Every finding on record at Lfg Frontliners Holdings, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 3/26/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements, on 3/26/25. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients POC = Plan of Care RN = Registered Nurse AG = silver AM = morning PM = afternoon % = Percent OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined that in of 54 of 219 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 10/1/24 to 2/26/25 (12 months), was reviewed on 3/25/25. The report included a warning for Error # -3330. The Error included 54 (24.66 %) of 219 assessments that were submitted late. 2. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 12:30 PM, the Agency Supervisor confirmed the above findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, it was determined for 4 of 7 Pts. (Pts. #4, 5, 6 and 7) the Agency failed to ensure that the comprehensive assessments included a complete review of body systems. 2. Pt. #5 was admitted to home health services on 12/27/24 with diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 2/21/25 lacked documentation of the assessments for genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 3. Pt. #6 was admitted to home health services on 3/23/24 with diagnosis of Encounter for change or removal of non-surgical wound. The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 5/17/24 lacked documentation of the assessments for genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 4. Pt. #7 was admitted to home health services on 4/21/24 with diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/26/24. The comprehensive assessment dated 6/18/24 lacked documentation of the assessments for genitourinary, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 5. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 10:45 AM and 12:30 PM, the administrative staff confirmed the above findings. Findings include: 1. Pt. #4 was admitted to home health services on 12/4/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 1/28/25 lacked documentation of the assessments of the genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews, policy review and staff interviews, it was determined that for 1 of 7 (Pt. #4) clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders and as indicated in the POC. Findings include: 1. Pt. #4 was admitted for home health services on 12/4/24 with the Cutaneous Abscess of the Groin and Non-pressure Chronic Ulcer Unspecified Part of Right Lower Leg with Fat Layer Exposed. The clinical record was reviewed on 3/25/25. The clinical record contained, “Order/Telephone Order” dated 3/10/25, requiring: “Posterior neck wound: Cleanse with normal saline, pat dry, and apply skin prep to the peri-wound. If the wound is dry, leave it open to air with skin prep applied…Right breast and left groin wounds: Lightly tuck Prisma AG-collagen to the depth of the wound. Fill wounds with Vashe-moistened ribbon. Cover with drawtext and secure with bordered foam…" The “Wound Care Worksheets” included the same documentation of treatment provided for the following dates, 3/12/25, 3/14/25 and 3/19/25: “Posterior neck, Dehisced Surgical wound, treatment: Apply Acquacel AG then cover with bordered foam dressing… Right breast: Subcutaneous abscess, treatment: Pack the wound with mesalt leave the tail out for easy removal…Left Groin: Subcutaneous abscess, treatment: Pack the wound with mesalt …cover with dry gauze, change daily…” The RN failed to follow the wound treatment ordered by the Physician. 2. During an interview with the Agency Supervisor and the Assistant (Alternate)Administrator on 3/26/25, the Agency Supervisor stated all treatments provided by the nurse is documented on the Wound Notes under “Treatment Order.” It was also stated that all care, treatment, and services should have an order from the Physician. During the same interview, the above finding was confirmed.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Agency Supervisor. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 3/24/25. The folder lacked the name and information to contact the Agency Supervisor. 2. The following home visits were conducted on 3/24/25 and 3/25/25: Patient #1. SOC 3/18/25. Patient #3. SOC 2/3/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Agency Supervisor. 3. The following clinical records were reviewed on 3/25/25 and 3/26/25: Pt. #1. SOC 3/18/25. Pt. #2. SOC 1/11/25. Pt. #3. SOC 2/3/25. Pt. #4. SOC 12/4/24. Pt. #5. SOC 12/27/24. Pt. #6. SOC 3/23/24. Pt. #7. SOC 4/21/24. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Agency Supervisor. 4. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 12:30 PM, the Agency Supervisor confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: POC = Plan of Care Pt./Pts. = Patient/Patients SN = Skilled Nurse SOC = Start of Care

