Every finding on record at Allied Professional Nursing Care Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted January 31, 2022 through February 3, 2022. Representing the Department: Surveyors: 35183 and 44841 Census: 63 Unduplicated Admissions: 6 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All conditions of participation were met.

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 interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the agency’s “Emergency Preparedness Binder,” dated 2021 to 2022 was conducted. There was no documented evidence to show the agency had collaborated with the emergency management offices in the counties and cities were the agency’s patients lived. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and Planning and Intelligence (P&I) on February 3, 2022, at 10:26 AM, P&I stated she was responsible for the Emergency Preparedness Program (EPP). P&I stated she made a good faith effort to find the emergency management office for San Bernardino County but was unsuccessful. P&I stated she had not collaborated with their local emergency management office. A review of the agency’s policy and procedure titled “Emergency Preparedness Plan,” dated January 1, 2018, indicated, “Procedure: Before an emergency …2. The management team will work with regional or local emergency management officials when available in establishing priorities related to potential emergencies…”

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 interview and record review, the agency failed to develop procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the agency’s policy and procedure titled “Emergency Preparedness Plan,” dated January 1, 2018, indicated, “Procedure: Before an emergency …10. The management team will develop a method of communicating pertinent patient information if the patient requires evacuation or move to a higher level of care…” A review of the agency’s “Emergency Preparedness Binder,” from January 1, 2021, to February 3, 2022, was conducted. There was no documented evidence to show a method to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 13-month time period reviewed. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and Planning and Intelligence (P&I) on February 3, 2022, at 11:02 AM, P&I stated she was responsible for the Emergency Preparedness Program (EPP). P&I stated a method had not been developed to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the agency’s policy and procedure titled “Emergency Preparedness Plan,” dated January 1, 2018, indicated, “Communication Plan: …9. The contact information for patients that the Logistics Officer or designee has not been able to contact will be sent to the local EOC [Emergency Operations Center].” There was no documented evidence to show a procedure to inform state and local officials of on-duty staff the agency was unable to contact. A review of the agency’s “Emergency Preparedness Binder,” from January 1, 2021, to February 3, 2022, was conducted. There was no documented evidence to show a process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the 13-month time period reviewed. There was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agency’s patients lived. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and Planning and Intelligence (P&I) on February 3, 2022, at 11:12 AM, P&I stated she was responsible for the Emergency Preparedness Program (EPP). P&I stated she made a good faith effort to find the emergency management office for San Bernardino County but was unsuccessful. P&I stated she did not have a phone number for the emergency management office to report on-duty staff and patients the agency was unable to contact. P&I verified the Emergency Preparedness Plan did not indicate to inform state and local officials of on-duty staff the agency was unable to contact.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the agency’s policy and procedure titled “Emergency Preparedness Plan,” dated January 1, 2018, was conducted. There was no documented evidence to show the agency had developed a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications failure during a disaster or emergency. A review of the agency’s “Emergency Preparedness Binder,” dated 2021 to 2022 was conducted. There was no documented evidence to show the agency had a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and Planning and Intelligence (P&I) on February 3, 2022, at 11:22 AM, P&I stated she was responsible for the Emergency Preparedness Program (EPP). P&I stated she made a good faith effort to find the emergency management office for San Bernardino County but was unsuccessful. P&I verified she had not developed a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications failure during a disaster or emergency.

