Every finding on record at Rainbow Health Care Services, P C

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/29/26. Standard level deficiencies cited.

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 review of Agency's Emergency Preparedness Plan and staff Interviews, the Agency failed to ensure the Emergency Preparedness Plan was based on a community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 05/27/26. The plan lacked documentation that a facility based and/or a community-based risk assessment was completed after 2023. 2. During an interview with the Administrator, Physical Therapy Coordinator and Quality Assurance Assistant on 05/28/26 at 10:15 AM, the Administrator confirmed the above findings.

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 review of the Agency's Emergency Preparedness plan and staff interviews, it was determined the Agency failed to ensure the communication plan was complete. Findings include: 1. The Emergency Preparedness plan was reviewed on 05/27/26. The binder lacked the names and contact information of the patient’s physicians and contracted staff. 2. During an interview with the Administrator, Physical Therapy Coordinator and Quality Assurance Assistant on 05/28/26 at 10:15 AM, the Administrator confirmed the above findings

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interviews, the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency's plan as required. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 05/27/26. The Plan included tabletop exercises for the year 2023, 2024 and 2025. The Plan lacked documentation that the Agency activated its Emergency Preparedness plan for an actual emergency or conducted/participated in full-scale or facility-based exercises, as required. 2. During an interview with the Administrator, Physical Therapy Coordinator and Quality Assurance Assistant on 05/28/26 at 10:15 AM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/28/26. Standard level deficiencies cited. Abbreviations: SOC = Start of Care PsOC / POC = Plans of Care / Plan of Care PT = Physical Therapy QA = Quality Assurance

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 90 of 128 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 05/26/25 to 05/26/26, was reviewed on 05/26/26. The report documented 90 of 128 (70.31 %) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 05/28/26 at 11:30 AM, the Administrator confirmed the above findings.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on clinical records review, Agency's patient admission folder review and staff interview, In 7 of 7 (Pts. 1-7) clinical records reviewed, the Agency failed to provide the name and contact information of the Administrator to Pts. or their families to report complaints/grievances. - Findings include: 1. The Agency patient admission folder was reviewed on 05/26/26. The admission folder lacked the Administrator's name and contact information. .2. The clinical records of the following Pts. were reviewed from 05/26/26 to 05/28/26. Pt. #1 SOC 02/19/2026 Pt. #2 SOC 04/04/2026 Pt. #3 SOC 03/25/2026 Pt. #4 SOC 11/25/2025 Pt. #5 SOC 08/19/2024 Pt. #6 SOC 05/06/2025 Pt. #7 SOC 11/25/2025 The clinical records lacked information identifying the Administrator's name and contact information was provided to Pts,/representatives to report any complaints/grievances. 2. The above finding was confirmed during an interview with the Administrator, QA assistant and PT coordinator on 05/28/26 at 11:30 AM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview in 2 of 7 (Pts #5 and 8) clinical records reviewed the Agency staff failed to provide services according to the Physicians orders. Finding include: 1. Pt. # 3 was admitted to Home Health Services on 03/25/26 with Diagnosis of Other Polyosteoarthritis. The clinical record was reviewed on 05/26/26. The clinical record included a PT evaluation dated 04/09/26, signed by the physician with a frequency of 1 time a week for 7 weeks. The clinical records lacked weekly PT visits for week 5, week 6 and week 7 after the PT evaluation. No frequency modification physician orders were found in the clinical record. 2. Pt. #5 was admitted to Home Health Services on 08/19/24 with Diagnosis of Essential Hypertension. The clinical record was reviewed on 05/27/26. The clinical record included a PT evaluation visit dated 02/06/26, signed by the physician that included a frequency of 2 times a week for 6 weeks starting 02/10/26. The clinical record lacked 2 PT visits on Weeks 3, 4 and 5 after the PT evaluation of 02/10/26. No frequency modification physician orders were found in the clinical record. 3. The above findings were confirmed during an interview with the Administrator, QA assistant and PT coordinator on 05/28/26 at 11:30 AM.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, clinical record reviews, and staff interviews, in 7 of 7 (Pts. 1 -7) clinical records reviewed, the Agency failed to provide the name and contact information of the Agency Supervisor (Director of Nursing) to Pts. or their families / representatives on admission. - Findings include: . 1. The Agency patient admission folder was reviewed on 05/26/26. The admission folder lacked information identifying the Agency Supervisor's (Director of Nursing) name and contact information. 2. The clinical records of the following Pts. were reviewed from 05/26/26 to 05/28/26. Pt. #1 SOC 02/19/2026 Pt. #2 SOC 04/04/2026 Pt. #3 SOC 03/25/2026 Pt. #4 SOC 11/25/2025 Pt. #5 SOC 08/19/2024 Pt. #6 SOC 05/06/2025 Pt. #7 SOC 11/25/2025 The clinical records reviewed lacked information identifying the Agency Supervisor's (Director of Nursing) name and contact information. 3. The above finding was confirmed during an interview with the Administrator, QA assistant and PT coordinator on 05/28/26 at 11:30 AM.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 6/1/23. The Agency was not in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

