Every finding on record at National Home Health Care Serv

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/31/25. Standard level deficiencies cited.

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 a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct staff training, relative to the Agency's Emergency Preparedness Plan. Findings include: 1. The Emergency Preparedness Plan binders were reviewed on 12/30/25 and lacked documentation of in-service training related to Agency’s Emergency Preparedness Plan from 2023 to current. 2. During an interview with the Administrator on 12/30/25 at 1:30 PM, the Administrator confirmed the above findings.

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 a review of the Agency's Emergency Preparedness Plan and staff interview, the Agency failed to conduct testing of the emergency preparedness plan to ensure the effectiveness of plan for the year 2024. Findings include: 1. The Agency's Emergency Preparedness Plan binders were reviewed on 12/30/25. The Emergency Preparedness Plan lacked documentation that testing exercises were conducted by the Agency for the year 2024. 2. During an interview with the Administrator on 12/30/25 at 1:30 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/31/25. Standard level deficiencies cited. Abbreviations: SOC: Start of Care Pt / Pts = Patient / Patients

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and staff interviews, the Agency failed to ensure Pts. received a copy of the Agency's transfer and discharge policy. Findings include: 1. The Agency Pt. admission folder was reviewed on 12/29/25. The folder lacked a copy of the Agency's transfer and discharge policy. 2. During staff interviews with the Administrator on 12/30/25 at 1:30 PM, the Administrator indicated the same folder is given to all Patients. During the same interview, the Administrator confirmed the above findings.

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: Based on clinical records review, and staff interviews, in 3 of 7 (Pts. # 5, 6 and 7) clinical records reviewed, the Agency failed to ensure that the Pt. / representative participate and consent to care and services provided by the Agency. Findings include: 1. The following clinical records were reviewed from 12/29/25 to 12/30/25. The clinical records lacked documentation of an informed consent to care and services provided by the Agency: Pt. #5 SOC 01/20/25 Pt. #6 SOC 11/25/24 Pt. #7 SOC 11/11/24 2. During interviews with the Administrator on 12/30/25 at 1:30 PM, the Administrator confirmed that Pts. agreed to the care and services provided by the Agency, but unable to provide copy of the signed consent. During the same interview, the Administrator confirmed the above findings.

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 review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct staff training relative to the Agency's Emergency Preparedness Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Emergency Preparedness plan last updated in 2020 was reviewed on 10/12/22 at 2:27 PM with the Administrator. The Plan lacked documentation the Agency conducted staff training in 2019, 2020, 2021 and 2022 pertaining to the Agency's Emergency Preparedness Plan. 2. During an interview with the Administrator on 10/12/22 at 2:27 PM, the Administrator stated the Agency had not provided any staff training regarding the Emergency Preparedness Plan and confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times wk = week # = number svc. = service ml = milliliter Tar = Tartrate E = Employee Tab = tablet(s) PO = by mouth IH - Inhalation AM = morning QD = every day PRN = as needed SUCC = Succinate SN = Skilled Nurse POC = Plan of care SOC = Start of care mg/MG = milligrams PsOC = Plans of Care ER = extended release RN = Registered Nurse PM = afternoon/evening POA = Power of Attorney Pt./ Pts. = Patient/Patients HCTZ = Hydrochlorothiazide QPM = every afternoon/evening COVID-19 = Coronavirus disease 2019 CDC = Centers for Disease Control and Prevention

