Every finding on record at Accessible Healthcare, LLC

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. The survey conducted from 07/18/2022 to 07/20/2022 resulted in a finding of standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

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), §485.625(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 interview, review of the agency’s Emergency Preparedness (EP) plan, and review of agency policy, the agency failed to ensure a review of the Emergency Preparedness Plan at least every two years. This failure had the potential to create a delayed response during an emergency due to the use of an outdated needs assessment, contact information, and policies and procedures. This had the potential to put the 26 patients of the agency at risk. Findings include: Review of the agency’s “Emergency Preparedness [EP] Plan,” revealed the last documented date of revision was 2017. Review of the “Hazard Vulnerability Assessment (HVA)” and the “Staff Contact Information” were undated. During an interview with the Director of Clinical Services (DCS) on 07/18/2022 at 1:25 PM, the DCS was responsible for the agency’s EP Plan. The DCS was, “in the process of reviewing the EP Plan,” but it had not been completed and the DCS was unable to determine when the last review had been completed. Review of the agency policy titled, “Emergency Operations Plan and Policies,” last revised June 2017, revealed, “The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually.”

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 document review, staff interview, and review of agency policies and procedures, the agency failed to ensure policies and procedures for Emergency Preparedness were developed using their Hazard Vulnerability Assessment. Failure to prepare for the most anticipated and potentially harmful emergency events could potentially put all 26 patients receiving services from the agency at risk for harm. Findings include: Review of the “Hazard Vulnerability Assessment [HVA]” contained within the agency’s “Emergency Preparedness [EP] Plan,” revealed that among the top five events determined to place agency patients most at risk of harm included “Earthquake,” “Terrorist Attacks,” and “Altered Air Quality/Pollution.” Review of the policies and procedures in the “EP Plan,” revealed no policies and/or procedures related to readiness or response to earthquakes, terrorist attacks, or altered air quality events. During an interview with the Director of Clinical Services (DCS) on 07/18/2022 at 1:25 PM, the DCS was responsible for the agency’s EP Plan. The DCS was unable to locate any policies and/or procedures related to readiness or response to earthquakes, terrorist attacks, or altered air quality events. The DCS agreed these policies and/or procedures should have been developed following identification of these events as potentially harmful in the HVA. Review of the agency policy titled, “Emergency Operations Plan and Policies,” last revised June 2017, revealed, “The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. The plan: Is based on and includes a documented facility-based (Agency) and community-based risk assessment, utilizing an all-hazards approach.”

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), §485.625(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 document review, staff interview, and review of agency policies and procedures, the agency failed to ensure the staff emergency contact information was reviewed and updated as needed at least every two years. Failure to maintain current contact information could lead to delays in contacting staff assistance with emergency procedures, placing all 26 patients receiving services from this agency at risk. Findings include: Review of the agency’s “Staffing List” revealed the agency employed a total of 26 employees. Review of the agency’s “Emergency Preparedness [EP] Plan,” revealed the last documented date of revision was 2017. Review of the “Staff Contact Information” contained in the plan revealed the list contained 14 names and was undated. During an interview with the Director of Clinical Services (DCS) on 07/18/2022 at 1:25 PM, the DCS was responsible for the agency’s EP Plan. The DCS was, “in the process of reviewing the EP Plan,” but it had not been completed and the DCS was unable to determine when the last review had been completed. The DCS agreed the staff contact information was not current. Review of the agency policy titled, “Emergency Operations Plan and Policies,” last revised June 2017, revealed, “The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually…the Agency will follow up by telephone with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services...The Agency will track patients and staff by telephone or in person during an emergency.” Review of the agency EP Plan policy titled, “Communication Plan and Policy for Emergency Operations plan (EOP),” last revised 2017, revealed, “The Agency has developed and maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan is reviewed and updated at least annually. The communication plan includes the following: Names and contact information for the following: Staff.”

