Every finding on record at N.O.S. Healthcare Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/16/25. 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 05/16/25. Standard level deficiencies cited. Abbreviations: Pt. / Pts. = Patient/Patients # = number AM = morning PM = afternoon/evening POC / PsOC = Plan of Care/Plans of Care mg/dL / mg/dl = milligrams/deciliter Q = every MD = Medical Doctor BS = Blood Sugar > = more than RBS = Random Blood Sugar SN = Skilled Nurse/Skilled Nursing mmHg = millimeters of mercury

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation and interview during home visits, clinical records review, and staff interviews, it was determined that in 3 of 7 (Pts. #1, 2 and 3) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The clinical records and home visits were conducted on 05/13/25 and 05/14/25 for the following Pts.: Pt. #1. SOC 05/12/25. Pt. #2. SOC 01/27/25. Pt. #3. SOC 01/27/25. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact information of the Administrator to file a complaint or grievance. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. Interviews were conducted with the Pt./patient’s representative, they were not aware of the name and contact information of the Administrator to file a complaint and/or grievance. 2. During an interviews with the Clinical Manager/Director of Nursing on 05/15/25 at 9:45 AM and at 10:30 AM, the Clinical Manager/Director of Nursing confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record reviews and Staff interviews, it was determined that in 2 of 7 (Pts.# 3 and 6) clinical records reviewed, the Agency failed to ensure Staff provide care as ordered in the POC. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record contained a POC effective 03/28/25 to 05/26/25, required: “Notify Physician of vital sign parameters out of range:….Diastolic Blood Pressure:….less than (The record lacked documentation the SN rechecked Pt. #3’s blood pressure or reported to the Physician, the Diastolic Blood Pressure readings of less than 60, as ordered. 2. Pt. #6 was admitted to Home Health Services on 01/29/24 with the Diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Unspecified Abdominal Pain, Other Chest Pain, Type 2 Diabetes Mellitus without complications, Fibromyalgia and Spinal Stenosis. The clinical record was reviewed on 05/13/25. The record contained a POC effective 03/29/24 to 05/27/24, required: “Notify Physician of vital sign parameters out of range:….Pain Level: Greater Than (>) 6….Blood sugar, Fasting…Greater Than (>180) Less Than ()200 Less Than ( 3. During an interview with the Clinical Manager/Director of Nursing on 05/15/25 at 9:45 AM, the Clinical Manager confirmed the above findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews and Staff interviews, it was determined that in 5 of 7 (Pts. #3, 4, 5, 6 and 2) clinical records reviewed, the Agency failed to ensure the POC contained specific interventions related to Pt.'s diagnoses and medications. 5. Pt. # 2 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Bilateral Primary Osteoarthritis of Knee and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25. The record contained POC effective 03/28/25 to 05/26/25 that included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range: Fasting Blood Sugar greater than (>) 180mg/dl less than () 200 mg/dl less than ( 6. During interviews with the Clinical Manager / Director of Nursing on 05/15/25 between 9:45 AM and 10:30 AM., the findings related to the PsOC not including pertinent patient specific interventions were confirmed. Findings include: 1. Pt. # 3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record contained POC effective 03/28/25 to 05/26/25, included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar….Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not indicated for Pt. #3’s diagnosis. The POC effective 03/28/25 to 05/26/25, included the following medications: “Biofreeze Cool The Pain…. Hydrocholorothiazide…. Tizanidine…. Amlodipine Besylate….Aspirin…. Losartan Potassium….Rosuvastatin Calcium….Metoprolol…. and Trazodone….” A home visit was conducted with Employee #4 (Registered Nurse) on 05/14/25 at 9:00 AM. During the home visit, Pt. #3, stated that she has been taking “Tylenol Extra Strength” for pain. The medication bottle labeled "Tylenol Extra Strength” was observed. Pt. #3 and Employee #4 confirmed that Pt. #3 has been taking the medication for more than a month. The POC was inaccurate. 