Every finding on record at Allied Home Health Care Services

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from 06/22/2026 through 06/24/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484.102 – Emergency Preparedness Program. The unannounced, on-site inspection was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. There were no regulatory deficiencies identified.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey and Complaint investigation conducted at your agency from 06/22/2026 through 06/24/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484 – Home Health Agencies. The unannounced, on-site inspection was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The active census on the first day of the survey was 16. There were 12 clinical records reviewed and three home visits conducted. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 record review, interview, and policy review, the agency failed to complete an initial start of care assessment within 48 hours of the referral order date for 2 of 12 sampled patients (Patient 2 and Patient 4). The agency put the patients’ health and safety at risk by failing to identify immediate care and support needs within 48 hours from the referral date. Findings include: . For Quality Assurance Purposes Only

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview, record review and policy review, the agency failed to ensure the physical therapist completed and uploaded a plan of care into the electronic medical record for 1 of 12 patients (Patient 1). The failure to complete and upload the plan of care into the electronic medical record had the potential to prevent other staff from providing the appropriate care and treatment necessary for the patient’s recovery. Findings include: .) For Quality Assurance Purposes Only Patient 1 (P1) P1 was admitted to the agency on 06/09/2026, with a recent history of a right-sided total knee replacement. P1's electronic medical record (EMR) included a physician order for skilled nursing and physical therapy to assess and treat the patient. A “Demographics” page noted that skilled nursing (SN), physical therapy (PT), and physical therapy assistant (PTA) would be providing care to the patient. On 06/09/2026, SN completed P2 initial SOC assessment and home care admission documents. On 06/13/2026, PT9 conducted an initial visit to assess P1’s status and home rehabilitation needs. PT9 did not enter the assessment or a plan of care into the patient’s EMR. On 06/17/2026 and 06/19/2026, PTA10 visited P1 with the intention of providing balance and gait training, therapeutic and strengthening exercises, mobility skills and patient and caregiver education. On 06/23/2026, the second day of the agency’s recertification survey, the physical therapy section of P1’s EMR lacked documentation of an assessment. There was no documented plan of care for the PTA to follow. On 06/23/2026 at 09:50 AM during an interview, the Quality Assurance Assistant (QAA)3 confirmed P1’s physical therapy initial assessment was blank and had not been completed by PT9. QAA3 indicated the assessment documentation should be completed within 48 hours of the assessment. On 06/24/2026 at 12:10 PM during an interview, PT9 confirmed not having entered P1’s initial assessment documentation and plan of care into the EMR within 48 hours of completing the assessment. Regarding P1’s assessment and plan of care not being entered into the EMR, PT9 told the surveyor, “I got busy and just hadn’t put it in the computer system . . . I talked to the PTA about the treatment plan over the phone.” The agency's undated "Submission of Notes" policy indicated the following: "Purpose: . . . To ensure accurate and timely submission of visit notes . . . All documents pertaining to the visit must be submitted every Monday and Friday, even if it falls on a holiday (so we may receive your documents by 9o'clock in the morning the following business day). . . ."

A Medicare recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of health and Human Services. The survey conducted from 08/10/2022 to 08/11/2022 resulted in 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 Emergency Preparedness (EP) plan review, EP policy review and interview, the home health agency (HHA) failed to maintain an EP plan that was reviewed and updated at least every two years. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the "Emergency Preparedness Program 2017" Revised 10-02-2017, presented by Chief Executive Officer (CEO) on 08/10/2022 indicated the EP plan had not been reviewed and updated since 10/02/2017. Review of the "Emergency Preparedness Policy of [name of HHA]" presented by the CEO on 08/11/2022 indicated the policy was not dated. In an interview on 08/11/2022 at 1:00 PM, the CEO stated there was an email with the date the EP plan had been reviewed and sent for review. The CEO could not find the email. The CEO could not provide documentation the EP plan had been reviewed and updated at least every two years.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP) plan review, the EP policy and interview, the home health agency (HHA) failed to ensure the emergency preparedness (EP) plan addressed the patient population and the type of services the HHA had the ability to provide in an emergency. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the "Emergency Preparedness Program 2017” revised 10-02-2017 indicated the EP plan had not been reviewed and updated since 10/02/2017. Review of the undated "Emergency Preparedness Policy of [name of HHA]" revealed the policy did not address the patient population and the type of services the HHA could provide in an emergency. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP plan did not address which services the HHA could provide for its patients during an emergency.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP) plan review, EP policy and interview, the home health agency (HHA) failed to ensure the plan included a process for cooperating and collaborating with local, regional, State, and Federal EP officials' efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" revealed the plan did not address the process to be used to cooperate and collaborate with local, regional, State, and Federal emergency preparedness officials' efforts in order to have an integrated response during a disaster. In an interview on 08/11/2022 at 1:00 PM, the CEO confirmed the HHA's EP plan did not include a process for cooperating and collaborating with local, regional, State, and Federal emergency preparedness officials.