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 document review, staff interview, and review of agency policies and procedures, the agency failed to ensure completion of annual exercises of their Emergency Preparedness Plan (EP Plan).This failure had the potential to negatively impact the agency’s ability to evaluate the staff's skills and readiness needed in the event of an actual emergency, placing all 26 patients receiving services from this agency at risk. Findings include: Review of the agency’s “Emergency Preparedness [EP] Plan,” revealed the last documented date of revision was 2017. Review of the most current documented exercise revealed an agency-wide fire drill was conducted on 06/03/2022. No other documented drills could be located in the EP Plan. During an interview with the Director of Clinical Services (DCS) on 07/18/2022 at 1:25 PM, the DCS was responsible for the agency’s EP Plan. The DCS was, “in the process of reviewing the EP Plan,” but it had not been completed. The DCS was unable to locate a documented agency-wide or community-wide drill completed since 2018. The DCS agreed the agency had failed to conduct annual drills between 2018 and 2022. Review of the agency policy titled, “Testing Program for Emergency Operations Plan (EOP),” last revised June 2017, revealed, “The Agency will conduct exercises to test the EOP at least annually. The Agency will do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise. The Agency is encouraged to seek out local state emergency agencies and health care coalitions to participate in a full-scale, community-based exercise. If the Agency experiences an actual natural or man-made emergency that requires activation of the EOP, the Agency is exempt from engaging in a community-based or individual, facility-based full-scale exercise for one (1) year following the onset of the actual event. A full-scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and/or "boots on the ground" response (e.g., firefighters decontaminating mock victims).

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. The survey conducted from 07/18/2022 to 07/20/2022 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

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 record review, staff interview and review of the agency's policies and procedures, the agency failed to ensure the assigned clinicians followed the plan of care as ordered for four of nine patients sampled (Patient (P)1 P2, P8, and P9). This failure had the potential to cause negative outcomes for all 26 patients receiving care from this agency. Findings include: 1) Review of P1's electronic medical record (EMR) revealed a start of care (SOC) date of 05/16/2022 with a primary diagnosis of hypertension (high blood pressure) and heart failure. Review of the Plan of Care (POC) orders for the certification period of 05/16/2022 through 07/14/2022 revealed orders for Occupational Therapy (OT) to, “Evaluate and treat.” Review of the Physician’s Order dated 06/06/2022 following the OT evaluation revealed the order, “OT 1wk6 (OT visits once per week for six weeks).” Review of P1’s Visit Notes for the certification period revealed no weekly visit was documented for P1 during the week of 06/26/2022 through 07/02/2022. 2) Review of P2’s EMR revealed a SOC date of 04/25/2022 with a primary diagnosis of Gastroesophageal Reflux. Review of the POC orders for the certification period 06/25/2022 through 08/22/2022 revealed orders for a Skilled Nurse (SN) visit frequency of, “1w1, 2w8 (once a week for one week, then twice a week for eight weeks).” Review of P2’s Visit Notes for the certification period 06/25/2022 to the current date revealed only one SN visit was documented for P2 during the week of 07/03/2022 through 07/09/2022. 3) Review of P8’s EMR revealed a SOC date of 05/27/2022 with a primary diagnosis of Cerebrovascular Accident (CVA/stroke). Review of the POC orders for the certification period 05/27/2022 through 07/25/2022 revealed orders for a Home Health Aide (HHA) frequency of, “2w2, 1w6 (two times a week for two weeks, then one time a week for six weeks).” Review of P8’s Visit Notes for the certification period of 05/27/2022 to the current date revealed no HHA visit was documented for to P8 during the week of 07/03/2022 through 07/09/2022. 4) Review of P9’s EMR revealed a SOC date of 01/21/2022 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the POC orders for the certification period 05/21/2022 through 07/19/2022 revealed orders for a SN visit frequency of, “2w1, 1w7 (twice a week for one week, then once a week for seven weeks).” Review of P9’s Visit Notes for the certification period 05/21/2022 through 07/19/2022 revealed no SN visit was documented for to P9 during the week of 06/26/2022 through 07/02/2022, or for the week 07/03/2022 through 07/09/2022. During an interview with the Director of Clinical Services (DCS) on 07/20/2022 at 12:30 PM, the above documentation was reviewed and confirmed as correct and complete. The DCS confirmed that no visits were documented to the patients as reviewed, stating, “Those were misses.” Review of the agency policy titled, “Professional Standards of Practice,” last revised 2014, revealed, “Agency staff will provide care, treatment and services to each patient according to the plan of care.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on staff interview and review of policies and procedures, the agency failed to ensure that a qualified person was designated to act as Administrator in the absence of the Administrator. This had the potential impact patient care to all 26 patients receiving services. Findings include: During an interview with the Director of Clinical Services (DCS) on 07/18/2022 at 3:00 PM, the DCS stated that the current back-up Administrator had been functioning in that capacity since 01/01/2022. The DCS was unable to provide documentation the Administrator and Governing body had designated the alternate administrator. Review of the agency policy titled, “Administrator: Defined,” last revised 2015, revealed, “The Administrator of the Agency has the following responsibilities: …Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the administrator.” The policy included an attachment titled, “Authorization of Agency Responsibility,” which revealed a form intended to be used by the Administrator to sign and date their authorization of a designated alternate Administrator.