Every finding on record at Nightingale Home Health Service

An unannounced Home Health Agency recertification survey was conducted on June 20 -22, 2023 by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found not to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and review of the agency's emergency preparedness (EP) program, it was identified that the agency failed to maintain an emergency preparedness plan that was reviewed and updated every two years. The findings: On June 21-22, 2023, the agency's emergency preparedness (EP) program plan and policies were reviewed in the agency. The EP binder contained a form in the back of the binder titled “Emergency Care Plan and On-Call Services” with a signed date of "06/2007" by the Administrator and with the revision date left blank. The agency failed to maintain an emergency preparedness plan that was reviewed and updated at least every two years. On June 22, 2023, at 11:30 AM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above noted findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on staff interview and the agency's emergency preparedness (EP) program it was determined the agency's emergency preparedness plan failed to review and update the all-hazard approach to include emerging infectious disease threats. The findings: The agency's emergency preparedness (EP) program was reviewed in the agency on June 21-22, 2023. The EP failed to contain an all-hazard approach based on a community-based risk assessment to include identification of any specific emerging infectious disease threats that offered strategies that would affect the home health’s ability to be prepared for surge events. The lack of the above noted information was reviewed and acknowledged with the Administrator prior to and during the exit conference conducted in the agency on 06/22/2023.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and review of the agency's emergency preparedness (EP) program it was revealed that the agency failed to have evidence that the policies and procedures included a risk assessment and a communication plan. The findings: On June 21-22, 2023, the agency's emergency preparedness (EP) program policies were reviewed in the agency. The EP binder contained a form in the back of the binder titled “Emergency Care Plan and On-Call Services” with a signed date of “06/2007” by the Administrator and with the revision date left blank. The agency's emergency preparedness (EP) program failed to have evidence that the policies and procedures included a risk assessment and a communication plan. On June 22, 2023, at 11:30 AM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above findings.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and review of the agency's emergency preparedness (EP) program it was determined the agency failed to have evidence of policies and procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. The findings: On June 21-22, 2023, the agency's emergency preparedness (EP) program policies were reviewed in the agency. The agency's polices failed to contain evidence within the EP policies the procedure to inform State and local officials of any on-duty staff or patients that they are unable to contact. On June 22, 2023 at 11:30 AM an interview was conducted with the Administrator, in the agency. The Administrator acknowledged the above findings.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness (EP) program, personnel files and staff interview it was determined the agency failed to maintain documentation of a training and testing program based on the agency's risk assessment required for staff. The findings: The agency's emergency preparedness (EP) program was reviewed in the agency on June 21-22, 2023. The plan failed to include evidence of a training and testing program to demonstrate knowledge of the agency’s EP. On 06/21/2023 at 3 PM the Medical Facilities Inspector (MFI) requested the agency's active staff list. The MFI chose eight (8) staff members to review as personnel files. The eight (8) personnel files did not contain any training or testing of the agency's emergency preparedness that reflected the identified risk assessments, policy and procedures or a communication plan. On 06/22/2023 at 11:35 AM the MFI requested any documentation that demonstrated the staff's training and knowledge on the emergency preparedness plan. The Administrator stated, “I didn’t know we had to."

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness (EP) program and staff interview it was determined the agency failed to maintain documentation of evidence of the staff’s ability to demonstrate knowledge of agency’s emergency preparedness plan. The findings: The agency's emergency preparedness (EP) program was reviewed in the agency on June 21-22, 2023. The agency’s EP binder contained a form in the front of the binder titled “Monthly in-services/staff meeting” The form was blank. The plan failed to include evidence of the staff’s ability to demonstrate knowledge of the agency emergency preparedness plan. On 06/22/2023 at 11 AM the Medical Facilities Inspector (MFI) requested any documentation that demonstrated the employee’s knowledge on the emergency preparedness plan. The failure to maintain documentation of the staff’s ability to demonstrate knowledge of the agency’s emergency plan was acknowledged by the Administrator during the review of the agency’s EP and again during the exit conference conducted in the agency on 06/22/2023.

