Always a Step Beyond

The agency failed to establish and maintain a comprehensive emergency preparedness program (Tag 004); failed to ensure the completion of an all-hazards risk assessment every two (2) years (Tag 006); failed to specify the population served (Tag 009); failed to maintain documentation of initial…

The agency failed to ensure a registered nurse conducted the initial evaluation, completed a comprehensive assessment that included the patient’s current health, psychosocial, functional, cognitive status, the patient’s strengths, goals, and care preferences, the patient’s continuing need for home…

The agency failed to ensure individualized care plans were developed (Tag 572);individualized to meet the patient's needs and cover all the required elements (tag 574); ordered and signed by a physician (Tag 580); reviewed and revised at least every sixty 60 days (Tag 592) for six (6) of six (6)…

The agency failed to ensure development of a Quality Assessment and Performance Improvement (QAPI) program that showed measurable outcomes indicators that would improve health outcomes, patient safety and quality of care by measuring, analyzing, and tracking quality indicators (Tag 642); failed to…

The agency failed to review and update the emergency preparedness plan at least every two (2) years.

The agency failed to complete an all-hazards risk assessment at least every two (2) years.

The agency failed to specify the population served by the agency one (1) of one (1) plan reviewed EP #1 Review of the agency emergency preparedness plan on February 10, 2026, at approximately 12:00 PM and February 17, 2026, at approximately 8:00 AM revealed no documentation of a plan that is…

The agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency preparedness plan, the risk assessment, policies and procedures, and the communication plan, which must be reviewed and updated at least every two (2) years.

The agency failed to maintain documentation of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, and no documentation of emergency preparedness training conducted at least every two (2)…

The agency failed to document exercises to test the emergency plan annually, which includes a full-scale exercise that is community-based every 2 years and an additional exercise at least every 2 years, opposite the year of the full-scale exercise.

The agency failed to ensure a Home Health Certification and Plan of Care/Treatment was created for six (6) out of six (6) clinical record reviewed (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately 11:30 AM and revealed the following: Agency…

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that showed measurable improvement in indicators that would improve health outcomes, patient safety and quality of care by measuring, analyzing, and tracking quality of indicators for one (1) of one (1)…

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested.

The agency failed to conduct performance improvement projects as part of the Quality Improvement Performance Improvement (QAPI) program for one (1) of one (1) QAPI requested.

The Governing body (GB) and the agency failed to follow its own policy and conduct a two (2) person governing body meeting and ensure documentation in regards to the reviewing and approval the the annual program evaluation and the agency policies for one (1) of one (1) GB reviewed.

The agency failed to ensure a registered nurse conducted the initial assessment visit within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date for six (6) out of six (6) clinical records reviewed (CR#1-6)…

The agency failed to ensure a registered nurse assessed the patient’s medical, nursing, rehabilitative, social, and discharge planning needs for six (6) out of six (6) clinical record reviewed (CR#1-6) Findings include: Review of agency policy was conducted on February 10, 2026, at approximately…

The agency failed to ensure an individualized plan of care was developed that covered all required elements per agency policy for six (6) of six (6) clinical records (CR) reviewed.

The agency failed to obtain a physician order for services, and treatments and/or medications for six (6) of the six (6) CRs reviewed.

The agency failed to ensure an individualized plan of care was reviewed and revised no less frequently than every 60 days for six (6) of six (6) clinical records (CR) reviewed.

The agency failed to ensure a revised plan of care reflecting current information from the updated comprehensive assessment contained information regarding the patient’s progress toward measurable outcomes and goals for six (6) of six (CR) reviewed.

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that contained performance improvement activities focused on high risk, high volume, or problem-prone areas for one (1) of one (1) QAPI requested.

The agency failed to ensure documentation of competency evaluation for clinical staff for ten (10) of the ten (10) PFs requested.

The Governing body (GB) failed to appoint a qualified professional to act as the Agency Administrator in writing for one (1) of one (1) GB reviewed.