Every finding on record at Adair County Health Department/Home Health Agency

A partial extended survey for Medicare recertification for the home health provider was completed on 12/07/2022. The agency had four current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/07/2022. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on employee file review, and interview, the agency failed to ensure/document if staff were provided initial and annual Emergency Preparedness (EP) training, in one (Employee #3) of three employee files reviewed. This deficient practice has the potential to affect all patients and staff served by the agency. Findings included: Employee #3 (E3); - Date of hire: 09/3/2020; - Position: Occupational therapist; and - No evidence of EP training on orientation or every two years. During an interview on 12/6/2022 at 3:30 PM, the administrator and clinical manager stated that EP training for orientation consists of the EP trainer just talking to employees about the basics and answering any questions. The overall training was scheduled for last month but was cancelled.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either 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. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to conduct the initial assessment visit to determine the immediate care and support needs of the patient within 48 (forty eight) hours of the patient’s return home in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to adversely affect the health and safety of late assessed patients with immediate care needs. Findings included: Review of the agency’s policy titled, “12 Home Health Initial Assessment (Start of Care), dated reviewed and approved by Governing Board October 28, 2019, showed, in part, the following: - The initial visit shall be made within 48 (forty eight) hours of referral or within 48 hours of the client’s return home or on the physician designated start of care date; and - The visit can be made to evaluate the case before actual assumption of care or can be made to start care. RECORD/PATIENT #1 Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set- a standardized assessment form) showed: - Item M0090- Date assessment completed: 11/21/2022; - Item M0102- Date of physician-ordered start of care: NA- No specific SOC date ordered by physician; and - Item M1005- Inpatient discharge date 11/18/2022 (seventy two hours prior to SOC assessment). Review of a referral with a fax date and time stamp of 11/17/2022 2:56:50 PM showed: - Physician order: Discharge with home health skilled nursing; - Home health frequency: 1 (one) visit in 7 (seven) days; - Needs: evaluate and develop plan of care; - Special Instructions: Confirm plan of care with home health primary physician; and - Requested Start Date/Time: 11/15/22 13:59:00. Further review of the clinical record failed to show a specific physician ordered start of care. During an interview on 12/07/2022 at 11:30 AM, the clinical manager stated that: - He/she would expect the initial visit to be completed within 48 (forty eight) hours of referral, or discharge from inpatient facility, or on the physician ordered start of care date; and - (while pointing to a faxed paper in the clinical record, dated 11/15/2022 13:59) it does show here a range for a visit in one to seven days.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation and interview, the agency failed to ensure an accurate and complete review of all medications was completed upon admission/SOC (start of care) and/or update of the patient’s medications was completed in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective use of medication for all patients served by the agency. Findings included: Review of the agency’s undated policy titled “16 Policy for Use of Medication and Treatment Profile”, dated reviewed and approved by Governing Board October 28, 2019, showed, in part: - All medications will be reviewed by skilled nurse; - All drugs will be entered into the medication profile of the electronic health information system used; - It shall be updated whenever any changes in medications occur; - Medications and treatments will be reviewed by a skilled nurse at home visits for any changes; - Nurses will update medication profile as needed; - Medications that are discontinued or added will be added to the profile upon completion of every visit; and - Patients/Caregivers/Responsible parties will have a medication profile in the home, and this will be reviewed and updated as needed with each skilled nursing and therapy visit. RECORD/PATIENT #2 Review of a patient discharge summary report from a local hospital dated 10/15/22 8:11:03 showed, in part, a discharge medication list that: - Included docusate sodium (a stool softener medication) 100 mg (milligram) cap (capsule) take 1 (one) capsule orally once a day; - Failed to include any medication that would be utilized in a nebulizer machine (a machine that changes medication from a liquid to a mist so you can inhale it in your lungs); and - Failed to include Finasteride (used to treat urinating difficulties) 5mg 1 (one) daily. Review of the Initial POC (plan of care) dated 10/17/2022 to 12/15/2022 showed: - DME (durable medical equipment) and supplies had a nebulizer listed; - Medications listed included docusate sodium 100 mg 1 capsule twice a day; - Medication list failed to include Ipratropium bromide 0.5mg and Albuterol Sulfate (medication used to relax the airways and increase airflow to the lungs) 3mg in nebulizer up to QID (four times a day); and - Medication list failed to include Finasteride 5mg 1 daily. Review of a physician order signed by the registered nurse (RN) on 10/18/2022 at 10:03 AM showed medications were reviewed and reconciled with the following changes: - Baclofen (an antispasmodic medication) DC (discontinue); - Bethanechol (used to treat urinating difficulties); - Clotrimazole lozenge (used to treat yeast infections of the mouth) 1 tablet po (by mouth) QID; and - It failed to include changing the docusate from once a day on the referral to twice a day as on the Initial POC. Review of the personal typed medication list the spouse provided to the surveyor during the home observation visit on 12/05/2022 at 2:00 PM that he/she