Every finding on record at Salmon Valley Home Health LLC

An unannounced Medicare recertification survey was conducted at your home health agency on 1/26/2026 through 1/28/2026. This included the Emergency Preparedness section where the following deficiencies were identified:

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 review of the agency Emergency Preparedness (EP) plan, policy review, and staff interview, it was determined the agency failed to demonstrate a biennial review had been conducted on the EP plan. Failure to review the EP plan at least every 2 years had the potential to cause harm to patients and staff in the event of a disaster. Findings included: An agency policy titled Emergency Management Plan, C:2-010.1, last updated 4/2018, was reviewed. The policy stated: "Communication Plan- The organization will maintain an EP communication plan that complies with Federal, state and local laws as is reviewed and updated annually." This policy was not followed. An example included: The agency EP plan was reviewed. The last documented review of the plan was conducted 4/1/2024. There was no documented review of the EP plan after that date. The Administrator was interviewed on 1/28/26 beginning at 10:00 AM. The EP plan was reviewed in her presence. She confirmed the last review of the EP plan was documented as 4/1/2024. The agency failed to review and update the EP plan as required. This had the potential to impact all staff and patients in the event of a disaster.

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 EP plan review, policy review, and staff interview, it was determined the agency failed to test the emergency plan at least annually. Failure to test the effectiveness of the EP plan had the potential to hinder performance during an actual emergency and cause harm to staff and patients. Findings include: An agency policy titled Emergency Management Plan, C:2-010.1, last updated 4/2018, was reviewed. The policy stated: "Testing: Salmon Valley Home Health will test the Emergency Preparedness plan...at least annually." This policy was not followed. An example included: The EP binder was reviewed. There was no evidence of an emergency drill since 2023. The Administrator was interviewed on 1/28/26 beginning at 10:00 AM. The EP plan was reviewed in her presence. The Administrator confirmed there had been no emergency drills since 2023. The agency failed to perform and document annual emergency drills as required. This had the potential to impact all staff and patients in the event of a disaster.

An unannounced Medicare recertification survey was conducted at your home health agency on 1/26/2026 through 1/28/2026. The following deficiencies were identified: The following abbreviations were used in this report: EP - Emergency Preparedness GB - Governing Body HHA - Home Health Agency QAPI - Quality Assurance and Performance Improvement