2. Pt. # 4 was admitted to Home Health Services on 01/30/25 with the Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25 and 05/14/25. The POC effective 03/13/25 to 05/29/25, included: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar: greater than (>)180mg/dL less than ()200 mg/dl less than ( 150 mg/dl or >250 mg/dl or 3. Pt. # 5 was admitted to Home Health Services on 11/12/24 with the Diagnosis of Hemiplegia following other Cerebrovascular Disease affecting right dominant side. The clinical record was reviewed on 05/14/25. The POC effective 03/12/25 to 05/10/25, included orders for discipline and treatment: “Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar….Random Blood Sugar….” The POC included a blood sugar assessment intervention that was not indicated for Pt. #5’s diagnosis. 4. Pt. # 6 was admitted to Home Health Services on 01/29/24 with the Diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25. The PsOC effective 01/29/24 to 03/28/24 and 03/29/24 to 05/27/24, included: “Notify Physician of vital sign parameters out of range:….Blood Sugar, Fasting: Greater Than (>)180 less than ()200 Less Than ( 150 mg/dl or >250 mg/dl or

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy review and Staff interview, it was determined that in 6 of 7 (Pts. # 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure Pts. were assessed for the Influenza and / or Pneumonia vaccination status per Agency policy. Findings include: 1. During the entrance interview on 05/13/25 at 9:30 AM, the Clinical Manager stated that the Influenza and Pneumonia vaccination assessment are completed at the SOC, using the Agency standardized form. 2. The following clinical records were reviewed on 05/13/25 and 05/14/25, and lacked an Influenza and /or Pneumonia vaccination assessment: Pt. #2 SOC 01/27/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #3 SOC 01/27/25 – lacked Influenza and Pneumonia vaccination assessment. Pt. #4 SOC 01/30/25 - lacked Influenza and Pneumonia vaccination assessment. Pt. #5 SOC 11/12/24 – lacked Influenza and Pneumonia vaccination assessment. Pt. #6 SOC 01/29/24 – lacked Influenza and Pneumonia vaccination assessment. Pt. #7 SOC 10/19/24 – lacked Influenza and Pneumonia vaccination assessment. 3. The Agency policy was reviewed on 05/15/25. The policy titled: “Flu Vaccination” required, clinicians upon Start of Care, will obtain patient information regarding the patient’s flu vaccination status, will document where and when patient obtain their vaccination….The following shall be considered to be documentation….individual patient record entries identifying the assessment for the need of vaccination; date of offer or referral; patient response; administration, contraindication, or refusal; and any follow up activities….standardized check-off form recording patient specific information including assessment for the need of vaccination; date of offer or referral; patient response; administration, contraindication, or refusal; and any follow up activities .” The policy titled: “Pneumonia Vaccination” required, clinicians upon Start of Care obtain patient information patient information regarding the patient’s pneumonia vaccination status, will document where and when patient obtain their vaccination….The following shall be considered to be documentation….individual patient record entries….standardized check-off form….” 4. During interviews with the Clinical Manager/ Director of Nursing on 05/15/25 from 9:45 AM and at 10:30 AM, the Clinical Manager/ Director of Nursing confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record reviews and Staff interview, it was determined that in 5 of 7 (Pts. # 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure documentation entered into the clinical record was complete. Findings include: 1. Pt. #3 was admitted to Home Health Services on 01/27/25 with the Diagnosis of Primary Generalized (Osteo) Arthritis and Essential (primary) Hypertension. The clinical record was reviewed on 05/13/25 and 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 2. Pt. #4 was admitted to Home Health Services on 01/30/25 with the Diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25 