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 interview and review of the agency's emergency preparedness (EP) program it was determined the plan failed to contain evidence of conducting annual testing including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. The findings: On June 21-22, 2023 the agency's emergency preparedness (EP) program policies were reviewed in the agency. The agency failed to have evidence of a policy and annual testing program activities including unannounced staff drills using the emergency procedures and/or participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. On June 22, 2023, at 11:35 AM an interview was conducted with the Administrator in the agency. The Administrator acknowledged the above findings.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency June 20-22, 2023 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 52 unduplicated admissions for the past twelve (12) months and 38 active patients. In conjunction with the survey, seven (7) clinical records and eight (8) personnel files were reviewed. Three (3) home visits and were conducted. The agency was found not to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. Deficiencies were identified and cited in this report.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on review of clinical records and staff member interviews, it was determined the agency failed to have written evidence of furnishing the patient's rights in a language and manner the individual understands during the initial evaluation visit in advance of care in order to protect promote the exercise of these rights for two (2) of two (2) patients in the survey sample with closed records (Clinical record #s 1 and 2). The findings: Two (2) closed/discharged records were reviewed as paper charts in the agency on June 21-22, 2023. 1 The clinical record for patient #1 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the start of care (SOC). 2 The clinical record for patient #2 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the start of care (SOC). SStaff interview: On 06/21/2023 at 5:30 PM, the Assistant Administrator stated, “These burned in the office fire of October 2022. An exit interview was conducted with the Administrator where these findings were again acknowledged on 06/22/2023.

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 clinical records and staff member interview, it was determined that the agency failed to have written evidence of furnishing the Patient's Rights and Responsibilities and the agencies transfer and discharge policies since the start of care (SOC) for two (2) of two (2) patients in the survey sample with closed records (Clinical record #s 1 and 2). The findings: Two (2) closed/discharged records were reviewed as paper charts in the agency on June 21-22, 2023. 1 The clinical record for patient #1 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the SOC, including Patient's Rights and Responsibilities and the agencies transfer and discharge policies. 2 The clinical record for patient #1 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the SOC, including Patient's Rights and Responsibilities and the agencies transfer and discharge policies. Staff interview: On 06/21/2023 at 5:30 PM, the Assistant Administrator stated, “These burned in the office fire of October 2022." An exit interview was conducted with the Administrator where these findings were again acknowledged on 06/22/2023.

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 record review and staff member interviews it was determined the agency staff failed to have written evidence to include visit frequencies on the “Service Agreement” for two (2) of two (2) patients in the survey sample closed records (Clinical record #s 1 and 2). The findings: Two (2) closed/discharged records were reviewed as paper charts in the agency on June 21-22, 2023. 1. The clinical record for patient #1 failed to contain consents or other forms of written evidence by the HHA of the visit frequencies to be made by the disciplines. 2. The clinical record for patient #1 failed to contain consents or other forms of written evidence by the HHA of the visit frequencies to be made by the disciplines. Staff interview: On 06/21/2023 at 5:30 PM, the Assistant Administrator stated, “These burned in the office fire of October 2022." An exit interview was conducted with the Administrator where these findings were again acknowledged on 06/22/2023.