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on policy review, QAPI and Infection document review, GB meeting minutes review, and staff interview, it was determined the facility failed to ensure a comprehensive QAPI program was developed and maintained. This impeded the ability of the Home Health to evaluate its practices and improve patient care. Findings include: Refer to G 0642 as it relates to the HHA's failure to ensure an ongoing quality program that demonstrated measurable improvement in patient health outcomes was developed and maintained. Refer to G 0644 as it relates to the HHA's failure to collect program data. Refer to G 0654 as it relates to the HHA's failure to track adverse patient events. Refer to G 0658 as it relates to the HHA's failure to set and work on performance improvement projects. The cumulative effect of these systemic failures limited the HHA’s ability to evaluate the effectiveness of its practices and impeded sustained improvement in patient care and outcomes.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on HHA policy, documents, meeting minutes and staff interview, it was determined the HHA failed to ensure that quality indicators, including adverse patient events, and infections were being tracked, measured and analyzed. Findings included: A HHA policy titled, "Responsibilities in Improving Performance" dated October 2014 was reviewed. The policy stated "Senior management will have the responsibility: to guide the organization's efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service." This policy was not followed. An example included: Quality documents and GB minutes were reviewed. There was no documentation of GB meetings after April 2024. HHA QAPI meeting minutes were reviewed for 2025 and 2026 and while infection and fall numbers were documented, documentation on investigations, infection prevention or control were not found. The language "not related to staff spread or poor care", followed the monthly numeration of infections in each QAPI agenda minutes for 2025 with no additional investigation or follow up documentation found. The QAPI coordinator was interviewed on 1/28/26 beginning at 9:30 AM. The coordinator confirmed no additional measurement or investigations were conducted or documented including no tracking of trends or performance indicators. The HHA Administrator was interviewed on 1/28/26 beginning at 10:00 AM. The HHA Administrator confirmed that no formal GB meetings had occurred since April 2024, resulting in the HHA’s failure to select QAPI performance indicators to track and implement improvmeent projects. The HHA Administrator further confirmed that although falls and infections were identified in QAPI meeting minutes, the HHA did not conduct additional tracking, investigations, or analysis of these events. Refer to G 0644 as it relates to the HHA's failure to collect program data. Refer to G 0654 as it relates to the HHA's failure to track adverse patient events. The cumulative effect of these failures resulted in the HHA’s inability to identify areas of risk, implement corrective actions, and improve the quality of care and patient outcomes.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on review of HHAs policies and procedures, QAPI and Governing Body meeting minutes, and staff interviews, it was determined the Home Health Agency failed to analyze quality indicator data to monitor the effectiveness and safety of services and the quality of care, and failed to identify opportunities for improvement. In addition, the GB failed to approve the frequency and level of detail of data collected for performance improvement activities. This deficient practice resulted in the HHA’s inability to effectively evaluate and improve patient care processes. Findings include: A HHA Policy titled, " Responsibilities in Improving Performance" dated October 2014 was reviewed. The policy stated "Senior management will: Identify and participate in benchmarking activities that utilize: 1. Internal standards: a. Measuring current performance against past performance b. Measuring against internally established goals 2. Processes and protocols 3. Practice or service guidelines 4. Industry research or best practices.", this policy was not followed. An examples included: QAPI meeting minutes from 2025 were reviewed. Infections and falls were identified; however, no surveillance tools, tracking methods, or forms were found, and no OASIS-based indicators were documented. Each monthly QAPI meeting minute, regardless of the number of infections identified, included the statement “not related to staff spread or poor care,” with no supporting investigation, analysis, or follow-up documentation found. There was no documentation of Governing Body (GB) meetings after April 2024. The QAPI Coordinator was interviewed on 1/28/26, beginning at 9:30 AM. The QAPI coordinator confirmed that no additional measurements, investigations, or analyses were conducted or documented, including the absence of trend tracking or monitoring of performance indicators. The HHA Administrator was interviewed on 1/28/26, beginning at 10:00 AM. The Administrator confirmed that no formal GB meetings had occurred since April 2024. The Administrator further confirmed that QAPI performance indicators were not selected and that, beyond the QAPI meeting minutes identifying falls and infections, no additional tracking, analysis, or investigations were conducted. These failures resulted in the HHA’s inability to systematically track, analyze, and identify areas of need necessary to improve the quality of patient care and outcomes.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on policy review, patient record review, quality review, and staff interview, it was determined the agency failed to track all adverse patient events for 1 of 2 patients (Patient #1) whose records were reviewed and were no longer on service. This failure to identify the adverse event prohibited investigation and possible identification of issues which put all HHA patients at risk of additional harm and resulting in incomplete QAPI data. Findings include: A policy titled "Incident Reporting, Policy # C:2-076.1," last revised 4/2018, was reviewed. The policy stated, "the incident reporting system will be part of the organization's overall performance improvement and risk management plan. "The policy stated the definition of a "Serious Adverse Event" as: "an unexpected occurrence involving death or serious physical or psychological injury." This policy was not followed. Example included: Patient #1 was a 71-year-old female on service with a primary diagnosis of diverticulosis of large intestine. Patient #1 received SN services for wound care to bilateral lower extremities and teaching for safety and nutrition. The start of care date was 10/20/25 and her date of death was 10/22/25. Patient #1 had been on home health services previously from 4/3/24 to 6/1/24. During that benefit period, Patient #1 had required emergency interventions of a narcotic reversal agent. There was no mention of Patient #1 in the reviewed Incident Reports for 2025. The QAPI coordinator was interviewed on 1/28/26 beginning at 9:30 AM. She was asked why Patient #1 was not identified in any incident report. She stated, "I did not think of this as an adverse event." The agency failed to identify an unexpected death as an adverse event and therefore, did not capture the event or proceed with any analysis. .