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 a review of clinical records, observation during home visits and staff interview, it was determined that the Agency failed to inform the Pt./patient's representative in writing of the disciplines to furnish care, and the frequency of visits. This was found in 6 of 7 (Pts. #1, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 10/11/22 at 1:00 PM to 10/13/22 10:00 AM. The records lacked documentation of the Pt./patient's representative consent to the disciplines that will furnish care, and the frequency of the proposed visits. Pt. #1 SOC: 10/3/22 Pt. #3 SOC: 9/14/22 Pt. #4 SOC: 12/21/21 Pt. #5 SOC: 12/22/21 Pt. #6 SOC: 11/29/21 Pt. #7 SOC: 6/13/22 2. The following home visits were conducted on 10/12/22 at 11:00 AM to 1:30 PM. Pt. #1 SOC: 10/3/22 Pt. #3 SOC: 9/14/22 During the home visits, the patient's admission folder was reviewed and lacked documentation that the Pt./patient's representative was informed of the disciplines to provide care, and the frequency of the proposed visits. 3. During an interview with the Administrator on 10/13/22 from 10:30 AM to 11:15 AM, the Administrator confirmed the Agency failed to inform the Pt./patient's representative in writing of the disciplines to furnish care, and the frequency of visits.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: A. Based on a review of the Patient's Admission Folder, clinical record review, and staff interview, it was determined the Agency failed to ensure Pts. were provided with the correct address to file a concern or complaint with the Illinois Department of Public Health. This was found in 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6, and 7). Findings include: 1. The Patient's Admission folder was reviewed on 10/12/22 at 10:00 AM. The folder contained the form “Consent for Home Care Services and Agreement,” which included “…a concern or complaint about…home health agencies that are Medicare certified and operate in Illinois…can be made in writing to: 100 West Randolph Street, Suite 6-600, Chicago, IL 60601…” 2. The following clinical records were reviewed beginning 10/11/22 at 1:00 PM to 10/12/22 at 10:00 AM: Pt. #1 SOC: 10/3/22. Pt. #2 SOC: 9/14/22. Pt. #3 SOC: 9/14/22. Pt. #4 SOC: 3/18//21. Pt. #5 SOC: 12/22/21. Pt. #6 SOC: 11/29/21. Pt. #7 SOC: 6/13/22. These records all contained the form “Consent for Home Care Services and Agreement,” which included “…a concern or complaint about…home health agencies that are Medicare certified and operate in Illinois…can be made in writing to: 100 West Randolph Street, Suite 6-600, Chicago, IL 60601…” This address is inaccurate. 3. During an interview with the Administrator on 10/13/22 at 10:30 AM, the above findings were confirmed.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was updated. This was found in 1 of 4 (Pt. #6) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 11/29/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/13/22 at 9:45 AM. The record contained the "Physician's Telephone Order" completed by the SN with an effective date of 12/17/21 and included: "Discharge patient from...svc..." As of 10/13/22, the record lacked documentation the SN completed a discharge comprehensive assessment. 2. During an interview with the Administration on 10/13/22 at 10:58 AM, the Administrator confirmed the SN failed to update the comprehensive assessment upon Agency discharge.

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: A. Based on clinical record review, observations and interviews during home visits and staff interview, it was determined the Agency failed to ensure PsOC accurately listed Pt. medications. This was found in 3 of 7 (Pts. #1, 2, and 3) clinical records reviewed. 3. Pt. #3. SOC 9/14/22. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 10/11/22 at 1:15 PM. The record contained the POC effective 9/14/22 which included the medications: "Losartan Potassium HCTZ 100-12.5 1 Tab QD PO" and "Metoprolol Succ ER 50 MG QD PO". A home visit was conducted on 10/12/22 at 11:00 AM with the Administrator. During the home visit, observed the prescription medication bottles labeled: "Losartan 25 MG Tablet Take One Tablet (25 MG) by mouth daily" and "Metoprolol Tar Tab 25 MG Take One Half Tablet (25 MG) by mouth two times per day with food". During an interview with the Administrator, she stated the Pt. began the medications when discharged from an inpatient facility in September 2022. As of 10/12/22, the POC effective 9/14/22 lacked Losartan 25 MG Tablet Take One Tablet daily, and Metoprolol Tar Tab 25 MG Take One Half Tablet two times per day; and was inaccurate to include Losartan Potassium HCTZ and Metoprolol SUCC ER. 4. During an interview with the Administrator on 10/13/22 from 10:30 AM to 11:15 AM, the Administrator confirmed the PsOC lacked accurate medications. 1. Pt. #1. SOC 10/3/22. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 10/11/22 at 1:00 PM. The record contained the POC effective 10/3/22. A home visit was conducted on 10/12/22 at 1:35 PM, along with the Agency Supervisor. Pt. #1’s medications as listed on the POC were reviewed with Pt. #1’s Caregiver. The POC included “Albuterol Sulfate inhaler 3 mg BID IH;” however, Pt. #1’s Caregiver stated Pt. #1 takes Albuterol Sulfate 2.5 mg/3ml via nebulizer “for the past 2 years.” The POC contained “Tramadol 50 mg QD PO.” Pt #1’s Caregiver stated Pt. #1’s takes Tramadol as needed only, if Tylenol doesn’t work.” The POC included “Trazadone 50 mg, 2 tabs QD PO.” Pt. #1’s Caregiver stated Pt. #1 takes Trazadone 100 mg tablets, 2 tablets (200 mg) by mourh every night at bedtime, since September 11.” In addition, Pt. #1’s Caregiver stated Pt. #1 takes the following medications, not listed on the POC: Fluticasone Propionate nasal spray, 50 mcg, one spray per nostril daily, “for at least two years;” Budesonide 0.5 mg/2 ml via nebulizer twice a day “for at least 5 months;” Amlodipine 2.5 mg by mouth daily “for at least two years”; and Nystop topical powder 100,000 Units/gm to the rash on his groin and buttocks three times a day “for at least the last 3 weeks.” The POC was inaccurate. 2. Pt. #2. SOC 9/14/22. Primary Diagnosis: Hypertensive Heart Disease without Heart Failure. The clinical record was reviewed on 10/11/22 at 1:30 PM. The record contained the POC effective 9/14/22. A home visit was conducted on 10/12/22 at 10:00 AM, along with E #1. During this home visit, Pt. #2’s medications as listed on the POC were reviewed with Pt. #2’s Caregiver/POA. Pt. #1’s POC included “Metoprolol 25 mg QD.” Pt. #1’s Caregiver/POA stated Pt. #2 takes 25 mg by mouth daily if Pt. #2’s systolic blood pressure is under 150; if Pt. #2’s systolic blood pressure is above 150, Pt. #2 takes 50 mg, and this has been the dosage for “quite a while.” Pt. #2’s POC contained “Losartan 50 mg QD PO.” Pt. #2’s Caregiver/POA stated this medication was “discontinued a year ago.” The POC also included “Mirtazapine 15 mg QPM PO.” Pt. #2’s Caregiver/POA stated Pt. #2 takes this medication only as needed. Pt. #2’s POC also contained “Ramipril 2.5 mg QD PO;” Pt. #2’s Caregiver/POA stated Pt. #2’s dosage of this medication is 5.0 mg daily “since mid September.” In addition, Pt.#2’s Caregiver/POA stated Pt. #2 takes Alendronate 70 mg by mouth weekly on Saturdays “since July.” Alendronate is not listed on Pt. #2’s POC. Pt. #2’s Caregiver/POA also stated Pt. #2 takes Donepezil 5 mg by mouth daily “for a long time.” Donepezil is not listed on Pt. #2’s POC. The POC was inaccurate.