utilized to fill the patient’s medication planner in comparison to the current medication profile supplied to the surveyor by the agency showed the following discrepancies: - Baclofen 10mg half tablet at bedtime was listed on the agency medication list but failed to be on the patient’s medication list; - Bethanechol 50mg one tablet by mouth twice each day was listed on the agency medication list but failed to be on the patient’s medication list; - Docusate sodium 100mg was listed twice a day on the agency’s medication list but failed to be on the patient’s medication list; - Clotrimazole lozenge 10 mg 1 tablet by mouth four times each day was listed on the agency’s medication list but was listed on the patient’s medication list as four times daily as needed. - Finasteride 5mg 1 daily was on the patient’s mediation list but failed to be on the agency’s medication list; and - Ipratropium bromide 0.5mg and Albuterol sulfate 3mg in nebulizer up to four times a day was listed on the patient’s medication list but failed to be on the agency’s medication profile; Observation on 12/05/2022 at 2:00 PM, during the patient’s home visit observation showed: - The PT (physical therapist) asked the patient if there had been any medication changes which the patient and the spouse denied; and - The PT failed to look at the patient’s medication list or any of the patient’s medication bottles. Per interview conducted during observation 12/05/2022 at 2:00 PM, the patient’s spouse that filled the medication planner stated that the patient: - Is not taking baclofen; - Is not taking bethanechol; - Is only taking the clotrimazole lozenge as needed, usually just twice a day; - Hasn’t been taking the docusate, just as needed because the miralax is working; - Is taking finasteride 5mg daily and has been for about a year; and - Is taking the ipratroprium bromide and albuterol sulfate in the nebulizer up to four times daily. During an interview on 12/07/2022 at 1:58 PM the clinical manager stated that he/she would expect the patient’s medication list to match the agency’s current medication profile.

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 policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Treatment/Care," dated 10/28/2019 showed, in part, the plan of treatment used for all clients shall include types of services and equipment required. RECORD/PATIENT #3: Review of the registered nurse (RN) assessment, dated 11/21/2022, showed, in part: - Diagnoses of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (heart muscle doesn't pump blood as well as it should) and pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity); and - Dyspneic or noticeably short of breath with moderate exertion (for example, while dressing, using commode or bedpan, walking distances less than 20 feet). Review of the physical therapist (PT) assessment, dated 11/2/2022, showed, in part: - Medical equipment: portable oxygen (O2) tanks; - O2 saturation [shows the percentage of oxygen in someone's blood - normal level is usually 95% or higher] re: 95; - Oxygen L (liters) per min (minute): 2; and - Frequency of O2: continuous. Review of the patient's plan of care dated 11/21/2022 to 1/19/2023, showed, in part: - Diagnoses of hypertensive heart disease with heart failure, and pleural effusion; and - Durable medical equipment (DME): home oxygen. The plan of care failed to include portable O2 tanks. During an interview on 12/06/2022 11:47 AM, the clinical manager stated he/she expected durable medical equipment to be on the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to follow the plan of care when they provided two additional nursing visits without a physician order in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled “15 Plan of Treatment/Care,” dated reviewed and approved by the Governing Board October 28, 2019 showed, in part: -The plan of treatment used for all clients shall include frequency of visits for nursing, HH (home health) aide and therapists; and - All personnel making home visits must conform to all physician’s orders. RECORD/PATIENT #2: Review of the POC (plan of care) dated 10/17/2022 to 12/15/2022 showed SN (skilled nursing) 2wk3 (two times a week for three weeks) effective 10/17/2022. Review of the clinical record showed a SN visit made during week four, on 11/10/2022, and a SN visit during week seven on 12/01/2022. Further review of the clinical record failed to show physician's orders had been obtained for the SN visit during week four or for the SN visit during week seven, and the plan of care updated. During an interview on 12/07/2022 at 10:58PM the clinical manager stated that he/she would expect the staff to follow the orders on the plan of care.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA (home health agency) as frequently as the patient’s condition or needs require, in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect the quality of care provided to all the patients served by the agency. Findings included: Review of the agency’s policy titled, “15 Plan of Treatment/Care”, reviewed and approved by the Governing Board October 28, 2019, showed in part, the following: - Changes in plan of treatment- If changes are needed after the initial evaluation/visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders; - The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment; and - Any revision to the plan of care, including changes in discharge plan, due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians issuing orders for the HH (home health) plan of care. RECORD/PATIENT #2: Review of the initial POC (plan of care) dated 10/17/2022 to 12/15/2022 showed: - Physician or other approved provider: (named primary responsible physician); and - It failed to contain any other physicians involved in the patient’s care. Review of a general note dated 11/10/2022 showed, in part, 14:35: T/C [telephone call] to (named pulmonologist) office and spoke with (named employee) and reported findings by PT [physical therapists] and SN [skilled nurse], client’s home phone number given and HH [home health] agency number given. (named pulmonologist employee) to send message with urgent status. Review of a general note dated 12/01/2022 showed, in part: - 1035: T/C to (named