Every finding on record at Reign Management Group, Inc.

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 01/19/24. Standard level deficiencies cited. Abbreviations: # = number E = Employee AM = morning

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. On 01/17/24 from 10:05 AM to 11:50 AM, the Agency's Emergency Preparedness plan was reviewed with the Director of Nursing. The undated Emergency Preparedness plan lacked a date, indicating when the plan was last reviewed and updated. 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the Agency failed to review and update the Emergency Preparedness plan.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to complete an all-hazards risk assessment. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. On 01/17/24 from 10:05 AM to 11:50 AM, the Agency's Emergency Preparedness plan was reviewed with the Director of Nursing. The undated Emergency Preparedness plan lacked a facility and community-based risk assessment, using an all-hazards approach. 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the above findings.

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 a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update the Emergency Preparedness plan policies and procedures. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. On 01/17/24 from 10:05 AM to 11:50 AM, the Emergency Preparedness plan was reviewed with the Director of Nursing. The undated Emergency Preparedness plan lacked a date, indicating when the plan's policies and procedures were last reviewed and updated. 2. During an interview with the Director of Nursing on 01/17/23 at 11:50 AM, the Director of Nursing confirmed the above findings.

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), §485.542(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: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its communication plan. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The Agency's undated "Emergency Preparedness Plan" was reviewed on 01/17/24 from 10:20 AM to 11:50 AM. The undated communication plan lacked the date the Agency last reviewed and updated the plan. As of 01/17/24, the Agency lacked any documentation, indicating the communication plan was reviewed and revised as required. 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the Agency failed to review and update its communication plan and policies as required.

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 a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the communication plan include an accurate list of staff, Patient Physicians, and their contact information. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The undated Emergency Preparedness plan was reviewed with the Director of Nursing on 01/17/24 from 10:20 AM to 11:50 AM. The plan contained an undated Agency staff list which lacked the names and contact information of current employees (E #4, E #7, E #8, E# 14 and E #15); contained the names of multiple staff that had left/separated from the Agency; lacked the names and contact information of entities providing service under a contractual agreement for physical therapy, occupational therapy, speech therapy, and medical social services; and lacked a current list of Patient Physicians. As of 01/17/24, the communication plan lacked accurate and current information. 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the communication plan lacked an accurate list of staff, Patient Physicians and their contact information.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct staff training, relative to the Agency's Emergency Preparedness plan. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed with the Director of Nursing on 01/17/24 from 10:20 AM to 11:50 AM. As of 01/17/24, the Agency lacked documentation that staff received any training in 2021, 2022 and 2023, pertaining to the Agency's Emergency Preparedness plan . 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the Agency was unable to provide documentation that staff received training relative to the Agency's Emergency Preparedness plan.

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, it was determined the Agency failed to conduct emergency exercises as required. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed with the Director of Nursing on 01/17/24 from 10:20 AM to 11:50 AM. As of 01/17/24, the Agency lacked documentation the Agency conducted any exercises in 2021, 2022 and 2023, pertaining to the Agency's Emergency Preparedness plan . 2. During an interview with the Director of Nursing on 01/17/24 at 11:50 AM, the Director of Nursing confirmed the Agency was unable to provide documentation that the Agency conducted emergency exercises as required.

Recertification survey conducted. Standard level deficiencies cited. Abbreviations: Pt/Pts = patients # = number E = Employee SOC = Start of Care w = week

