" indicated " … "1.2 The following guidelines will be utilized when planning for emergency situations:" (There was nothing else included in the policy) Review of the HHA's binder labeled "Emergency Preparedness" revealed that the binder contained the "Emergency Preparedness Plan Policy;" however, the binder did not contain a Comprehensive Emergency Preparedness Plan including testing the emergency plan at least annually, participate in a full-scale exercise that is community based, or conduct an annual individual, facility based functional exercise every two years. During an interview on 08/10/23 at 8:50 AM, the Administrator confirmed that a protocol for conducting a full-scale exercise, a mock disaster drill, or a tabletop exercise every two years had not been developed.

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) from 08/09/23 to 08/11/23 resulted in a finding of substantial compliance respective to the applicable Condition of Participation under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency's (HHAs) sample patient admission folder, review of HHA policy, and staff interview, the HHA failed to provide patients with the Outcome and Assessment Information Set (OASIS) Privacy Notice prior to providing care. This deficient practice had the potential to affect all Medicare patients receiving services from the HHA. Review of the HHA's sample patient admission folder revealed that the OASIS Privacy Notice was not part of the admission package as required under the privacy laws. Review of the HHA's undated policy number 3.001.1 titled "Rights, Responsibilities and Ethics" on page three indicated "The Agency staff will ensure that during the initial evaluation visit before initiation of treatment, that the client or their legal representative receives a written notice concerning all policies governing client conduct and responsibility and client rights … The client has the right to confidential treatment of his or her personal and medical records. To be advised of Agency's policy and procedure regulation disclosure of clinical records … " During an interview on 08/11/23 at 1:00 PM, the Administrator confirmed that the OASIS Privacy Notice was not part of the patient's admission folder, and the patients were not receiving the privacy notice.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency's (HHAs) patient admission folder, review of the HHA's policy, and staff interview, the HHA failed to provide patients with the following Federally funded and State funded addresses and telephone numbers: 1.) Agency on Aging; 2.) Center for Independent Living; 3.) Protection and Advocacy Agency; 4.) Aging and Disability Resource Center; and 5.) Quality Improvement Organization. This deficient practice had the potential to affect all patients receiving care from the HHA. 1. Review of the HHA's admission package revealed that the addresses and telephone numbers for the following agencies were not provided to the patients upon admission: a. Agency on Aging b. Center for Independent Living c. Protection and Advocacy Agency d. Aging and Disability Resource Center e. Quality Improvement Organization. 2. Review of the HHA's undated policy number 3.001.1 titled "Rights, Responsibilities and Ethics" on page three indicated "The Agency staff will ensure that during the initial evaluation visit before initiation of treatment, that the client or their legal representative receives a written notice concerning all policies governing client conduct and responsibility and client rights … " 3. During an interview on 08/11/23 at 1:00 PM, the Administrator confirmed that the names, addresses and telephone numbers for the Federally funded and State funded entities were not provided to the patients.

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 observation, review of the Home Health Agency's (HHAs) policy, review of the Centers for Disease Control's (CDC's) guidelines, and staff interview, the HHA failed to ensure that wound care was performed for one (Patient (P) 3) of two observed patients' according to the CDC infection control guidelines. This deficient practice had the potential to affect patients receiving wound care services from the HHA. 1. Observation of P3's wound care performed on 08/11/23 by Registered Nurse (RN)1, revealed the following: a. At 11:50 AM, RN1 placed on gloves, removed a blood pressure cuff, monitor and pulse oximeter (measures blood oxygenation level) from a bag, squeezed hand sanitizer from the bottle into the gloved hand, sanitized the gloved hands, obtained P3's vital signs, removed the gloves, and disposed of them in the trash. b. At 12:00 PM, RN1 placed on gloves, cleaned the blood pressure cuff, monitor and pulse oximeter, squeezed hand sanitizer from the bottle into the gloved hand, sanitized the gloved hands, placed the clean equipment back in the bag, removed the gloves, and disposed of them in the trash. c. At 12:10 PM, RN1 placed on gloves, removed the soiled dressing on P3's leg wound, changed the gloves, squeezed hand sanitizer from the bottle into the gloved hand, sanitized the gloved hands, performed wound care, and disposed of the gloves in the trash. d. At 12:20 PM, RN1 placed a new dressing on P3's leg wound and, after completion, squeezed hand sanitizer from the bottle into the gloved hand, sanitized the gloved hands, disposed of the barrier that contained the soiled dressing with the gloved hands, hand sanitized his/her gloved hands, and continued to put the supplies away. 2. During an interview on 08/11/23 at 4:00 PM, RN1 confirmed that he/she should not be using hand sanitizer on gloved hands. 3. Review of the CDC's website at https://stacks.cdc.gov under the section titled "Methods for Performing Hand Hygiene of Gloved Hands for Extended Use of Disposable Medical Gloves" indicated, "CDC does not recommend disinfection of disposable medical gloves as standard practice. This practice is inconsistent with general disposable gloves usage, but, in times of extreme disposable medical glove shortages, this option may need to be considered …" 4. Review of undated policy number 7.002.1 titled "Universal Body Substance Precautions" indicated "a) Gloves are to be worn by the family/caregiver when direct contact with body substances is anticipated (blood, urine, pus, feces, saliva, drainage of any kind). b) Gloves are to be worn when contact with non-intact skin is anticipated. c) Gloves are to be worn when handling soiled linen. d) Sterile gloves are to be worn for sterile procedures e) Changes gloves between patient/client contacts. f) Gloves should not be washed or disinfected for reuse.