and 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 3. Pt. # 5 was admitted to Home Health Services on 11/12/24 with the Diagnosis of Hemiplegia following other Cerebrovascular Disease affecting right dominant side. The clinical record was reviewed on 05/14/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. The record included a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. The sections mentioned above were left blank. The record included a form titled “ Home Health Change of Care Notice (HHCCN), dated at the SOC and signed by the Pt. The form contained sections that require the SN to enter items/services that have changed and reasons for the change. The sections mentioned above were left blank. 4. Pt. # 6 was admitted to Home Health Services on 01/29/24 with the Diagnoses of Chronic Obstructive Pulmonary Disease with acute exacerbation and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 05/13/25. The record included the “Authorization and Agreement for Home Health Services” dated at the SOC, signed by the SN and by the Pt. The form contained a section on Advance Directives, which was left blank. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Pt. The form contained sections regarding the Agency that the Pt. transferred from, reason for transfer and effective transfer date. The sections mentioned above were left blank. 5. Pt. #7 was admitted to Home Health Services on 10/19/24 with Diagnoses of Type 2 Diabetes Mellitus Without Complications. The clinical record was reviewed on 05/14/25. The record included a form titled “Beneficiary-Elected Letter of Transfer” dated at the SOC, signed by the SN and by the Patient. The form contained blank sections regarding the Agency that the Pt. transferred from and reason for transfer and effective transfer date. Pt #7 clinical record also contained a form titled “Advance Beneficiary Notice of Non-coverage (ABN), dated at the SOC, signed by the Pt. The form contained blank sections that required the SN to enter the service that Medicare may not pay, the reason, estimated cost of the service, and the option to choose whether the Pt. still wanted the service. 6. During interviews with the Clinical Manager / Director of Nursing on 05/15/24 between 9:45 AM and 10:30 AM. The findings of the incomplete clinical records were confirmed.

Recertification survey conducted. Determination has been made that this Agency is not in compliance with the Condition of Participation for: 42 CFR 484.70 Infection Prevention and Control. Identification of abbreviations: Covid -19 = Coronavirus disease 2019 CDC = Center for Disease Control and Prevention SOC = Start of care POC = Plan of care

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to ensure that the Agency conducted or participated in a full scale Community Based Exercise or Facility Based Exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 02/23/22 at 10:00 AM. The Emergency Preparedness Plan did not include documentation indicating that the Agency conducted or participated in a full scale Community Based or Facility Based exercise since 2019. 2. During an interview with the Administrator and the Agency Supervisor on 02/24/2022 at 11:00 AM, it was confirmed that the Agency failed to conduct or participate in a Full Scale exercise since 2019.

Recertification survey conducted. Determination has been made that this Agency is not in compliance with the Condition of Participation for: 42 CFR 484.70 Infection Prevention and Control. Recertification survey conducted. Standard deficiencies cited. Identification of abbreviations: Covid-19 = Coronavirus disease 2019 CDC = Center for Disease Control and Prevention SOC = Start of care POC = Plan of care