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 interview and record review, the agency failed to develop a policy and procedure to provide information about the agency’s occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to place the agency’s patients at risk when the agency was not prepared to respond in an emergency or disaster. A review of the agency’s policy and procedure titled “Emergency Preparedness Plan,” dated January 1, 2018, indicated, “Administration: …4. The Incident Command Team will complete the Emergency Needs Assessment form and deliver it to the local EOC [Emergency Operations Center] upon request. This form will include the immediate needs of the agency in order to maintain safe operations.” There was no documented evidence to show the agency would also report their occupancy or staff available to help. A review of the agency’s “Emergency Preparedness Binder,” dated 2021 to 2022 was conducted. There was no documented evidence to show a blank “Emergency Needs Assessment” form available for use. There was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agency’s patients lived. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and Planning and Intelligence (P&I) on February 3, 2022, at 10:51 AM, P&I stated she was responsible for the Emergency Preparedness Program (EPP). P&I stated she made a good faith effort to find the emergency management office for San Bernardino County but was unsuccessful. P&I stated she did not have a phone number for the emergency management office. P&I verified that the “Emergency Preparedness Plan” did not indicate reporting their occupancy or staff available to help.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted January 31, 2022 through February 3, 2022. Representing the Department: Surveyors: 35183 and 44841 Census: 63 Unduplicated Admissions: 6 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All conditions of participation were met.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to conduct a recertification assessment (ReCert-an assessment to determine if home health services continue to be required by a patient for another 60-day period) within the last five days of the 60-recertification period for one of seven sampled patients (Patient 4). This failure had the potential to cause inaccuracy in identifying Patient 4’s care and support needs. A review of Patient 4’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 16, 2021, with a certification period of January 12, 2022, to March 12, 2022. Patient 4 had diagnoses that included exomphalos (a condition when a baby abdominal (tummy) wall does not fully develop during pregnancy) There was no documented evidence to show a recertification assessment had been conducted. A review of the agency’s “Current Admission List Report, Current Active Patients as of January 31, 2021,” was conducted. The “Current Admission List Report,” indicated Patient 4 as a current and active patient. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on February 2, 2022, at 3:00 PM, the Admin/DPCS stated Patient 4 was a current and active patient at the agency. Admin/DPCS verified that Patient 4 had not received a recertification assessment. Admin/DPCS stated, “I should have called the physician for a verbal order for the RN [Registered Nurse] to go out after the cancelation of 1/10/21 [January 10, 2021] visit to assess the patient to be recertified and I did not.” During record review on February 2, 2022, at 3:20 PM of form title “Therapy team conference/coordination of care” dated 01/10/21 [January 10, 2021] indicated “Pcg [patient care giver]/mom requested to canceled today RNCM [Registered Nurse Case Manager] assessment due to MD appointments” During an interview with the Admin/DPCS on February 2, 2022, at 3:20 PM, the Admin/DPCS stated Patient 4's recertification assessment should have been conducted the last five days of every 60 days beginning with the start-of-care date [January 12, 2021], and it was not. A review of the agency’s policy and procedure titled, “Comprehensive Assessment of Patient,” dated 1/29/1999 [January 29,1999], indicated, “(d) Updated of the comprehensive assessment. The comprehensive assessment must be updated and revised…, but no less frequently than 62 days. (I) The last 5 days of every 60 days beginning of the start-of-care date, …”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for 13 of 13 months reviewed, in a universe of 63 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unaddressed and continue. A review of the agency’s Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021, to February 3, 2022, was conducted. There was no documented evidence to show a Performance Improvement Project (PIP) had been identified, developed or conducted. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and a QAPI Coordinator (QAPI Coord) on February 3, 2022, at 9:47 AM, the Admin/DPCS stated she was responsible for the QAPI Program, however, the QAPI Coord assisted her and was responsible for the day-to-day processes. The QAPI Coord stated she could not provide documented evidence to show a Performance Improvement Project (PIP) had been undertaken, the reasons for conducting the PIP or measurable goals to show progress achieved. The Admin/DPCS stated she was unaware that a PIP had not been conducted and documented. A review of the agency’s policy and procedure titled “Quality Assessment and Performance Improvement,” dated January 1, 2018, indicated, “Performance Improvement Projects. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity and past performance of the agency’s services and operations. The agency must document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects…”

