Every finding on record at Serenity Home Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/06/24. Standard deficiencies cited.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to have a communication plan that meets the requirements. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed 12/04/24. The plan lacked a communication plan that includes Names and contact information for the staff and the entities providing services under arrangement. 2. The finding, regarding the lack of a communication plan was confirmed during an interview with the Assistant Administrator and Director of Nursing on 12/05/24 at 10:30 AM.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to ensure that the Agency conducted / participated in full scale community-based exercise or facility-based exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed 12/04/24. The plan lacked documentation indicating Agency participated in a full-scale community-based exercise, facility-based exercise or implemented the Emergency Preparedness Plan since 2021. 2. During an interview with the Assistant Administrator and Director of Nursing on 12/05/24 at 10:30 AM, the Assistant Administrator confirmed that the Agency failed to conduct / participate in full scale exercise.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/06/24. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse SOC = Start of care RN = Registered Nurse Pt./ Pts. = Patient/Patients PT = Physical Therapy OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Agency’s OASIS Error Summary report and Staff interview, it was determined in 5 of 8 OASIS reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s OASIS Error Summary report for 11/01/23 thru 10/31/24, was reviewed on 12/03/24 at 10:30 AM. The report included error # -3330 for 5 of 8 submissions. 62.50% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Assistant Administrator and Director of Nursing, on 12/04/24 at 11:00 AM.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Patient Admissions folder and Staff interview, it was determined that the Agency failed to ensure the Agency provide the contact information for the Administrator upon Patient Admission. Findings include: 1. A copy of the Agency's patient Admissions folder was reviewed 12/04/24. The Admissions folder lacked contact information for the Administrator. 2. During an interview with the Assistant Administrator and Director of Nursing on 12/05/24 at 11:00 AM. the Assistant Administrator confirmed that the Admissions folder lacked the contact information for the Administrator.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 3 of 7 (Pts. # 3, 4 and 5) clinical records reviewed, the patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 03/10/23 with the diagnoses of: COVID-19 and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 03/10/23, that required SN to assess the patient 1 time a week for 9 weeks and notify the MD immediately of potential problems. The SN visit notes dated 03/31/23 and 04/28/23 included that the patient was short of breath and lacked the oxygen saturation assessment. 2. Pt. #4 was admitted to the Home Health Services on 05/11/23 with the diagnoses of: Alzheimer’s Disease and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 05/11/23, that required SN to assess the patient 1 time a week for 9 weeks and notify the MD immediately of potential problems. The SN lacked the assessment/visit notes for weeks #2 and #3. 3. Pt. #5 was admitted to the Home Health Services on 08/16/23 with the diagnoses of: Hypertensive Chronic Kidney Disease with stage 1-4/ unspecified Chronic Kidney and Alzheimer’s Disease. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 08/16/23, that required PT to assess the patient 1 time a week for 1 week, 2 times a week for 3 weeks and 3 times a week for 1 week. The PT lacked the assessment/visit notes for 08/23/23 (week #2). 4. The above findings were confirmed, during the interview with the Assistant Administrator and Director of Nursing, on 12/04/24 at 11:00 AM.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical records reviewed and staff interview, it was determined in 4 of 7 (Pts. #3, 4, 1 and 6) clinical records reviewed, the PsOC failed to included all the requirements. 3. Pt. # 1 was admitted to Home Health Services on 01/29/24 with diagnosis of Acute Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 12/03/24. The clinical record contained SN visit notes dated 02/10, 03/02, 03/09 and 03/15/2024 that contained weight assessments. The POC for Pt.#1 lacked order for weight assessments and patient specific weight parameters. 4. Pt. # 6 was admitted to Home Health Services on 06/14/23 with diagnosis of Muscle Weakness. The clinical record was reviewed on 12/04/24. Pt #6 clinical record contains a hospital referral for home health services dated 06/12/23 that contains a list medications patient is currently taking. The home health POC for certification period 06/14/23 to 08/12/23 lacked a listing of medications the patient is currently taking. 5. During interviews with the Assistant Administrator and Director of Nursing between 12/04/24 and 12/05/24 the Assistant Administrator confirmed that the individualized Plans of Care did not include the requirements. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 03/10/23 with the diagnoses of: COVID-19 and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 03/10/23. The SN visit note date 04/28/23 included a blood pressure of 126/88 and heart rate of 91. The POC lacked the parameter for the blood pressure and heart rate to notify the MD. 2. Pt. #4 was admitted to the Home Health Services on 05/11/23 with the diagnoses of: Alzheimer’s Disease and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a POC dated 05/11/23. The POC lacked the diagnosis for the random blood sugar orders.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Patient Admissions Folder and Staff interview, it was determined that the Agency failed to ensure the Agency provide the Name and contact information for the Clinical Manager. Findings Include: 1. The Agency's Admissions folder was reviewed 12/04/24. The Admissions folder lacked the Name and contact information for the Clinical Manager. 2. During an interview with the Assistant Administrator and Director of Nursing on 12/05/24 at 11:00 AM. the Assistant Administrator confirmed that the Admissions folder lacked the Name and contact information for the Clinical Manager.

