Every finding on record at Tender Touch Health Care Services

During the recertification survey conducted on January 5 - 8,2026 at Tender Touch HealthCare Services, a home health agency, Emergency Preparedness was reviewed. The agency was in compliance with Emergency Preparedness per Home Health Agency Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was completed on January 5 - 8, 2026 at Tender Touch HealthCare Services in Panama City, Florida. The facility was not in compliance with Home Health Agency Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Agencies.

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 record review and interview, the home health agency (HHA) failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set.) assessment to the Centers for Medicare and Medicaid Services, (CMS), regarding each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary. The findings include: A review of The HHA Error Summary by Agency OASIS report was reviewed on 1/4/2026. The focus of this review was on one specific error, -3330, “Record Submitted Late: The submission date is more than 30 days after M0090 (Date Assessment Completed) on this new record. The criteria for this report is the prior calendar year. The home health agency had 163 assessments with error -3300, out of 1784, which was 9.14%. An interview was conducted with the administrator on 1/7/2026 at 9:30 AM. The administrator confirmed they had experienced a problem with submission and was working to correct it.

During the Recertification survey conducted January 23 through January 25, 2023 at Tender Touch Health Care Services, a home health agency, Emergency Preparedness was reviewed. The agency was not in compliance with Emergency Preparedness per Code of federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

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 review of agency policies and procedures and interview with the Administrator, the agency failed to develop and document a facility-based and community-based risk assessment utilizing an all-hazards approach. Review of the agency's emergency preparedness plan and policies and procedures for emergency preparedness revealed no documentation of a facility-based or community-based risk assessment to be utilized to identify hazards addressed in the emergency preparedness plan. Interview with the Administrator on 1/25/23 at 12:05 PM, revealed confirmation that emergency preparedness policies and procedures did not include either a facility-based or community-based risk assessment. He voiced some confusion over the term "risk assessment". When asked how the agency determined what hazards to identify and plan for, he stated he just included any hazards he could think of which may occur in the area covered by the agency. He confirmed no risk assessment had been completed or utilized to determine which hazards have the greatest potential to affect agency patients, or the community served by the agency.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness policies and procedures and interview with the Administrator, the agency failed to develop and maintain policies and procedures which describe facility-based and community-based risk assessment to be used to identify potential hazards which are included in the emergency preparedness plan. Review of the agency's emergency preparedness plan and policies and procedures for emergency preparedness revealed no documentation of a facility-based or community-based risk assessment to be utilized to identify hazards addressed in the emergency preparedness plan. Interview with the Administrator on 1/25/23 at 12:05 PM revealed confirmation that emergency preparedness policies and procedures do not include either a facility-based or community-based risk assessment. He voiced some confusion over the term "risk assessment". When asked how the agency determined what hazards to identify and plan for, he stated he just included any hazards he could think of which may occur in the area covered by the agency. He confirmed no risk assessment had been completed or utilized to determine which hazards have the greatest potential to affect agency patients, or the community served by the agency.

A recertification survey was conducted January 23 through January 25, 2023 at Tender Touch Health Care Services, a home health agency. The agency was in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.