Every finding on record at Physicians Preferred Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/11/25. Standard level deficiencies cited.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on Agency’s Emergency Preparedness plan review and staff interview, the Agency failed to have a communication plan that meets the requirements. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/09/25. The Emergency Preparedness Plan lacked the current Agency staff Names and contact information. 2. The above finding, regarding the lack of updated communication plan was confirmed during an interview with the DON on 12/10/25 at 11:15 AM.

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 a full - scale exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 12/09/25. The Emergency Preparedness Plan lacked documentation indicating that the Agency conducted any full-scale exercise or implemented the Emergency Preparedness since 2022. 2. During an interview with the DON on 12/10/25 at 11:30 AM, the DON confirmed that the Agency has no documentation supporting the Agency conducted a full – scale testing of the Emergency Preparedness.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/11/25. Standard level deficiencies cited. Abbreviations: SOC: Start of Care POC / PsOC = Plan of Care / Plans of Care Pt / Pts = Patient / Patients SN = Skilled Nurse DON = Director of Nursing

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 4 of 7 (Pts. # 2, 3, 5 and 7) clinical records reviewed, the Agency failed to ensure that the Pt. / representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The following clinical records were reviewed from 12/08/25 to 12/09/25. The clinical records included a consent and verification of receipt of information/ admission agreement form by the Agency, and lacked documentation of the proposed service(s) and visit frequencies to be provided: Pt. #2 SOC: 12/05/24. Pt. #3 SOC: 07/21/25. Pt. #5 SOC: 08/25/25. Pt. #7 SOC: 07/02/25. 2. During an interview with the Director of Nursing and Office Manager on 12/10/25 at 1:30 PM, the DON confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, in 3 of 7 (Pts # 1, 4 and 3) the Agency failed to ensure the initial SOC assessment was conducted within 48 hours of the referral date. 3. Pt.# 3 was admitted to Home Health Services on 07/21/25 with the Diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney disease or Unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 12/09/25. The record included a Physician referral for home health services dated 07/03/25. The record included the initial SOC assessment, dated 07/21/25 (18 days after the referral date). The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 12/10/25, the record lacked documentation the Agency initiated service within the required time frame. 4. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the DON confirmed the above findings. Findings include: 1. Pt. # 1 was admitted to Home Health Services on 06/23/25 with Diagnosis of Essential primary Hypertension. The clinical record was reviewed on 12/09/25. The record included a referral for homecare with request indication for SOC 06/16/25. Pt#1 initial SOC assessment was completed 06/23/25. 7 days after the referral, no documentation was found in the clinical record indicating reason for delay in SOC assessment. 2. Pt. #4 was admitted to Home Health Services on 07/29/24 with Diagnosis of Permanent Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The clinical record was reviewed on 12/09/25. The record included a referral for homecare dated 07/24/24. Pt#4 initial SOC assessment was completed 07/29/24. 5 days after the referral, no documentation was found in the clinical record indicating reason for delay in SOC assessment