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 the clinical records review and Staff interview, it was determined that in 4 of 7 (Pts. # 4, 5, 1 and 7) clinical records reviewed, the Agency failed to ensure the discharge summary was sent to the physician. 3. Pt. # 1 was admitted to Home Health Services on 01/29/24 with diagnosis of Acute Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 12/03/24. The clinical record contained a SN discharge assessment / summary dated 03/26/24. The clinical record lacked evidence that a discharge summary was sent to the physician. 4. Pt. # 7 was admitted to Home Health Services on 06/03/23 with diagnosis of Type 2 diabetes mellitus without complication. The clinical record was reviewed on 12/04/24. The clinical record contained a SN discharge assessment / summary dated 07/27/23. The clinical record lacked evidence that a discharge summary was sent to the physician.\ 5. During interviews with the Assistant Administrator and Director of Nursing between 12/04/24 and 12/05/24 the Assistant Administrator confirmed that the clinical records lacked evidence of a discharge summary was sent to the physician. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 05/11/23 with the diagnoses of: Alzheimer’s Disease and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a discharge summary dated 06/08/23, that was not sent to the physician. 2. Pt. #5 was admitted to the Home Health Services on 08/16/23 with the diagnoses of: Hypertensive Chronic Kidney Disease with stage 1-4/ unspecified Chronic Kidney and Alzheimer’s Disease. The clinical record was reviewed on 12/03/24. The clinical record contained a discharge summary dated 08/28/23, that was not sent 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 the clinical records review and Staff interview, it was determined that in 4 of 7 (Pts. #3, 5, 6 and 7) clinical records reviewed, the Agency failed to ensure the clinical records were complete and accurate. 3. Pt. # 1 was admitted to Home Health Services on 01/29/24 with diagnosis of Acute Combined Systolic and Diastolic Heart Failure. The clinical record was reviewed on 12/03/24. The clinical record contained a POC signed by the physician with a start of care date on 01/29/24. The clinical record also contained an admission consent for treatment signed by the patient dated 01/25/24. 4. Pt. # 6 was admitted to Home Health Services on 06/14/23 with diagnosis of Muscle Weakness. The clinical record was reviewed on 12/04/24. The clinical record contained an undated admission consent for treatment signed by the patient. 5. Pt. # 7 was admitted to Home Health Services on 06/03/23 with diagnosis of Type 2 diabetes mellitus without complication. The clinical record was reviewed on 12/04/24. The clinical record contained an admission consent signed by the patient with an illegible date. 6. During interviews with the Assistant Administrator and Director of Nursing on 12/04/24 and 12/05/24 between, the Assistant Administrator confirmed that the clinical records were illegible, inaccurate and incomplete. Findings include: 1.Pt. #3 was admitted to the Home Health Services on 03/10/24 with the diagnoses of: COVID-19 and Essential (Primary) Hypertension. The clinical record was reviewed on 12/03/24. The clinical record contained a SN visit note dated 04/21/23 with 18% as the oxygen saturation. During the interview with the Director of Nursing, it was stated the 18% was a documentation error. 2. Pt. #5 was admitted to the Home Health Services on 08/16/23 with the diagnoses of: Hypertensive Chronic Kidney Disease with stage 1-4/ unspecified Chronic Kidney and Alzheimer’s Disease. The clinical record was reviewed on 12/03/24. The clinical record contained an incomplete “OASIS-E transfer” note dated 09/01/23 by the Director of Nursing. On 12/04/23, at 11:30 AM, during the interview with the Director of Nursing, it was stated the patient was transferred to the hospital. The clinical record lacked the transfer order and documentation of the care coordination.