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on HHA policy review, quality document, including meeting minute review, and staff interview, it was determined the agency failed to ensure that distinct performance improvement projects which reflected the scope, complexity and past performance of the HHA were identified and analyzed. This failure resulted in the inability of the agency to evaluate its processes of patient care. Findings include: A HHA Policy titled, " Responsibilities in Improving Performance" dated October 2014 was reviewed. The policy stated "Senior management will have the responsibility: to guide the organization's efforts in improving organizational performance; to define expectations of the performance improvement activities; and to generate the plan and processes the organization will utilize to assess, improve and maintain quality of care and service." This policy was not followed. An example included: Quality documents, including QAPI and Governing Body (GB) meeting minutes, were reviewed. There was no documentation of GB meetings after April 2024. HHA QAPI meeting minutes from 2025 were reviewed, and the only performance improvement activity identified was “advertising and searching for therapy.” No additional performance improvement projects addressing patient care or quality outcomes were identified. The QAPI Coordinator was interviewed on 1/28/26, beginning at 9:30 AM. The coordinator confirmed that no performance improvement projects, other than efforts to obtain a therapist, were identified or implemented. The HHA Administrator was interviewed on 1/28/26, beginning at 10:00 AM. The administrator confirmed that no formal GB meetings had occurred since April 2024 and confirmed that no performance improvement projects, beyond searching for a therapist, were identified or implemented. These failures resulted in the HHA’s inability to identify, implement, and evaluate performance improvement projects necessary to address areas of need and improve the quality of patient care and outcomes.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, HHA policy review, and staff interviews, it was determined the agency failed to ensure a functional infection control program in the HHA . This resulted in the HHA 's failure to document and maintain infection control guidelines and practices. Findings include: Refer to G 0682 Infection Prevention as it refers to the HHA ensuring prevention and treatment of infections and communicable diseases. Refer to G 0684 Infection Control as it refers to the HHA maintaining a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases The cumulative effect of these systemic practices prevented the Home Health from evaluating its Infection Control guidelines and practices to maintain patient safety.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and staff interviews, it was determined the agency failed to maintain a sanitary environment for 1 of 3 patients (Patient #3) who had observation visits and received care at the Home Health agency. This had the potential to impact all patients receiving services at the agency and placed patients at an increased risk for infections. Findings included: The CDC website (https://www.cdc.gov/infection-control/hcp/hand-hygiene/index.html) accessed on 2/03/26 posted a document titled, “Guideline for Hand Hygiene in Health-Care Settings.” Under the heading “Recommendations” was written, “1. Indications for handwashing and hand antisepsis…C. Decontaminate hands before having direct contact with patients….F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)…. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled…. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care….I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient…J. Decontaminate hands after removing gloves….2. Hand-hygiene technique A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all services of hands and fingers, until the hands are dry...” These guidelines were not followed. An example included: The surveyors requested a policy on hand hygiene or wound care and none was provided. Patient #3 was a 75-year-old female admitted to the agency on 1/22/26 with a primary diagnosis of venous insufficiency. Patient #3 received SN and aide services. On 1/27/26, an observational visit was conducted for Patient #3 beginning at 3:00 PM with the RN. The RN was observed performing wound care to bilateral lower extremities. The RN performed hand hygiene and donned gloves. She then removed soiled dressings to the right lower leg and removed her gloves. The RN then proceeded to pick up her tablet and document the wounds and then donned new gloves without performing hand hygiene and redressed the right leg wounds. The same procedure was then performed to the left lower leg. There was no further hand hygiene performed until the end of the visit. The infection control coordinator was interviewed on 1/28/26 beginning at 9:30 AM. She was asked what guidelines were followed for infection control. She stated they follow CDC guidelines. The agency failed to monitor and ensure guidelines were followed for proper infection control measures.