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. were informed of the disciplines that will furnish care, and the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 2/22/22 at 9:40 AM to 2/23/22 at 11:00 AM. Pt. #1 SOC: 11/22/21 Pt. #2 SOC: 09/08/21 Pt. #3 SOC: 9/8/21 Pt. #4 SOC: 1/21/22 Pt. #5 SOC: 11/22/21 Pt. #6 SOC: 10/2/20 Pt. #7 SOC: 4/6/21 The records lacked documentation of patient consenting to the disciplines that will furnish care and the frequency of visits. 2. During an interview with the Administrator and the Agency Supervisor on 2/23/22 at 2:33 PM, the Agency Supervisor confirmed the clinical records lacked documentation of the disciplines that furnished care, and the frequency of visits provided by each discipline.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined that the Agency failed to ensure Pts are informed of the extent of their financial liability before care is initiated. This was found in 6 of 7 clinical records reviewed. (Pts. # 1, 2, 4, 5, 6 and 7) Findings include: 1. The following clinical records were reviewed between 2/22/22 at 9:40 AM to 2/23/22 at 2:00 PM. Pt. #1 SOC: 11/22/21 Pt. #2 SOC: 09/08/21 Pt. # 4 SOC: 01/21/22 Pt. #5 SOC: 11/22/21 Pt. #6 SOC: 10/02/20 Pt. #7 SOC: 04/06/21 The clinical records lacked documentation that the patients were informed of the extent of their financial liability. 2. During interviews with the Administrator and the Agency Supervisor on 2/23/22 at 2:33 PM and on 2/24/22 at 11:00 AM, the Agency Supervisor confirmed the above findings.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: A. Based on a review of Agency policy, interview during home visits and staff interview, it was determined the Agency failed to ensure documentation of 100 percent COVID-19 vaccination for staff, initiate additional precautions for staff not vaccinated for COVID-19, develop and implement processes pertaining to staff COVID-19 vaccination status. This has the potential to affect all Pts. receiving care from the Agency. Findings include: 1. The Agency failed to develop and implement processes pertaining to staff COVID-19 vaccination status and provide vaccination status of staff providing care (G684). 2. The Agency failed to ensure 100 percent COVID -19 staff vaccination, provide documentation of vaccination and initiate additional precautions for staff not vaccinated for COVID-19 (G687). The cumulative effect of these systemic practices resulted in the Agency’s inability to ensure the safety of Pts. and infection control practices of staff.

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: A. Based on a review of Agency policy, interviews during home visits and staff interview, it was determined the Agency failed to develop and implement processes pertaining to staff COVID-19 vaccination status. This has the potential to affect all Pts. receiving care from the Agency. Findings include: 1. On 2/22/22 at 11:00 AM, the Agency presented a binder labeled "COVID-19 Pandemic Infectious Disease" which was reviewed on 2/22/22 at 11:50 AM. The binder contained a form titled, "COVID-19 Vaccination Waiver/Consent" which lacked any exemptions identified by CMS. 2. On 2/24/22 at 9:40 AM, the Agency Supervisor presented a second policy titled, "COVID-19 Vaccine Policy" which was reviewed on 2/24/22 at 11:00 AM, and the policy titled "COVID-19 Vaccination Guidelines For Staff" reviewed on 2/22/22 at 11:50 AM lacked: A process for verifying and ensuring that all staff that provide direct Pt. care and/or services received at least one dose of a COVID-19 vaccine, a process for tracing and documenting staff COVID-19 vaccination status, implementation of a process and forms containing the religious and/or medical exemptions identified by CMS. 3. The Agency's policy titled, COVID-19 Vaccine Policy" reviewed on 2/24/22 at 11:00 AM required: "...CMS requires agencies to develop and implement...procedures to ensure that all staff are fully vaccinated for COVID-19...1. All staff who are fully vaccinated will have documentation of vaccinations that include the vaccine received, date(s) of vaccinations and boosters if received... 3. Agency will provide medical or religious exemption forms for staff seeking exemptions... 5. Agency will develop a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC..." 4. The Agency policy titled, "COVID-19 Vaccination Guidelines For Staff" reviewed on 2/22/22 at 11:50 AM contained: "... (e) Any staff who refuse to get COVID-19 vaccination will not be penalized or reprimanded. However, the policy titled, "COVID-19 Vaccine Policy" reviewed on 2/24/22 at 11:00 AM contained: "...1. Staff who are not fully vaccinated will not provide care, treatment, or other services for the agency..." The 2 policies contradictory or oppose each other. 5. During the home visits conducted on 2/22/22 (2:00 PM with Employees #5 and 7) and 2/23/22 (12:30 PM with Employee #6). All three (3) employees stated they were fully vaccinated. As of 2/24/22, the Agency lacked documentation indicating the vaccination status of these employees. 