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 Emergency Preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure the EP plan's policies and procedures were reviewed and updated at least every two years. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" indicated there was no documentation of the date the policies and procedures were reviewed and updated. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP plan was not dated. CEO confirmed there was no documentation to present that indicated the policies and procedures were reviewed and updated at least every two years.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP), EP policy review and interview, the home health agency (HHA) failed to ensure procedures were developed to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" revealed it did not address procedures to be implemented to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP plan did not address the process for informing State and local emergency preparedness officials about HHA patients needing to be evacuated from their residences.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP) plan review, EP policy and interview, the home health agency (HHA) failed to ensure the communication plan complied with Federal, State, and local laws and was reviewed and updated at least every two years. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" indicated there was no documentation of the date the communication plan was reviewed and updated at least every two years. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP communication plan was not dated. CEO confirmed there was no documentation to present that indicated the communication plan was reviewed and updated at least every two years.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on plan review and interview, the home health agency (HHA) failed to ensure the Emergency Preparedness (EP) communication plan included contact information for Federal, State, regional, and local EP staff. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" presented by the Chief Executive Officer (CEO) indicated the communication plan did not include contact information for Federal, State, regional, and local emergency preparedness staff. In an interview on 08/11/2022 at 1:00 PM, CEO confirmed the HHA's EP communication plan did not include contact information for Federal, State, regional, and local emergency preparedness staff.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP) communication plan review, EP policy and interview, the home health agency (HHA) failed to ensure the EP communication plan included the method to be used to share information and medical documentation for patients under their care with other health providers to ensure continuity of care was maintained. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services. Finding include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" indicated the communication plan did not include a method for sharing information and medical documentation with other health providers to ensure continuity of care for its patients. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP communication plan did not include a method for sharing patient information and medical documentation with other health providers.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on Emergency Preparedness (EP) plan review, EP policy review and interview, the home health agency (HHA) failed to ensure the EP communication plan included a means of providing information about the HHA's occupancy, needs, and the agency's ability to assist the authority having jurisdiction during an emergency. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services. Findings include: Review of the undated "Emergency Preparedness Policy of [name of HHA]" indicated the communication plan did not include a means of providing information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction during an emergency. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed the HHA's EP communication plan did not include the manner to be used to provide information about the HHA's occupancy, needs, and its ability to assist the authority having jurisdiction during an emergency.

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 Emergency Preparedness (EP) plan review and interview, the home health agency (HHA) failed to provide documentation of testing of the emergency preparedness (EP) plan. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired. Findings include: Review of the EP plan revealed there was no documentation of testing of the EP plan for the past two years. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) revealed there was no documentation the agency had tested the EP plan, such as drills and/or table-top discussions.

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 08/10/2022 to 08/11/2022 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484 Subparts A through C and the following standard-level deficiencies listed below.