The following deficiencies were cited as a result of a recertification survey completed on 02/19/2021 for the requirements of 42 CFR 11.02 Federal Requirements for Home Health Agencies. A COVID-19 Focused Infection Control Survey was conducted by the New Mexico Department of Health Division of Health Improvement on 02/19/2021. The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations and has not implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

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 observations, interviews, and record reviews the facility failed to adequately screen and trace employees (process of identify individuals concerning for an infectious disease and then identifying those exposed to them) for COVID-19 (coronavirus, respiratory viral infection). This failed practice is likely to poorly identify individuals with possible COVID-19 infections and increase the risk of transmission. The findings are: A. On 02/17/2021 at 10:05am, observed no temperature screening or COVID-19 symptom (cough, fever, shortness of breath) check being done on visiting Department of Health Surveyors. B. On 02/17/2021 at 12:10pm, observed no temperature screening or COVID-19 symptom check being done on visiting employee. C. On 02/17/2021 at 12:15pm, interview with S6 (Administrative Assistant) confirmed that no temperature or COVID-19 symptom screening was done on employees that entered the facility today. S6 also reported that temperature and symptom checks are done daily, but not recorded in a daily log. D. On 02/17/2021 at 01:15pm, interview with S1 (Administrator) confirmed that temperature and COVID-19 symptom checks are done, but not logged daily. When provided additional information, S#1 confirmed that logs have an essential role regarding contact tracing as they allow the facility to quickly notify those who have been potentially exposed to someone that was screened as concerning for COVID-19. E. On 02/17/2021 at 03:13pm, observed no temperature screening or COVID-19 symptom check being performed on visitor that entered the facility. F. On 02/18/2021, record review of facility's "What our Agency is doing to help prevent the spread of COVID-19" attestation revealed: 1. Caregivers and patients are monitored for symptoms of respiratory infection. 2. Visitors must be screened for symptoms of respiratory infection

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, the Governing Body to maintain documentation of annual evaluations completed for 3 staff (S3, S4, and S5) of 6 (S1, S2, and S6) to ensure appropriate patient care is provided in daily operations. This failed practice has the potential to result in the agency not having oversight of personnel not being adequate for the skilled position requirements, thereby resulting in poor quality of patient care. The findings are: A. Record review of S3, S4, and S5 personnel files, revealed no completed annual evaluation trainings. S3 (Physical Therapist) start date 11/14/2019 S4 (Occupational Therapist) start date 07/21/2019 S5 (Occupational Therapist Assistant) start date 08/30/2019 B. Record review of [name of facility] Category: Human Resources, Number 2.013.1, Subject: Performance Evaluation, Applies to: All Staff, Page: 1 of 1, undated, revealed, under Purpose: To provide for annual and periodic evaluation of an employee's production/performance. Policy: The written performance of each employee shall be performed on at least an annual basis. C. On 02/18/21 at 1:45 pm during interview, S1 (Administrator) confirmed annual evaluations for S3, S4, and S5 had not been completed and no information was in the personnel files.