6. During an interview with the Administrator and Agency Supervisor on 2/23/22 at 2:15 PM, the Administrator stated "I have a nurse that refuse to get the COVID vaccine". As of 2/23/22, the Agency lacked documentation of this nurses' vaccination status. 7. During an interview with the Administrator and Agency Supervisor on 2/23/22 at 2:15 PM, and the Agency Supervisor on 2/24/22 at 1:45 PM, the Agency Supervisor confirmed the Agency failed to develop and implement processes pertaining to staff COVID-19 vaccination status.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on a review of Agency policy and staff interview, it was determined the Agency failed to ensure documentation of 100 percent staff COVID-19 vaccination and initiate additional precautions for staff not vaccinated for COVID-19. This has the potential to affect all Pts. receiving care from the Agency. Findings include: 1. On 2/22/22 at 11:00 AM, the Agency presented a binder titled, "COVID-19 Pandemic Infectious Disease". The binder was reviewed on 2/22/22 at 11:50 AM and contained one policy pertaining to COVID-19 staff vaccination requirements titled, "COVID-19 Vaccination Guidelines For Staff" which lacked any additional precautions for staff not vaccinated or fully vaccinated to prevent staff from contracting COVID-19 or the spreading of this virus. The binder also lacked documentation of proof of vaccination status for staff providing patient care. 2. On 2/24/22 at 9:40 AM, the Agency presented a second policy titled, "COVID-19 Vaccine Policy" which included a section titled: "Infection Prevention and Control" and contained: "...Contingency Plans...2. Planning must also address the safe provision of services by individuals who have requested an exemption from vaccination while their request is being considered." As of 2/24/22, the Agency lacked a process identifying how the Agency will implement services safely by individuals who had requested a postponement for receiving the COVID-19 vaccine, while their request is being considered. 3. During an interview with the Administrator and Agency Supervisor on 2/23/22 at 2:15 PM and the Agency Supervisor on 2/24/22 at 2:00 PM, the Agency Supervisor confirmed the Agency failed to initiate additional precautions for staff not vaccinated for COVID-19 and failed to provide proof of vaccination for 100 percent of staff.

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 the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 10/02/20. Primary Diagnosis: Laceration without Foreign Body of Scalp, Initial Encounter. The closed clinical record was reviewed on 02/23/22 at 10:20 AM. The record contained the Agency's discharge comprehensive assessment and discharge summary dated 5/28/21. The Agency lacked documentation that a copy of the discharge summary was sent to the Physician. 2. Pt. #7. SOC 04/06/2021. Primary Diagnosis: Other Polyosteoarthritis. The clinical record was reviewed on 02/23/22 at 1:20 PM. The record contained a discharge comprehensive assessment dated 08/03/2021. The clinical record lacked documentation that a copy of the discharge summary was sent to the Physician. 3. During interviews with the Administrator and the Agency Supervisor on 2/23/22 at 2:33 PM and on 2/24/22 at 11:00 AM, the Agency Supervisor confirmed that the discharged summaries were not sent to the physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview it was determined that Agency failed to ensure all documentation entries to the clinical record were complete. This was found in 7 of 7 clinical records reviewed. ( Pts #1, 2, 3, 4, 5, 6 and 7 ) Findings include: 1. The following clinical records were reviewed between 2/22/22 at 9:40 AM to 2/23/22 at 2:00 PM. Pt. #1 SOC: 11/22/21 Pt. #2 SOC: 09/08/21 Pt. #3 SOC: 09/08/21 Pt. #4 SOC: 01/21/22 Pt. #5 SOC: 11/22/21 Pt. #6 SOC: 10/02/20 Pt. #7 SOC: 04/06/21 The records contain patient consents titled "Authorization and Agreement for Home Health Services". The questionnaire section on the consents for Advance Directive was not complete. 2. During interviews with the Administrator and the Agency Supervisor on 2/23/22 at 2:33 PM and on 2/24/22 at 11:00 AM, the Agency Supervisor confirmed the patient consents were incomplete.