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews, the Agency failed to ensure that, in 3 of 7 (Pts. # 2, 3 and 5) clinical records reviewed, the Plans of Care (PsOC) included Pt. specific interventions. Findings include: 1. Pt. #2 was admitted to Home Health Services on 12/05/24 with the Diagnosis of Hypertensive Heart Disease Without Heart Failure. The clinical record was reviewed on 12/08/25. The PsOC effective 10/01/25 to 11/29/25 and 11/30/25 to 01/28/26, required: “....Skilled Nurse to assess and instruct patient/ caregiver on signs and symptoms requiring notification of healthcare provider:….significant weight gain….” The POC lacked Pt. specific weight parameters to report to healthcare provider. 2. Pt.# 3 was admitted to Home Health Services on 07/21/25 with the Diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney disease or Unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 12/09/25. The PsOC effective 09/19/25 to 11/17/25 and 11/18/25 to 01/16/26, included that Pt. is on “Novolin N insulin” for Type 2 Diabetes Mellitus but lacked Pt. specific interventions related to blood sugar parameters and monitoring. 3. Pt. #5 was admitted to Home Health Services on 08/25/25 with the Diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/08/25. The PsOC effective 08/25/25 to 10/23/25 and 10/24/25 to 12/22/25, “....Skilled Nurse to assess and instruct patient/ caregiver on signs and symptoms requiring notification of healthcare provider:….significant weight gain….” The POC lacked Pt. specific weight parameters to report to healthcare provider. 4. During an interview with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM, the DON confirmed the above findings.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical records review, Agency policy review and staff interviews, in 4 of 7 (Pts. #1, 3, 4 and 7) clinical records reviewed, the Agency failed to ensure that Pts. were assessed for Pneumonia vaccination status. Findings include: 1. The following clinical records were reviewed from 12/08/25 to 12/10/25. The records lacked documentation of the pneumonia vaccination assessment: Pt. #1 SOC 06/23/25. Pt. #3 SOC 07/21/25. Pt. #4 SOC 07/29/24. Pt. #7 SOC 07/02/25. 2. The Agency policy titled “Vaccinations” was reviewed on 12/09/25. The Policy required: “…. Pneumococcal pneumonia vaccination….(Agency) will administer or arrange for the administration of a pneumococcal vaccination to each patient age 65 or over who has not received this immunization prior to or upon service initiation unless medically contraindicated or refused by the patient….1. Arranging for vaccination includes referring patients to their supervising or primary physician, referral to local health department….3. Documentation shall include…. a. The assessment of need of the vaccination…b. Date of offer or referral…. c. indications/contraindications…. d. Patient education…e. Patient response, including refusal…. f. Arrangements made…. g. Follow-up activities…..” 3. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the DON 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: Based on clinical records review and staff interview, in 3 of 7 (Pts # 4, 6 and 7) clinical records the Agency failed to complete and send a transfer / discharge summary to the Physician. 3. Pt. #7 was admitted to Home Health Services on 07/02/25 with the Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 12/08/25. The clinical record included a discharge summary dated 10/29/25. The clinical record lacked evidence that the discharge summary was complete and sent to the physician. 4. During staff interviews with the Director of Nursing and Office Manager on 12/09/25 at 1:30 PM and on 12/10/25 at 11:30 AM, the Director of Nursing confirmed the above findings. Findings include: 1. Pt. #4 was admitted to Home Health Services on 07/29/24 with Diagnosis of Permanent Atrial Fibrillation. The clinical record was reviewed on 12/09/25. The record included a transfer summary dated 11/21/25. The clinical record lacked evidence that the transfer summary was complete and sent to the physician. 2. 2. Pt. #6 was admitted to Home Health Services on 12/16/24 with Diagnosis of Spondylosis without myelopathy. The clinical record was reviewed on 12/09/25. The record included a discharge summary dated 12/02/25. The clinical record lacked evidence that the discharge summary was complete and sent to the physician.

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), §485.625(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: A. Based on review of the Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan biennially. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 10/3/22 at 3:09 PM. The plan lacked the date it was initiated, reviewed and/or updated. As of 10/5/22, the Agency lacked any documentation, indicating the plan was reviewed and revised every 2 years. 2. During an interview with the Administrator, Designated Alternate for the Clinical Manager and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 11:15 AM, the above findings were confirmed.

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), §485.625(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: A. Based on review of the Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness plan policies and procedures biennially. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 10/3/22 at 3:09 PM. As of 10/5/22, the plan lacked any dates indicating the plan was reviewed and updated every 2 years. 2. During an interview with the Administrator, Designated Alternate for the Clinical Manager and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 11:15 AM, the above findings were confirmed.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: A. Based on review of the Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness communication plan biennially. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 10/3/22 at 3:09 PM. As of 10/5/22, the communication plan lacked any dates indicating it was reviewed and updated every 2 years. 2. During an interview with the Administrator, Designated Alternate for the Clinical Manager and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 11:15 AM, the above findings were confirmed.

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), §485.625(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, 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: A. Based on review of the Emergency Preparedness Plan, personnel files and staff interview, it was determined the Agency failed to conduct staff training and testing relative to the Agency's Emergency Preparedness plan. Findings include: 1. The Agency's undated Emergency Preparedness Plan was reviewed on 10/3/22 at 3:09 PM. As of 10/5/22, the plan lacked documentation of staff training and testing for 2020, 2021 or 2022. 2. On 10/4/22, a request was made to review the direct staff/employee personnel files providing direct Pt. care and/or service (3 employees). As of 10/4/22, the agency was unable to provide a personnel file for Employee #1. The personnel files of Employees #2 and #3 were reviewed on 10/4/22 at 1:00 PM, and indicated Emergency Preparedness training in 2019. The Agency's records lacked documentation the employees received any Emergency Preparedness plan training and testing in 2020, 2021 and 2022 (as of 10/5/22). 3. During interviews with the Administrator on 10/3/22 at 11:50 AM and 10/4/22 at 12:45 PM, requests were made to review all staff/employee in-services, education and training for 2020, 2021 and 2022. On 10/4/22 at 2:25 PM, the Administrator stated the Agency had not provided any staff in-services since 2019. 4. During an interview with the Administrator, Designated Alternate for the Clinical Manager and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 11:15 AM, the Administrator stated the staff did not receive any Emergency Preparedness plan testing and training in 2020, 2021 and 2022.