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 the review of the Agency's Emergency Preparedness Plan, policy review, and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 5/31/23 at 1:30 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement and Patients' Physicians. 2. The Agency policy titled, “Emergency Management" was reviewed on 5/31/23 at 11:00 AM. The policy required: "The organization will maintain an emergency preparedness communication plan that complies with Federal, State and local laws and is reviewed and updated…. The plan includes the following: 1. Names and contact information for the following: a. Staff; b. Entities providing services under arrangement; c. Patient’s physician. 3. During an interview with the Administrator on 5/31/23 at 3:15 PM, the above finding was confirmed.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirement on 6/1/23. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Afternoon/ Evening mg = milligram mcg = microgram IU = International units

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observations and interviews during home visits, review of clinical records, policy review and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 2 of 7 (Pts. # 1 and #2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 12/6/22. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. A home visit was conducted on 5/30/23 at 2:00 PM with the Registered Nurse (E#4). During the home visit, the medications were reviewed. The following medications were found at the patient's home but not listed in the form titled, “Patient Medication Record”: Furosemide 20 mg (order date on bottle – 4/20/23), Ferrous Sulfate 325 mg (order date on bottle - 2/8/23), Meloxicam 50 mg (order date on bottle – 2/8/23) and Levothyroxine 25 mcg (order date on bottle – 1/29/23). E#4 stated that Pt. #1’s medications are organized in a medication box/tray by E#4 every week which included all of the above-mentioned medications. E#4 also stated that medication list should be updated when there are changes. The clinical record was reviewed on 5/31/23 at 11:30 AM. The record contained a form titled "Patient Medication Record" completed by E#4 and dated 4/5/23. The same list also contained the medication Atorvastatin Calcium oral 10 mg but it was not available at the Pt. #1’s home during the home visit. The Medication Profile was not accurate. 2. Pt. #2. SOC 2/8/22. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A home visit was conducted on 5/31/23 at 9:45 AM with the Registered Nurse (E#5). During the home visit, the medications were reviewed. The following medications were found at the patient’s home but not listed in the form titled “Patient Medication Record”: Vitamin D2 1.25 mg /50,000 IU (order date on bottle - 5/9/23), Gabapentin 300 mg (order date on bottle – 5/18/23). E#5 stated that E#5 does medication reconciliation at every visit. The clinical record was reviewed on 5/31/23 at 1:00 PM. The record contained a form titled “Patient Medication Record” completed by E#5 and dated 4/20/23. The form listed the medication Aspirin 81 mg but it was not available at the patient's home during the visit. Pt. #2 stated that Aspirin has been discontinued a few months ago. The medication Hydrochlorothiazide oral 12.5 mg 1 capsule once daily was also on the list, but the bottle at Pt. #2’s home was labeled Hydrochlorothiazide 25 mg 1 capsule once daily. The Medication Profile was not accurate. 3. The policy titled “Medication Profile” was reviewed on 5/31/23, and required, “The Registered Nurse or Therapist will complete a medication profile for each client…shall include all prescription and non-prescription including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the client is taking...” 4. On 5/31/23 at 3:00 PM, an interview was conducted with the Administrator. During the same interview, the above findings were confirmed. The Administrator stated that the medication profile should be updated as necessary.