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, meeting minutes, document and policy review, and staff interviews, it was determined the HHA failed to ensure a functional infection control program to track and ensure the provision of services in the agency. This resulted in the HHA's failure to ensure infection control guidelines were implemented. Findings include: The HHA had a policy title " Evaluating and Maintaining Records of Infection Among Patients" dated October 2014. The policy stated, "All patients with a new, actual or suspected infection will have a patient infection report completed within 24 hours of discovery." This policy was not followed. An example included: QAPI meeting minutes from 2025 were reviewed and documented infections for each month. Patient-specific infection reports or supporting infection surveillance documentation were not found. Each monthly QAPI meeting minute, regardless of the number of infections identified, included the statement “not related to staff spread or poor care,” with no accompanying investigation, analysis, or follow-up documentation found. The QAPI Coordinator was interviewed on 1/28/26, beginning at 9:30 AM. The coordinator confirmed that infections were reviewed during QAPI meetings; however, patient infection reports were not completed for each infection. When asked about tracking infection trends over time, the coordinator stated, “If needed I can drill down.” The coordinator further stated that additional tracking was not believed to be necessary and confirmed that no infection-related performance improvement projects were implemented or in place during the past year. These findings demonstrated the HHA’s failure to ensure the development and implementation of an active, ongoing, and systematic infection prevention and control program designed to identify, analyze, and reduce infection risks.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on HHA policy, staff interview, and GB meeting minute and document review, the GB failed to ensure that the HHA operated in accordance with its own policies and failed to ensure proper oversight, including administrative and supervisory functions, were performed. Refer to G0640 as it relates to the GB's failure of effective oversight of the agency's QAPI program Refer to G0680 as it relates to the GB's failure to effective oversight of the agency's Infection control program Findings include: Refer to G 0942 as it relates to the agency's failure to ensure that the Governing Body provided responsibility and oversight for the operation and management of the Home Health. The cumulative effect of these systemic practices prevented the Home Health from following its own policies and from evaluating its practices to improve patient care.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on HHA policy, staff interview, and GB meeting minutes and document review, the GB failed to ensure the HHA operated in accordance with its own policies. In addition, the agency failed to ensure proper administrative and supervisory functions were performed.” Findings include: The Home Health has a policy titled "Governing Body" dated April 2018 was reviewed. The policy states, "The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services, fiscal operations, review of the organization's budget and its operational plans, and its quality assessment and performance improvement (QAPI) program." This policy was not followed. An example included: The GB minutes were reviewed with the last documented meeting April 2024. The HHA administrator was interviewed on 1/28/26 beginning at 10:00 AM. The HHA administrator confirmed the governing body has not met since April 2024. The HHA failed to ensure the governing body assumed responsibility for the operation and management of the HHA with regular oversight. Refer to G0640 as it relates to the GB's failure of effective oversight of the agency's QAPI program Refer to G0680 as it relates to the GB's failure to effective oversight of the agency's Infection control program