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 a review of clinical records, observation during home visits, and staff interviews, it was determined that the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. This was found in 6 of 7 (Pts. #1, 2, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 01/16/24 to 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. Patient #4. SOC 02/14/23. Patient #5. SOC 12/29/23. Patient #6. SOC 07/25/23. Patient #7. SOC 10/31/23. The records contained the form titled, "Authorization and Agreements for Home Health Services". The form included the section: "Types of Services and Proposed Frequency of Visits" requiring the Skilled Nurse that completes the SOC visit to place a checkmark next to the discipline(s) to provide service, and write the proposed frequency for each discipline in the space provided, this section was left blank for the Pts. indicated above. 2. The following home visits were conducted on 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. During the home visits, the Patient's admission folder was observed and contained the form titled, "Authorization and Agreements for Home Health Services", the forms lacked the discipline(s) to provide service and the proposed frequency for each discipline. 3. During an interview with the Director of Nursing on 01/17/24 at 1:00 PM, the Director of Nursing confirmed the Agency failed to ensure Pts. were informed in writing of the discipline(s) to provide service, and the frequency of visits provided by each discipline.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the Agency's Patient admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide information regarding Federal and state funded organizations that provide service in the Patient's community. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Patient admission folder was reviewed on 01/16/24 and lacked documentation that the Agency provided the names and contact information of Federal and State funded organizations. 2. The following clinical records were reviewed from 01/16/24 to 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. Patient #3. SOC 02/07/23 Patient #4. SOC 02/14/23. Patient #5. SOC 12/29/23. Patient #6. SOC 07/25/23. Patient #7. SOC 10/31/23 The records lacked documentation the Agency provided the names and contact information of Federal and State funded organizations. 3. The following home visits were conducted on 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. Patient #3. SOC 02/07/23. During the home visits, the Patient's admission folder was observed and lacked documentation that the Agency provided the names and contact information of Federal and State funded organizations. 4. During an interview with the Director of Nursing on 01/17/24 at 1:00 PM, the Director of Nursing confirmed the Agency failed to provide Pts. the names and contact information of Federal and State funded organizations.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on a review of the Agency's Patient admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Patient's admission folder was reviewed on 01/16/24 and lacked documentation of the Agency's transfer and discharge policies. 2. The following clinical records were reviewed from 01/16/24 to 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. Patient #3. SOC 02/07/23 Patient #4. SOC 02/14/23. Patient #5. SOC 12/29/23. Patient #6. SOC 07/25/23. Patient #7. SOC 10/31/23 The records lacked documentation the Agency provided Pts. information, regarding the Agency's transfer and discharge policies. 3. The following home visits were conducted on 01/17/24: Patient #1. SOC 04/14/23. Patient #2. SOC 12/02/23. Patient #3. SOC 02/07/23. During the home visits, the Patient's admission folder was observed, and lacked documentation the Agency had provided Pts. information regarding the Agency's transfer and discharge policies. 4. During an interview with the Director of Nursing on 01/17/24 at 1:00 PM, the Director of Nursing confirmed the Agency failed to provide Pts. information pertaining to the Agency's transfer and discharge policies.