A recertification survey was conducted on 10/6/22. The Facility was not in compliance with the Condition of Participation for 42 CFR 484.102, Emergency Preparedness. Abbreviations: SN = Skilled Nurse MD = Medical Doctor POC = Plan of care SOC = Start of care SN = Skilled Nurse AM = morning PM = afternoon/evening Pt./ Pts. = Patient/Patients ABN = Advance Beneficiary Notice of Non-coverage mg= milligram

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure verbal orders were put in writing. This was found in 2 of 7 (Pts. #2 and 6) clinical records reviewed. Findings include: 1. Pt. #2. SOC 6/7/22. Primary Diagnosis: Immune Thrombocytopenia Purpura. The clinical record was reviewed on 10/4/22 at 8:50 AM. The record contained the SN visit note dated 8/17/22 which included: "...Platelets drawn on 8/16/22, high at 632, reported to MD office. MD decreased frequency to Promacta 25 mg, 1 tablet every other day..." As of 10/4/22, the record lacked the Physician's order for "Promacta 25 mg, 1 tablet every other day". 2. Pt. #6. SOC 10/14/21. Primary Diagnosis: Type 2 Diabetes Mellitus Without Complications. The closed clinical record was reviewed on 10/4/22 at 1:00 PM. The record contained the SOC comprehensive assessment dated 10/14/21, and that service was provided until 2/18/22. As of 10/5/22, the Agency was unable to provide a Physician's order for the SOC conducted on 10/14/21. 3. The Agency policy titled, "Verification of Physician Orders" was reviewed on 10/5/22 at 1:15 PM and included: "...2. Verbal orders will be documented on a form provided..." 4. During an interview with the Administrator, Designated Alternate for the Clinical Director, and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 10:20 AM, the Administrator stated the Agency received a verbal order for the SOC of Pt. #6, but failed to write the Physician's order. During the same interview, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on review of clinical records, Agency policy and staff interviews, it was determined the Agency failed to ensure that documentation of forms were complete and applicable. This was found in 4 of 7 (Pts. #3, 7, 2 and 5) clinical records reviewed. 3. Pt. #2. SOC 6/7/22. Primary Diagnosis: Immune Thrombocytopenia Purpura. The clinical record was reviewed on 10/4/22 at 8:50 AM. The record contained the form titled: "Advance Beneficiary Notice of Non-coverage (ABN)", signed by the Pt. and dated 6/7/22. The form included documentation that "SN" service was not covered by the patient's insurance. The form required the Agency to enter the reason for non-coverage and the estimated cost, these sections were left blank. 4. Pt. #5. SOC 8/30/22. Primary Diagnosis: Unspecified Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 10/4/22 at 9:30 AM. The record contained the form titled: "Advance Beneficiary Notice of Non-coverage (ABN)", signed by the Pt. and dated 8/30/22. The form included documentation that "SN" service was not covered by the patient's insurance. The form required the Agency to enter the reason for non-coverage and the estimated cost, these sections were left blank. 5. The Agency's policy titled, "Entries into the Clinical Record" was reviewed on 10/6/22 at 10:08 AM and included: "...3. Entries into the clinical record will be...concise, and specific statements of fact..." 6. The Agency's policy titled, "Clinical Record Review" was reviewed on 10/6/22 at 10:10 AM and required: "...Each clinical record will be reviewed on a regularly scheduled basis by the Performance Improvement Coordinator, Clinical Director, Clinical Supervisor, or designees for... B. Completeness of clinical records C. Accuracy of clinical records..." 7. During an interview with the Administrator, Designated Alternate for the Clinical Director and the Community Liaison Officer/Marketer/Co-owner on 10/5/22 at 10:20 AM, it was determined the ABN forms signed by the Pts. indicated above were incomplete and not applicable. Findings include: 1.Pt. #3. SOC 8/31/22. Primary Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 10/4/22 at 11:30 AM. The record included a form titled: "Advance Beneficiary Notice of Non-coverage (ABN)," signed by the Pt. and dated 8/31/22. The form indicated that "SN" service was not covered by patient’s insurance. The form lacked the reason for non-coverage and the estimated cost. 2.Pt. #7. SOC 11/19/21. Primary Diagnosis: Type 2 Diabetes Mellitus with other specified complication. The clinical record was reviewed on 10/4/22 at 1:00PM. The record included a form titled: "Advance Beneficiary Notice of Non-coverage (ABN)," signed by the Pt. and dated 11/19/21. The form indicated that "SN" services was not covered by patient’s insurance. The form lacked the reason for non-coverage and the estimated cost.