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 reviews, record reviews, and interviews, the home health agency (HHA) failed to ensure physician or allowed practitioner orders were received prior to patient care being performed for five (Patient (P) 1, P2, P3, P4, P7) of seven patient records reviewed from a sample of seven patients. This deficient practice had the potential to affect the 24 current patients and any future patient admitted for home health services. Findings include: Review of the undated policy titled "Referrals" indicated ". . . Referrals are accepted by phone, fax, walk in person to person or in writing from a licensed physician, podiatrist or dentist, discharge planner, a licensed professional or community representative as appropriate. Procedure: 1. The Director of Patient Care Services / Clinical designee or Authorized Employee shall complete a referral form. 2. The referral form shall have the following information but not limited to: . . . c. Physician information; Primary and Referring . . . 6. If a referral meets the home health criteria, an initial evaluation will be conducted by an RN [registered nurse], . . . w/in [within] 48 hours of receipt of a licensed physician from non-acute facility and w/in 24 hours if patient is released from an acute facility. 7. If referrals are made after the Initial Evaluation, the designated discipline . . . shall visit the patient w/in 48 hours after receipt of physician order." The policy did not include that a physician's or allowed practitioner's order was required prior to patient care being performed. Review of the undated policy titled "Physician Orders" indicated ". . . All treatment and care must be ordered, dated, and signed by the physician. . ." 1. Review of P1's undated Physical Therapy Referral Form and Occupational Therapy Referral Form, located under the Referral Intake tab, for the certification period of 07/06/2022 to 09/03/2022 indicated orders for evaluation, therapeutic exercise, transfer training, establish home exercise program, gait/balance training, and activities of daily living training. There was no documentation of a signature by a physician or other allowed practitioner. Review of P1's Home Health Certification and Plan of Care, located in the front of P1's medical record folder and not tabbed, for the certification period of 07/06/2022 to 09/03/2022 indicated P1's start of care date was 07/06/2022. There was no physician's or other allowed practitioner's signature for the start of care visit. 2. Review of P2's medical record for the certification period of 06/16/2022 to 08/14/2022 indicated the Referral Intake Form, located under the Communication Sheet tab, and dated 06/14/2022, had no physician or other allowed practitioner signature. Review of P2's Home Health Certification and Plan of Care, located in the front of P1's medical record folder and not tabbed, for the certification period of 06/16/2022 to 08/14/2022 indicated P2's start of care date was 06/16/2022. There was no physician's or other allowed practitioner's signature for the start of care visit. Review of P2's Telephone Communication, located under the Communication Sheet tab, indicated an order dated 06/23/2022 for skilled physical therapy (PT) visits two times a week for four weeks. Review of P2's Physical Therapy Visit Notes, located under the PT Notes tab, indicated PT visits were made on 07/18/2022, 07/21/2022, 07/25/2022, 07/27/2022 with no physician order for the visits. 3. Review of P3's medical record for the certification period of 07/16/2022 to 09/13/2022 indicated the Referral Intake Form, located under the Referral Intake tab, and dated 07/15/2022, did not have a physician's or other allowed practitioner's signature. Review of P3's Home Health Certification and Plan of Care, located in the front of P3's medical record folder and not tabbed, for the certification period of 07/16/2022 to 09/13/2022 indicated P3's start of care date was 07/16/2022. There was no physician's or other allowed practitioner's signature for the start of care visit. 4. Review of P4's medical record for the certification period of 07/19/2022 to 09/16/2022 indicated the Referral Intake Form, located under the Referral Intake tab, and dated 07/17/2022, did not have a physician's or other allowed practitioner's signature. Review of P4's Home Health Certification and Plan of Care, located in the front of P4's medical record folder and not tabbed, for the certification period of 07/19/2022 to 09/16/2022 indicated P4's start of care date was 07/19/2022. There was no physician's or other allowed practitioner's signature for the start of care visit. 5. Review of P7's medical record for the certification period of 04/28/2022 to 06/26/2022 indicated the Referral Intake Form, located under the Referral Intake tab, and dated 04/25/2022, did not have a physician's or other allowed practitioner's signature. Review of P7's Home Health Certification and Plan of Care, located in the front of P7's medical record folder and not tabbed, for the certification period of 04/28/2022 to 06/26/2022 indicated P7's start of care date was 04/28/2022. There was no physician's or other allowed practitioner's signature for the start of care visit. In an interview on 08/10/2022 at 11:55 AM, Chief Executive Officer (CEO) stated the Medical Director came to the agency to sign the referral order after the patient had already been admitted. The CEO stated the hospital sent the referral, and the agency admitted the patient without having a signed order by the physician. The CEO stated the Initial Evaluation Order form was written by the nurse after the admission visit was made, and the Medical Director came in once a week to sign the order. The CEO confirmed P1, P2, P3, P4, and P7 were admitted without first having received a signed physician's order. In an interview on 08/11/2022 at 1:00 PM, the CEO confirmed there was no physician order for the PT visits made for P2 on 07/18/2022, 07/21/2022, 07/25/2022, 07/27/2022.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review, "Quality, Safety & Oversight (QSO) memo 22-09”, document reviews, and interviews, the home health agency (HHA) failed to ensure the agency's COVID-19 vaccination policy contained all the required content. This deficient practice had the potential to affect the current 24 patients, all current staff, any future patient admitted to the HHA for home health services, and any future staff employed or contracted to provide home health services. Findings include: 1.Review of the undated policy titled "COVID-19 Vaccination Policy" presented by Chief Executive Officer (CEO) indicated "Policy: Vaccination requirement for health care providers working in health care settings to be fully vaccinated by January 4, 2022. . . C. Exemptions: . . . b. Staff with recognized medical conditions or religious beliefs, observances, or practices. In instance of medical exemption requests, providers must ensure that all documentation confirming recognized clinical contraindications are signed and dated by a licensed practitioner other than the individual requesting the exemption. . . Documentation of Staff Vaccinations: A. Providers must track and securely document the vaccination status of each staff member. B. Vaccination exemption and outcome must also be documented. C. All medical records and vaccination records must be kept confidential and stored separately from an employer's personnel files. . ." The agency policy, "COVID-19 Vaccination Policy" did not include the following content required by "QSO-22-09-ALL Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination": a. The process for tracking and securely documenting the COVID-19 vaccination status of all staff. b. A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law. c. A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements. d. A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (i) all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (ii) a statement by the authenticating practitioner recommending that the staff member be exempted from the HHA’s COVID-19 vaccination requirements for staff based on the recognized clinical contraindications. e. A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment. A request was made during the entrance conference, conducted on 08/10/22 at 8:40 AM, for a list of all staff's COVID-19 vaccination status with dates of vaccinations, a list of all staff who had requested a medical or religious exemption and the date of approval of the exemption, and a list of staff who had not received a COVID-19 vaccination. Lists of the above items were not provided to the surveyor for review during the survey. Documentation of COVID-19 vaccination cards with the date of vaccination was obtained by an Assistant, who provided a copy of the card found in each staff member's personnel file. In an interview on 08/11/2022 at 8:20 AM, the Assistant confirmed there was not a list or system in place for tracking the vaccination status of all staff. The Assistant had to check each staff member's personnel file for the COVID-19 vaccination card. In an interview on 08/11/2022 at 8:30 AM, the Chief Executive Officer (CEO) confirmed the agency's COVID-19 vaccination policy did not include the processes that were required in the QSO memo.