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 a review of clinical records and staff interview, it was determined the Agency failed to ensure the Plan of Care contained Skilled Nursing interventions. This was found in 1 of 7 (Pt. #7) clinical records reviewed. Findings include: 1. Patient #7 was admitted to home health services on 10/31/23 with the primary diagnosis of Infection/Inflammatory Reaction due to Initial Internal Knee Prosthesis. The closed clinical record was reviewed on 01/16/24. The record contained Skilled Nurse visit notes dated 11/08/23 and 11/15/23 which included documentation the Skilled Nurse instructed the Patient and caregiver on the administration of an intravenous antibiotic (Cefazolin) through the Patient's left arm peripherally inserted central catheter and flushed the catheter with Normal Saline and Heparin. The weekly Skilled Nurse visit notes from 11/8/23 to 11/29/23 included documentation the Skilled Nurse administered the intravenous antibiotic through the peripherally inserted central catheter, and flushed the catheter with Normal Saline and Heparin, performed a weekly dressing change to the catheter, and obtained blood from the catheter for weekly laboratory tests. The Skilled Nurse visit note dated 12/6/23 contained documentation the Skilled Nurse obtained blood from the catheter for laboratory tests, and removed the peripherally inserted central catheter from the left arm. The record contained the Plan of Care for the certification period of 10/31/23 to 12/29/23 which lacked instructions for the Skilled Nurse to provide any of the care indicated above. 2. During an interview with the Director of Nursing on 01/17/24 at 1:00 PM, the Director of Nursing confirmed the Plan of Care lacked the interventions performed by the Skilled Nurse.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service, as ordered by the Physician and indicated in the Plan of Care. This was found in 3 of 7 (Pts. #7, 1 and 6) clinical records reviewed. Findings include: 1. Patient #7 was admitted to home health services on 10/31/23 with the primary diagnosis of Infection/Inflammatory Reaction due to Initial Internal Knee Prosthesis. The closed clinical record was reviewed on 01/16/24. The record contained the Plan of Care for the certification period of 10/31/23 to 12/29/23, requiring the Skilled Nurse to provide services "2w1, 1w8..." The record lacked documentation that the Skilled Nurse provided a second visit during week 1 (10/31/23 to 11/4/23). The record lacked documentation the Skilled Nurse followed the Physician orders in the Plan of Care dated 10/31/23. The Plan of Care for the certification period of 10/31/23 to 12/29/23 required the Skilled Nurse to provide service "2w1, 1w8 2w1 1w8". During an interview with the Director of Nursing on 01/17/24, the Director of Nursing stated this was an error, the frequency was entered twice, the ordered frequency was "2w1, 1w8" for a total of 9 weeks. The Skilled Nurse provided service weekly from 10/31/23 to 12/6/23 (a total of 6 weeks). The record lacked any Skilled Nurse visits during the weeks of 12/10/23 to 12/16/23, 12/17/23 to 12/23/23 and 12/24/23 to 12/29/23. The Skilled Nurse discharged Patient #7 on 12/08/23, the record lacked a Physician order to discharge the Patient prior to 12/29/23. The record lacked documentation the Skilled Nurse followed the Physician orders in the Plan of Care dated 10/31/23. 2 . Patient #1 was admitted to home health services on 04/14/23 with primary diagnosis of Long Standing Atrial Fibrillation. The clinical record was reviewed on 01/16/24. The Plan of care for certification period of 12/10/23 to 02/07/24, required Skilled Nursing frequency of 1 time a week for 9 weeks. The clinical record lacked an SN visit for the week of 12/10/23 to 12/16/23 as ordered in the Plan of Care. 3. Patient #6 was admitted to home health services on 07/25/23 with primary diagnosis of Multiple Fracture of ribs. The clinical record was reviewed on 01/16/24. The Plan of care for certification period of 07/25/23 to 09/22/23 contained an order for Occupational Therapy evaluation. The record lacked documentation that an Occupational Therapy evaluation was done as ordered in the Plan of Care. 4. During interviews with the Director of Nursing on 01/17/24 from 1:00 PM to 2:00 PM, and with Administrator and Director of Nursing on 01/17/24 from 3:00 PM to 4:45 PM, the above findings were confirmed.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to ensure Home Health Aides provided services as ordered by a Physician, and included in the Plan of Care. This was found in 1of 1 (Patient #6) clinical records reviewed, wherein Home health aide services were provided. Findings include: 1. Patient #6 was admitted to home health services on 07/25/23 with primary diagnosis of Multiple Fracture of ribs. The clinical record was reviewed on 01/16/24. The clinical record contained Home Health Aide visits dated 0726/23, 08/03/23, 08/09/23 and 08/15/23. The Plan of Care for certification period of 07/25/23 to 09/22/23 did not include orders for Home Health aide services. 2. During interview with the Administrator and Director of Nursing on 01/17/24 from 3:00 PM to 4:45 PM, the above findings were confirmed.