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 interview and record review, the agency failed to develop a policy for staff to qualify for a temporary delay of a COVID‐19 vaccination and failed to develop a contingency plan for staff that refused a COVID‐19 vaccination and did not qualify for an exemption, for three of three months reviewed, in a universe of 63 patients. This failure had the potential to cause staff to receive a COVID-19 vaccination before it was safe and the agency to experience a staff shortage. A review of the agency’s COVID-19 Vaccination Binder from November 5, 2021, to February 2, 2022, and COVID-19 Vaccination Policies and Procedures dated November 5, 2021, was conducted. There was no documented evidence to show a policy and procedure that addressed the following: 1. A temporary delay in the administration of a COVID‐19 vaccination due to clinical precautions and considerations such as: individuals with acute illness secondary to COVID‐19 illness, or individuals who received monoclonal antibodies, or convalescent plasma for COVID‐19 treatment. Or a process to securely document and track the status of staff for whom vaccination is temporarily delayed. 2. Contingency plans for staff who are not fully vaccinated that included actions the facility would take when staff decline vaccination and do not qualify for an exemption, such as: obtaining temporary vaccinated staff until permanent vaccinated staff could be hired and actively seeking vaccinated staff through advertising. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Chief Executive Officer (CEO) and a Human Resources Manager (HRM) on February 2, 2022, at 2:35 PM, the Admin/DPCS stated she was responsible for the COVID-19 Vaccination Program. The Admin/DPCS stated a policy and procedure had not been developed to address a temporary delay in the administration of a COVID‐19 vaccination due to clinical precautions and considerations such as: individuals with acute illness secondary to COVID‐19 illness, or individuals who received monoclonal antibodies, or convalescent plasma for COVID‐19 treatment. The Admin/DPCS stated a policy and procedure had not been developed to address a process to securely document and track the status of staff for whom vaccination is temporarily delayed. The Admin/DPCS stated a policy and procedure had not been developed to address a contingency plan for staff who are not fully vaccinated that included actions the facility would take when staff declined vaccination and did not qualify for an exemption, such as: obtaining temporary vaccinated staff until permanent vaccinated staff could be hired and actively seeking vaccinated staff through advertising.

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 interview and record review, the agency failed to ensure a Registered Nurse (RN 1and RN 2) followed accepted professional standards of practice of patient (Patient 2) to be elevated 30-45 degrees when one of seven sampled patients (Patient 2) was not positioned at a 30 to 45-degree angle while receiving a G-tube feeding (A gastrostomy tube = a tube inserted through the belly that brings special liquid food mixture containing nutrition, given through a tube directly to the stomach). This failure had the potential to cause complications of aspiration (when something enters airway or lungs by accident, it may be food, liquid, or some other material lead to breathing problems) to Patient 2. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of May 03, 2011, with a certification period of January 05, 2022, to March 05, 2022. Patient 2 had diagnoses that included Dysphagia (difficulty or discomfort in swallowing) and Gastrostomy (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) status. During an interview on February 1, 2022, at 1:35 PM with RN 1 when ask as how to maintain 30-40 degrees position when receiving G tube feeding, RN 1 stated “I am not sure but that is how he [Patient 2] sleeps at night, in the morning when I came to my shift he is usually up and walking around the house already.” During concurrent interview and observation on February 1, 2022, at 1:45 PM with RN1 when asked about Patient 2 position when receiving G-tube feeding time, RN1 stated “head of the patient elevated using these two (2) pillows.”. Observed car shaped toddler bed with two (2) pillows at the leg side of the bed. During an interview on February 1, 2022, at 2:04 PM with Patient 2’s Grandmother, she stated, “Patient 2 receiving G tube feedings at night.” Furthermore, the grandmother stated “Patient 2 slept flat on his back and sometimes turn onto his side when he slept with her. This was while he receiving G-tube feeding.” During an interview on February 2, 2022, at 10:55 on the phone with RN 2 confirmed Patient 2 using two (2) pillows to elevated upper body portion when receiving G-tube feeding at night. RN 2 stated “I always beside him during the night, he did move around but when I with him I make sure he’s up using the two (2) pillows while receiving G-tube feeding.” During an interview on February 2, 2022, at 11:00 AM on the phone with RN 2 when ask is that safe for Patient 2 when receiving G-tube feeding elevated only with two (2) pillows and Patient 2 moving around to flat position during the night. Putting Patient 2 in higher risk for aspiration. RN 2 confirmed putting the patient in higher risk of aspiration. RN 2 stated, “it should be a different method, to maintain 30 – 40 degrees when receiving G-tube feeding. I talked to the mom last night about using wedge, I will talk to the mom again tonight.” During an interview on February 2, 2022, at 11:30 AM with Administrator/ Director of Patient Care Services (ADMIN/DPCS) confirmed to maintain elevated 30 – 40 degrees while receiving tube feeding. A review of the agency’s policy and procedure titled “Gastrostomy tube, administration” undated year 1988 indicated “Procedure: … elevated patient 30 – 40 degrees or as order.”