Every finding on record at Manhattan Retirement Foundation Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (60658-H1) at the above-named Home Health agency (HHA) from 07/17/23 to 07/20/23 resulted in the following standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

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 Emergency Preparedness Plan (EPP) the agency failed to review and updated the EPP at least every 2 years. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: On 07/18/23 between 9:00 am and 2:00 pm, while reviewing the Emergency Preparedness Program, it was observed that the Home Health agency (HHA) failed to conduct a review of the entire Emergency Preparedness Plans every 2 years. The last documented review of the plan was documented as revised in 2014, however based on interview and observation, it was clear policies have been changed and/or added, yet a documented thorough review was not completed as required. The Administrator was present and acknowledged the findings.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (60658-H1) conducted at the above-named Home Health Agency (HHA) from 07/17/23 through 07/20/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C.