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 record review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 1 of 1 (Patient #7) clinical record reviewed, wherein the Patient was discharged from the Agency. Findings include: 1. Patient #7 was admitted to home health services on 10/31/23 with the primary diagnosis of Infection/Inflammatory Reaction due to Initial Internal Knee Prosthesis. The closed clinical record was reviewed on 01/16/24. The record contained the Agency's Discharge Summary completed by the Skilled Nurse and dated 12/08/23. As of 01/16/24, the record lacked documentation the Agency forwarded a copy of the Discharge Summary to the Physician. 2. During an interview with the Director of Nursing and E #16 on 01/17/24 at 1:00 PM, both confirmed the Agency failed to send a copy of the Discharge Summary to the Physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined the Agency failed to ensure that documentation entered into the clinical record was complete. This was found in 5 of 7 (Pts. #2, 4, 7, 5 and 6) clinical records reviewed. Findings include: 1. Patient #2 was admitted to home health services on 12/02/23 with the primary diagnosis of Parkinson's Disease without Dyskinesia, without mention of fluctuations. The clinical record was reviewed on 01/16/24. The record contained the forms completed by the Skilled Nurse during the SOC visit dated 12/02/23 and titled: "Beneficiary Elected Transfer", this form was signed by the Skilled Nurse, Patient's representative, and contained a section for the Skilled Nurse to enter the name of the Agency the Patient previously received service, this section was left blank; the "Advance Directives Acknowledgement" form provided options for the Patient's representative to choose regarding Advance Directives, this form was signed by the Skilled Nurse, Patient's representative, and was left blank; the "Emergency Plan" lacked the contact person's phone number, Physician's phone number, the Patient's pharmacy phone number, equipment company and phone number (the Plan of Care effective 12/2/23 included the Patient's equipment - tub/shower bench, walker, wheelchair, hospital bed and elevated toilet seat); and the form allowing a Patient representative to sign the consent form and other Agency documents on behalf of the Patient, lacked the reason why the Patient was unable to sign. The forms entered into the clinical record were incomplete. 2. Patient #4 was admitted to home health services on 02/14/23 with the primary diagnosis of Encounter for Surgical Aftercare following Surgery on the Genitourinary System. The clinical record was reviewed on 01/16/24. The record contained forms completed by the Skilled Nurse during the SOC visit dated 02/14/23 and titled: "Beneficiary Elected Transfer", this form was signed by the Skilled Nurse, Patient, and lacked the name of the Agency the Patient previously received service; the "Advance Directives Acknowledgement" form was signed by the Skilled Nurse, Patient, and was left blank; the "Emergency Plan" lacked the Physician's name and phone number. The forms entered into the clinical record were incomplete. 3. Patient #7 was admitted to home health services on 10/31/23 with the primary diagnosis of Infection/Inflammatory Reaction due to Initial Internal Knee Prosthesis. The closed clinical record was reviewed on 01/16/24. The record contained forms completed by the Skilled Nurse during the SOC visit dated 10/31/23 and titled: "Beneficiary Elected Transfer", this form was signed by the Skilled Nurse, Patient, and lacked the name of the Agency the Patient previously received services; the "Advance Directives Acknowledgement" form was signed by the Skilled Nurse, Patient, and was left blank; the "Emergency Plan" lacked the Patient's address, contact person's name and phone number, Physician's name and phone number, the Patient's pharmacy phone number, equipment company and phone number (the Plan of Care dated 10/31/23 to 12/29/23 included the Patient's equipment - tub/shower bench, hospital bed, walker, wheelchair, toilet seat and grab bars). The forms entered into the clinical record were incomplete. 4. Patient # 5 was admitted to home health services on 12/29/23 with primary diagnosis of Essential Hypertension. The clinical record was reviewed on 01/16/24. The clinical record contained a form titled “Emergency Plan”. The form lacked telephone numbers for Patient #5’s physician and pharmacy. The record also contained a form, titled “Beneficiary Elected Transfer”, dated 12/29/23 and signed by Patient #5. The form contained a section for SN to enter name of Agency the Patient previously received service and this section was left blank. 5. Patient #6 was admitted to home health services on 07/25/23 with primary diagnosis of Multiple Fracture of ribs. The clinical record was reviewed on 01/16/24.The clinical record contained "Advance Directives Acknowledgement" form, dated 07/25/23 and signed by Patient #6. The form provided options for the Patient's representative to choose regarding Advance Directives, this section was left blank. The record also contained a form, titled “Beneficiary Elected Transfer”, dated 07/25/23 and signed by Patient #6. The form contained a section for the SN to enter the name of the Agency the Patient previously received service, this section was left blank. 6. During interviews with the Director of Nursing on 01/17/24 from 1:00 PM to 2:00 PM, and with Administrator and Director of Nursing on 01/17/24 from 3:00 PM to 4:45 PM, the above findings were confirmed.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 2/11/21. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: SOC = Start of care Pt./Pts. = Patient/patients AM = Morning PM = Afternoon POC = Plan of care ADLS = Activities of daily living

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 may choose to include. This ELEMENT is not met as evidenced by: . A. Based on clinical records review and staff interviews, it was determined that the Agency failed to ensure that the POC included supplies, patient-specific interventions and measurable outcomes and care and/or service to be provided. This was found in 1 of 3 (Pt. #3) home visits conducted. Findings include: 1. Pt. #3 SOC 9/10/20. Diagnosis: Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Urinary Tract Infection, Neuromuscular Dysfunction of Bladder, Chronic Kidney Disease, Dysphagia, Epilepsy, Traumatic Subdural Hematoma with Loss of Consciousness and Gastrostomy status. The clinical record was reviewed on 2/10/21 at 10:00 AM. The record contained a POC for certification period for 1/8/21 to 3/8/21. The POC contains documentation of Gastrostomy - tube placement. The POC lacked documentation of required equipment and patient specific interventions for Gastrostomy tube care. The same POC also required "Home Health Aide to provide assistance with personal care and ADLs as indicated by limitations on functional and physical status impeding self-care" but lacked documentation of frequency and duration of Home Health Aide visits. 2. During an interview with the Administrator and Agency Supervisor on 2/9/21 at 3:15 PM the Agency Supervisor confirmed the above findings and stated the Agency failed to ensure the POC included all the required elements.