A Federal recertification survey was conducted at your Home Health agency from 3/27/23 through 3/30/23. This survey included the Emergency Preparedness survey. The following deficiencies were noted for the EP section of the survey:

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 review of the agency Emergency Preparedness (EP) plan and staff interview, it was determined the agency failed to demonstrate that a biennial review had been conducted on the EP plan. Failure to review the EP plan at least every 2 years has the potential to provide information not relevant to the agency and hinder patients and staff in the event of a disaster. Findings included: The agency EP plan was reviewed. The last documented review of the plan was conducted 1/22/21. There was no documented review of the EP plan after that date. The Administrator was interviewed on 3/29/23 beginning at 2:00 PM. The EP plan was reviewed in her presence. She confirmed that the last review of the EP plan was done on 1/22/21. The agency failed to review and update the EP plan as required. This had the potential to impact all staff and patients in the event of a disaster.

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 EP plan review and staff interview, it was determined the agency failed to conduct a Hazard and Vulnerability Analysis (HVA) every 2 years. The HVA identifies risks to hazards and directs which emergencies the agency should prioritize and prepare for accordingly. This deficient practice had the potential to affect all patients and staff in the event of a disaster. Findings included: The agency's EP plan was reviewed. This included the agency HVA. The last documented HVA was conducted 1/22/21. The Administrator was interviewed on 3/29/23 beginning at 2:00 PM. The EP plan was reviewed in her presence. She confirmed that the last documented HVA was on 1/22/21. The agency failed to conduct a HVA as required every 2 years. This had the potential to impact all staff and patients in the event of a disaster.

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 EP plan review and staff interview, it was determined the agency failed to test the emergency plan at least annually. Failure to test the effectiveness of the emergency plan had the potential to hinder staff performance during an actual emergency. Findings included: The agency EP plan was reviewed. The last documented disaster drill was completed in 2021. There was no documented disaster drill or testing of the EP plan in 2022. The Administrator was interviewed on 3/29/23 beginning at 2:00 PM and the EP plan was reviewed in her presence. She confirmed the last documented disaster drill was completed in 2021. She was unable to provide any documentation of a performed disaster drill since 2021. The agency failed to test the effectiveness of the emergency plan with annual disaster drills.

A Federal recertification survey was conducted at your Home Health Agency from 3/27/23 through 3/31/23. The following deficiencies were cited during the recertification: The following abbreviations were used in this report: EP - Emergency Preparedness HHA - Home Health Agency MSW - Medical Social Worker OASIS - Outcome and Assessment Information Set RN - Registered Nurse

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review, and staff interview, it was determined the agency failed to ensure encoded OASIS data accurately reflected patient information at the time of discharge from the agency for 1 of 2 patients (Patient #6) whose closed records were reviewed. This resulted in inaccurate OASIS data being reported. Findings included: Patient #6 was a 63 year old male admitted to the agency on 6/01/22 with a primary diagnosis of epilepsy. Additional diagnoses included altered mental status and conversion disorder with deficits. Patient #6 received SN, PT, MSW, and aide services. Patient #6 was discharged from the agency on 7/31/22. Patient #6's medical record was reviewed. A clinical note for Patient #6 dated 6/21/22, signed by an RN, included in the narrative note: "...He continues to fall he fell this morning and has some bruising on his right lateral chest wall...." The Discharge OASIS -D1 was reviewed for Patient #6. OASIS item J1900 stated" NUMBER OF FALLS SINCE SOC/ROC,...0 - None" The Administrator was interviewed on 3/3/23, beginning at 4:00 PM. The medical record and OASIS data for patient #6 was reviewed in her presence. She confirmed Patient #6 had inaccurate data reported to OASIS. The agency failed to ensure all OASIS data was accurate.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on policy review, employee files, and staff interview, it was determined the agency failed to ensure all home health aides had the required hours of documented inservice training. This had the potential for aide services to be substandard. Findings included: A policy titled: Home Health Aide Training, Policy No. HH:3-012.1, was reviewed. It stated: "...6. The organization will offer 12 hours of inservice training annually..." This policy was not followed. The employee files of the agency's 2 aides were reviewed. The documented inservices for 2022 included April, May, June, July, September, October, November and December. There was no documentation of inservices for the months of January, February, March, and August. An agency Inservice binder was provided. It did not contain any documentation of further aide inservices. The Administrator was interviewed on 3/29/23, beginning at 11:00 AM. The Home Health Aide Training policy was reviewed in her presence. She confirmed the aide inservice requirement of 12 hours per year was not followed. She confirmed there was no documented inservice for agency aides for the months of January, February, March and August of 2022. The agency failed to ensure home health aides were provided the required hours of inservice training.