Recertification survey completed. Standard level deficiencies cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(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 ensure the plan was established based on an updated risk assessment utilizing an all-hazards approach. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 09/30/2021 at 12:30 PM. The Plan lacked a community specific updated risk assessment utilizing an all hazard approach for the years 2019, 2020 and 2021. 2. During an interview with the Assistant Administrator and the Director of Nursing on 09/30/2021 at 2:15 PM, the above findings were confirmed.

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), §485.625(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, 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 test the Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 09/30/2021 at 12:30 PM. The Plan lacked any evidence of testing or implementation of an actual emergency for the years 2019, 2020 and 2021. 2. During an interview with the Assistant Administrator and the Director of Nursing on 09/30/2021 at 2:15 PM, the above findings were confirmed. The Assistant Administrator stated, "We did not document any testing of the Emergency Preparedness Plan."

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC= Start of Care POC= Plan of Care PsOC= Plans of Care Pt.= Patient Pts.= Patients PT= Physical Therapist OT=Occupational Therapist AM= Morning PM= Afternoon/Evening #= Number BP= Blood Pressure w= week

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to provide services as ordered by the Physician in the POC. This was found in 7 of 13 (Pts. #9, 12, 3, 4, 5. 7 and 11 ) clinical records reviewed. Pt. # 9 SOC 05/28/2021. Primary Diagnosis: Paraplegia. The Clinical Record was reviewed on 09/29/2021 at 3:00 PM. The record included a POC with a certification period of 07/27/2021 to 09/24/2021. The POC ordered, “SN frequency: 1 w 9.” The record lacked documentation that a SN visit was made for the week beginning 08/01/2021. During an interview with the Assistant Administrator and Director of Nursing on 09/30/2021 at 2:15 PM, the Director of Nursing confirmed the physician was not notified of the missed visit during the week of 08/01/2021.Pt. #12 SOC 03/27/2021. Primary Diagnosis: Malignant neoplasm of the right and left breast. The Clinical Record was reviewed on 09/30/2021 at 9:30 AM. The record included a PT evaluation dated 04/25/2021 with a visit frequency of, “1 w 1, 2 w 3, 1 w 1.” During the week of 05/16/2021, PT documented a visit on 05/18/2021. The record lacked documentation of a second PT visit for that week. Additionally, the record contained an OT evaluation dated 04/30/2021 with a visit frequency of, “1 w 1, 2 w 3, 1 w 1.” During the week of 05/02/2021 an OT visit note dated 05/07/2021 was documented. The record lacked documentation of the second OT visit for that week. The record also contained an OT visit note dated 05/21/2021. The record lacked documentation of the second OT visit for the week of 05/16/20221. During an interview with the Assistant Administrator and Director of Nursing on 09/30/2021 at 2:15 PM, the Director of Nursing stated, "The physician was not notified of these missed visits." 3. Pt #3 SOC 09/11/2021. Primary Diagnosis: Weakness. The clinical record was reviewed on 09/29/2021 at 9:00 AM. The record included a POC with certification period of 09/11/2021 to 11/09/2021. The POC ordered: “SN frequency 3 W 4” (3 times a week for 4 weeks). The record included an SOC assessment dated 09/11/2021. The record lacked documentation of any other visits for week of 9/11/2021. The same record included 2 SN visits dated 09/15/2021 and 09/17/2021. The record lacked any other visits for week of 9/12/2021. No modification orders or communication notes were found in the record indicating reason for not following physician order. 4. Pt. #4 SOC 06/12/2021. Primary Diagnosis: Acute Embolism and Thrombosis of Deep Veins of Low Extremity, Bilateral. The clinical record was reviewed on 09/29/2021 at 10:30 AM. The record included a POC with certification period of 06/12/2021 to 08/10/2021 that required to “Notify physician of vital signs parameters out of range:…Systolic BP: Greater Than (>) 160 Less than ()90 Less Than () 100 Less Than () 102.5 Less Than () 24 Less Than () 160 Less Than () 100 Less Than (<) 60. The record included an SN note dated 04/03/2021 but lacked an assessment of vital signs. No modification orders or communication notes were found in the record indicating reason for not following physician order. During an interview with the Assistant Administrator and the Director of Nursing on 09/30/2021 at 1:00 PM, the Assistant Administrator and Director of Nursing confirmed missed visits and lack of vital sign assessments. The Assistant Administrator confimred the above findings during inteview on 09/30/2021 between 1:00 PM and 3:15 PM.