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 policy review, medical record review, and interview, the home health agency (HHA) failed to ensure services were provided as ordered by the physician in the patient's plan of care (POC) for one (Patient (P) 2) of seven sampled patients. This deficient practice had the potential to affect the 24 current home health patients and any future patient admitted for services. Findings include: Review of the undated policy titled "Missed Visit of Patient Care" indicated ". . . All patients must be seen according to Plan of Care frequency. . ." Review of P2's medical record for the certification period of 06/16/2022 to 08/14/2022 indicated a Telephone Communication, located under the Communication Sheet tab, which included an order dated 06/23/2022 for skilled physical therapy (PT) visits two times a week for four weeks. Review of P2's Physical Therapy Visit Notes, located under the PT Notes tab, indicated a second visit was not made the week of 07/03/2022 to 07/09/2022 as ordered. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed a second visit was not performed the week of 07/03/2022 to 07/09/2022 as ordered.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the home health agency (HHA) failed to ensure the physician was notified of a missed physical therapy (PT) visit in accordance with the agency policy for one (Patient (P) 1) of seven sampled patients. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services. Findings include: Review of the undated policy titled "Missed Visit of Patient Care" indicated ". . . All patients must be seen according to Plan of Care (POC) frequency. . . All missed visits must be reported to the physician and documented on missed visit note. . ." Review of P1's medical record for the certification period of 07/06/2022 to 09/03/2022 indicated a PT visit was missed on 07/08/2022 or 07/09/2022 (POC was for two PT visits a week for eight weeks). There was no documentation in P1's medical record of a missed visit note or that P1's physician was notified of the missed visit. In an interview on 08/11/2022 at 1:00 PM, the Chief Executive Officer (CEO) confirmed there was no missed visit note in P1's medical record for the PT visit missed on 07/08/2022 or 07/09/2022. The CEO confirmed there was no documentation that P1's physician was notified of the missed visit.

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 document review and interview, the home health agency (HHA) failed to ensure written documentation of the delegation of administrator duties in the absence of the administrator was accurate. This deficient practice had the potential to affect the current 24 patients and any future patient admitted for services and the current 13 employees and any future employee hired to provide HHA services. Findings include: Review of the undated "Delegation of Authority Administrator" indicated ". . . It is the policy of [name of HHA] for the Director of Nursing, [name of Administrator], to act and function as the Administrator of [name of HHA], in the absence of the Administrator, [name of Chief Executive Officer]." In an interview during the entrance conference on 08/10/2022 at 8:40 AM, the Chief Executive Officer (CEO) was the CEO, and Administrator was the Administrator of the HHA. In an interview on 08/11/2022 at 1:00 PM, the CEO confirmed the written delegation of authority was incorrect. The CEO stated the delegation should read that delegation of administrator duties should be delegated to CEO in the absence of Administrator.