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 personnel COVID-19 vaccination record review and staff interview, it was determined the Agency failed to ensure it has a COVID-19 staff vaccination policy which includes criteria for Administration to evaluate and either accept or reject employee requests for exemption from the COVID-19 vaccination, as well as what precautions the Agency will take to ensure staff who decline to be vaccinated do not become infected with COVID-19. This was found in 1 of 4 (E#1) employees/contracted employees reviewed for compliance with COVID-19 vaccinations. This has the potential to affect all pts. receiving services from the Agency. Findings include: 1. E #1’s COVID-19 vaccination status was reviewed on 10/12/22 at 12:50 PM. E #1 signed a form titled: “Declination of COVID-19 Vaccination Form,” which was dated 2/1/21. There was no documentation regarding why E #1 was declining to receive the COVID-19 vaccine, that E #1’s declination was evaluated or accepted/rejected by the Agency, or what actions the Agency would be undertaking to ensure E #1 remained free of COVID-19. 2. During interviews with the Administrator on 10/11/22 at 11:10AM, 12:15 PM, and 3:00PM, and on 10/12/22 at 12:15 PM, the Agency’s COVID-19 staff vaccination policy was requested, but was not provided. During an interview with the Administrator on 10/13/22 at 10:30 AM, the Administrator confirmed the above findings.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure Agency staff complete a summary at discharge. This was found in 1 of 4 (Pt. #6) closed clinical records. Findings include: 1. Pt. #6. SOC 11/29/21. Primary Diagnosis: Type 2 Diabetes Mellitus without Complications. The closed clinical record was reviewed on 10/13/22 at 9:45 AM. The record contained the SOC comprehensive assessment dated 11/29/21, the SN visit notes dated 12/3/21, 12/10/21 and 12/17/21. The "Physician's Telephone Order" dated 12/17/21 included: "Discharge patient from...svc..." As of 10/13/22, the record lacked documentation of a written report summarizing care/services provided, and goals met/not met at discharge. 2. During an interview with the Administrator on 10/13/22 at 10:58 AM, the Administrator confirmed the Pt. was discharged from the Agency, and that the Agency lacked a discharge summary for Pt. #6.