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 review and staff interview, the Agency failed to authenticate physician orders. This was found in 7 of 13 (Pts. # 2, 8, 9, 12, 13, 4 and 5) clinical record reviews. Pt. #2 SOC 03/11/2021. Primary Diagnosis: Multiple Sclerosis. The clinical record was reviewed on 09/29/2021 at 1:00 PM. The record included a POC with a certification period of 07/15/2021 to 09/12/2021. As of 09/30/2021 at 3 PM, the POC lacked the physician’s signature.Pt. # 8 SOC 07/09/2021. Primary Diagnosis: Lymphedema. The clinical record was reviewed on 09/30/2021 at 10:00 AM. The record included a POC with a certification period of 07/09/2021 to 09/06/2021. As of 09/30/2021 at 3 PM, the POC lacked the physician’s signature.Pt. #9 SOC 05/28/2021. Primary Diagnosis: Paraplegia. The clinical record was reviewed on 09/29/2021 at 3 PM. The record included a POC with a certification period of 07/27/2021 to 09/24/2021. As of 09/30/2021 at 3 PM, the POC lacked the physician’s signature. Pt. #12 SOC 03/27/2021. Primary Diagnosis: Malignant neoplasm of the right and left breast. The clinical record was reviewed on 09/30/2021 at 9:30 AM. The record contained a Physical Therapy evaluation dated 03/29/2021 and an Occupational Therapy evaluation dated 03/29/2021. As of 09/30/2021 at 3 PM, the evaluations both lacked a physician’s signature.Pt. # 13 SOC 06/22/2021. The clinical record was reviewed on 09/30/2021 at 12:15 PM. The record included a POC with a certification period of 06/22/2021 to 08/20/2021. The record also contained an Occupational Therapy evaluation dated 06/25/2021. As of 09/30/2021 at 3:00 PM, the POC and the Occupational Therapy evaluation lacked the physician’s signature.6. Pt #4 SOC 06/12/2021 Primary Diagnosis: Acute Embolism and Thrombosis of Deep Veins of Low Extremity, Bilateral. The clinical record was reviewed on 09/29/2021 at 10:30 AM. The record included a POC with a certification period of 6/12/2021 to 08/10/2021. As of 09/30/2021 at 4:00 PM, the POC lacked the Physician’s signature. 7. Pt. #5 SOC 07/17/2021 Primary Diagnosis: Hypertensive Heart disease with Heart failure. The clinical record was reviewed on 09/29/2021 at 10:45 AM. The record included a POC for certification period of 07/17/2021 to 09/14/2021. As of 09/30/2021 at 4:00 PM, the POC lacked the Physician’s signature. During interview with Assistant Administrator and Director of Nursing on 09/30/2021 between 1:00 PM and 3:15 PM, the Assistant Administrator stated that PsOC were sent to the physician for signature as required but confirmed the above findings that these PsOC were not signed.