pulmonologist) office and spoke with (named employee) re: client’s request for COVID vaccine booster #3. V/O (verbal order) obtained from (named employee) for Pfizer bivalent COVID vaccine, 0.3cc (cubic centimeter) IM (intramuscular) to be given today; and - 1400: T/C to (named pulmonologist) office and voicemail message left to update physician that client is using O2 today at 1.5L/minute/NC [nasal cannula] and requested order to change O2 rate from 3.5L/min/NC continuous. Requested return call for any orders/changes and agency number provided. Review of the physician orders showed: - Telephone orders from (named pulmonologist) with verbal order dates of 10/27/2022, 11/29/2022and 11/30/2022; and - There failed to contain physician orders from the responsible physician listed on the initial POC, allowing orders from (named pulmonologist) who was not listed on the initial plan of care. Further review of the clinical record failed to show documentation that the orders received from the pulmonologist were approved by the responsible physician and incorporated in to an updated plan of care. During an interview on 12/07/2022 at 1:58 PM the clinical manager stated that he/she was unaware that all physicians involved in the patient’s care should be included in the plan of care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Records/Patients #4) of five records reviewed. The home health agency failed to notify the physician for a stool softener order when one patient (Record/Patient #4), had a history of constipation and taking opioid pain medication and iron supplement. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, "Plan of Treatment/Care,” dated 10/28/2019, showed, in part, the following: - If changes are needed after the initial evaluation/visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders. The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. RECORD/PATIENT #4: Review of the physical therapist initial evaluation assessment dated 10/26/2022 showed current pain medication regimen Norco (opioid used to treat moderate to severe pain). Review of the POC dated 10/26/2022 through 12/24/2022, showed, in part: - The patient was admitted to home health services on 10/26/2022; - Diagnoses included: displaced spiral fracture shaft, type II diabetes mellitus, and gastroesophageal reflux disease; - Acetaminophen-hydrocodone (hydrocodone-acetaminophen 5 milligram (mg)-325 mg) tablet one tablet every six hours as needed; and - Iron capsule 150 mg one capsule by mouth daily. Review of the skilled nurse service note dated 10/28/2022, showed in part, current pain regimen included hydrocodone/acetaminophen 5mg-325mg one tablet by mouth every six hours as needed for pain. Review of the skilled nurse service note dated 11/03/2022, showed in part: - Task action - pain – comments - The client has a history of constipation and reviewed today with client to have skilled nurse contact physician to obtain order for stool softeners/laxative to assist with regular bowel movements while on opioid pain medication and iron supplements. The plan of care and physician orders failed to include any stool softeners/laxatives. During an interview on 12/06/2022 at 2:55 PM, the clinical manager stated he/she expected staff to follow up on stool softener order, especially with all the client had going on.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on employee file review and interview, the agency failed to maintain a coordinated agency-wide infection control program that included infection control education for a contracted staff which affected one (Employee #3) of three employee files reviewed. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: EMPLOYEE (E3): Review of E3's employee file showed: - Contracted employee; - Position: Occupational therapist; - Date of hire: 09/03/2022; and - No documentation found for orientation and yearly infection control training. During an interview on 12/06/2022 at 4:00 PM, the administrative assistant stated that he/she found no orientation or annual documentation in E3’s file for infection control.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on employee file review and interview, the agency failed to ensure staff were provided with agency in-service training in one (Employee #3) of three employee files reviewed. This deficient practice has the potential to affect all agency staff. Findings included: EMPLOYEE #3 (E3): Review of E3's employee file showed: - Contracted staff; - Hire date: 09/03/2020; and - No documentation of any agency in-service training. During an interview on 12/06/2022 at 4:00 PM, the administrative assistant stated that he/she found no in-service training in E3’s file.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on state law, employee file review, and interview, the agency failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire for two (Employee #1, and #3) of three employee files reviewed, and failed to ensure all staff had the Family Care Safety Registry (FCSR) checked prior to date of first patient contact, in one (Employee #1) of three employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of Section 192.2495.6, RSMo: "A provider is guilty of a Class A misdemeanor if the provider knowingly hires or retains person to have contact with patients or residents and the person has been found guilty in this state or any other states or has been found guilty of a crime, which if committed in Missouri would be a Class A or B felony violation of Chapter 565, 566, or 569, or any violation of Subsection 4 of section 198.070 or section 568.020." EMPLOYEE #1 (E1): Review of the E1's personnel file showed: - Registered nurse (RN): - Date of hire: 10/12/2022; - Date of first patient contact: 10/4/2022; - EDL results: 10/25/2022, 13 days after hire date; and - FCSR results: 10/25/2022, 11 days after hire date/patient contact. EMPLOYEE #3 (E3): Review of the E3's personnel file showed: - Occupational therapist (OT); - Date of hire: 9/03/2020; and - EDL results: 9/16/2020, 13 days after hire date. During an interview on 12/06/2022, the administrator stated that: - There was no policy for EDL’s; - There is a list of what the personnel file is to include; and - He/she knows EDL’s are to be completed prior to hire.