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: A. Based on a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the plan was established based on an updated risk assessment utilizing an all-hazards approach. This has the potential to affect all patients served. 1. The Agency’s Emergency Preparedness Plan was reviewed on 01/26/22 at 09:30 AM. The Plan lacked the community specific risk assessment utilizing an all hazard approach. 2. During an interview with the Agency Supervisor on 01/26/22 at 11:15 AM, the above findings were confirmed. The Agency Supervisor stated she does not have a risk assessment utilizing an all-hazards approach.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on a review of the Agency’s Emergency Preparedness Plan/Policy, trainings and Staff interview, it was determined the Agency failed to document the training of the Emergency Preparedness Plan. This has the potential to affect all patients served. Findings include: 1. The Agency’s Emergency Preparedness Plan/ policy and trainings were reviewed on 01/26/22 at 09:30 AM. The Agency's last documented in-service/training was dated 09/27/18. The Agency lacked any further documented training of the emergency preparedness plan. 2. The Agency’s policy titled “Emergency Preparedness” was reviewed on 01/27/22 at 10:00 AM and included : “…12....test the plan annually… all responses and exercises will be documented…. 14… Education will be provided during orientation and annually thereafter….. Drills and Exercises…. Agency staff members will participate in a minimum of one drill or exercise to determine the effectiveness and efficiency of the current policy…” 3. During an interview with the Agency Supervisor on 01/27/22 at 10:30 AM, it was stated the in-service for 2020 was online. As of 01/27/22 at 10:30 AM no supporting documentation has been provided. 4. It was confirmed, regarding the lack of documented Emergency Preparedness training, during the interview with the Agency Supervisor on 01/27/22 at 10:30 AM.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on review of clinical records and Staff interview, it was determined that the Agency failed to ensure the staff documented all interventions/ services and responses to those intervention/ services. This was found in 3 of 7 (Pts. #1, 3 and 5) clinical records reviewed. Findings include: 3. Pt. # 5 SOC 10/11/21 Diagnoses: Hypertension, Hyperlipidemia, COPD. The clinical record was reviewed on 01/25/22 at 1:00 PM. The Plan of Care for certification period 10/11/21 through 12/09/21 included, “…SN to instruct the patient/caregiver on proper use of nebulizer/inhaler and assess return demonstration.…” The clinical record lacked documentation of the intervention and response on the proper use of the inhaler and O2 status for the entire certification period. 4. During an interview with the Agency Supervisor on 01/26/22 between 11:15 AM and 12:15 PM the above findings were confirmed. 1. Pt. #1. SOC 10/11/21. Diagnoses: Bilateral Primary Osteoarthritis of Knee and Essential Primary Hypertension. The clinical record was reviewed on 01/25/22 at 2:00 PM. The record lacked the SN visit notes dated 11/01/21. The notes lacked documentation of the SN care and the patient/family responses. 2. Pt. #3. SOC 03/22/21. Diagnoses: “Athscl Heart Disease of Native Coronary Artery” and Essential Primary Hypertension. The clinical record was reviewed on 01/26/22 at 9:30 AM. The record contained SN visit notes dated 05/24/21. The notes lacked documentation of the SN care and the patient/family responses.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and Staff interview, it was determined that the Agency failed to ensure the staff documented a complete discharge summary and send a Discharge summary to the physician within 5 days of Discharge. This was found in 3 of 7 (Pts. #1, 5 and 6) clinical records reviewed. Findings include: 2. Pt. # 5 SOC 10/11/21 Diagnoses: Hypertension, Hyperlipidemia, COPD The Clinical Record was reviewed on 1/25/2022 at 1:00 PM. The Clinical record included a discharge OASIS dated 12/06/2021. The Clinical Record lacked a completed Discharge Summary. 3. Pt. #6 SOC 10/11/21 Diagnosis: Bilateral Primary Osteoarthritis of the Knee The Clinical Record was reviewed on 01/25/2022 at 1:30 PM. The Clinical record included a discharge OASIS dated 12/06/2021. The Clinical Record lacked a completed Discharge Summary. 4. During an interview at with the Agency Supervisor on 01/26/22 at 11:15 AM the above findings were confirmed. 1. Pt. #1. SOC 10/11/21. Diagnoses: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 01/25/22 at 2:00 PM. The record lacked the SN visit notes dated 11/01/21. The notes lacked documentation of the complete discharge summary.