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: Based on clinical records review and staff member interview, it was determined the agency failed to have written evidence of advising on the extent of payment by Medicare, Medicaid or any other federally funded or federal aid program known to the agency for services that maybe expected or may not be covered for two (2) of two (2) patients in the survey sample with closed records (Clinical record #s 1 and 2). The findings: Two (2) closed/discharged records were reviewed as paper charts in the agency on June 21-22, 2023. 1. The clinical record for patient #1 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the SOC, including the extent of payment for agency services that maybe expected by the patient. 2. The clinical record for patient #1 failed to contain signed and dated consents or other forms of written evidence by the patient or a patient legal representative authorizing the HHA to care and treat the patient or informing the patient of all the required information the patient is to receive prior to the SOC, including the extent of payment for agency services that maybe expected by the patient. Staff interview: On 06/21/2023 at 5:30 PM, the Assistant Administrator stated, “These burned in the office fire of October 2022." An exit interview was conducted with the Administrator where these findings were again acknowledged on 06/22/2023.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on review of clinical records and staff member interview the agency's staff failed to document patient measurable outcomes based on their strengths, goals, and care preferences, including information that may be used to determine the patient's progress toward achievement of identified goals for seven (7) of seven (7) patients in the survey sample (Client records # 1- 7). The findings: Seven clinical records were reviewed as paper charts in the agency on June 21-22, 2023. The patients for clinical record #s 1 – 7 failed to contain measurable outcomes that occurs over time with healthcare interventions. Some of the documented outcomes for the diagnosis of “Diabetes” were to “manage blood sugar with finger sticks”, or for the diagnosis of “Hypertension” were to “eat vegetables and fruits for better nutrition”. None of the patients contained a measurable outcome with a end result of whether the patient is declining, improving or no change toward the identified goals. On 06/22/2023 the MFI (Medical Facilities Inspector) asked the Administrator where the measurable outcomes for the above patients were. The Administrator was unable to find measurable outcomes for the patients and acknowledged the lack of measurable outcomes.

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on a review of personnel files and staff member interview the agency failed to document 75 hours of classroom and supervised practical training for their home health aides for four (4) out of four (4) in the survey sample. (Personnel records #s 2, 3, 4, and 8) Based on a review of personnel files and staff member interview the agency failed to document 75 hours of classroom and supervised practical training for their home health aides for four (4) out of four (4) in the survey sample. (Personnel records #s 2, 3, 4, and 8). The findings: Four (4) personnel files of the agency’s personal care aides (PCA) were reviewed in the agency on June 22, 2023. The PCA hired on 08/18/2022 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 01/29/2021 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 03/12/2021 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 03/31/2022 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. On 06/22/2023 at 10:20 AM the Medical Facilities Inspector called the Clinical Coordinator for Personal Care to ask if the PCA’s has 75 hours of classroom and supervisory training with 16 hours included as classroom training. The Clinical Coordinator stated, “No I did not do 75 hours of training with them”. The Administrator acknowledged the lack of documented PCA hours for the aides on 06/22/2023.

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on a review of personnel files and staff member interview the agency failed to document classroom training as part of the home health aides curriculum for four (4) out of four (4) in the survey sample. (Personnel records #s 2, 3, 4, and 8). Findings: Four (4) personnel files of the agency’s personal care aides (PCA) were reviewed in the agency on June 22, 2023. The PCA hired on 08/18/2022 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 01/29/2021 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 03/12/2021 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. The PCA hired on 03/31/2022 contained aide training but there were no hours documented to identify classroom training versus supervised practical training or the number of hours spent training for an aide. On 06/22/2023 at 10:20 AM the Medical Facilities Inspector called the Clinical Coordinator for Personal Care to ask if the PCA’s has 75 hours of classroom and supervisory training with 16 hours included as classroom training. The Clinical Coordinator stated, “No I did not do 75 hours of training with them”. The Administrator acknowledged the lack of documented PCA hours for the aides on 06/22/2023.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency failed to ensure each patient receiving home health aide services received a supervisory visit by the registered nurse or other skilled professional no less frequently than every 14 days for one (1) of one (1) clinical records a home health aide was applicable in the survey sample. (Clinical record #6). The findings: Seven clinical records were reviewed in the agency on June 21-22, 2023 via paper charts. 1. The clinical record of patient #6 was reviewed for the time frame of 6/03/2023 through 06/22/2023. The patient's plan of care contained orders for a home health aide once weekly. The clinical record failed to contain documentation of supervisory visits by the Registered Nurse in the 20 day period from 6/03/2023 - 06/22/2023. The findings were confirmed with the Administrator during record review on 6/21/2023 at 2:50 PM. The above noted findings and lack of documentation of a registered nurse performing onsite visits to the patient's home no less than every two (2) weeks to supervise the aide services was acknowledged by the Administrator during the exit conference conducted on 6/22/2023.