Every finding on record at Brightenlife Home Health, LLC

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for 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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure individual emergency plans (IEPs) were developed for the HHAs patients during a natural or man-made disaster or emergency. Specifically, the HHA did not provide IEPs for each patient as part of the comprehensive assessment for 7 of 7 patients. (Patient identifiers: 1, 2, 3 4, 5, 6, and 7) Findings include: A review of 7 patient medical records was completed on 04/08/2021. IEPs could not be found in any of the 7 patients' medical records. On 04/06/2021 at 3:56 PM, an e-mail correspondence was sent to the administrator. The administrator was asked to provide copies of IEPs for all patients reviewed. On 04/07/2021 at 10:17 AM, the administrator responded, "Unfortunately we do not have an individualized emergency plan, we just go over the information with the patient in the new admission packet."

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the agency did not maintain an emergency preparedness (EP) training and testing program that was based on the emergency plan, risk assessment, and policies and procedures. Specifically, the agency could not provide documented evidence that 4 out of 4 employees had been trained on the agency's emergency preparedness plan. (Employee identifiers: 1, 2, 3 and 4) Findings include: A review of four employee files was completed on 04/08/2021. There was no documented evidence that any of the sampled employees had training on the agency's emergency preparedness plan upon hire and/or at least once every 2 years. Hire dates for each employe were as follows: Employee 1: October, 2020 Employee 2: March, 2016 Employee 3: October, 2014 Employee 4: September, 2015 Through email correspondence with the administrator on 04/08/2021 at 9:38 AM, the surveyor requested the emergency preparedness training for the four sampled employees. At 10:06 AM the administrator responded, "We do not have these. We were scheduled for EP training on 4/15."

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to provide care planning, coordination of services, and quality of care as required. Specifically, for 7 of 7 patients the HHA failed to develop a plan of care that met all the requirements, and was reviewed and approved by a physician or other qualified practitioner(refer to tag G572). (Patient identifiers: 1, 2, 3, 4, 5, 6 and 7), Additionally, for 1 of 7 patients the HHA failed to provide documented evidence they had performed wound care according to their policy and accepted standards of practice, and per an individualized written plan of care that contained wound care orders, interventions, and measurable outcomes and goals, and had been reviewed and approved by a physician (refer to tag number 2 in this tag). (Patient identifier: 3) Findings include: 1. The HHA failed to ensure each patient received home health services that were written in an individualized plan of care that identified interventions and patient-specific measurable outcomes and goals; and, was established, periodically reviewed, and signed by a physician. (Refer to tag G572) 2. Additionally, for 1 of 7 patients (patient 3) the HHA failed to provide provide documented evidence they were providing wound care according to their policy and accepted standards of practice, and per an individualized written plan of care that contained wound care orders, interventions, and measurable outcomes and goals, and had been reviewed and approved by a physician, as follows: Patient 3 was admitted on 01/21/2021 with a diagnosis of chronic venous insufficiency. The plan of care had a nursing frequency of two times per week. a. Review of the individual plan of care dated 01/21/2021 to 03/21/2021 contained no specific orders, interventions, or goals for wound care. b. The wound care policy was requested from the agency. A policy and procedure titled, "Wound Care Policy & Procedure Clinical Services" was received and reviewed. The following was noted in the policy: "Policy: To provide wound care treatments/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician." Under the heading, "Initial Assessment" read, "6. The clinician, in conjunction with the patient and caregiver, will develop an appropriate plan of care based on the patient's needs and the assessment findings. Each patient will be evaluated and treated using an individualized care plan based on the patient's unique medical condition. 7. The plan of care will be approved by the ordering physician." Under the heading, "Continued/Ongoing Treatment" read, "2. At each visit the patient's skin will be assessed. At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing.... 3. At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present." Under the heading, "Wound Care and Treatments-Agency considerations" read, "1. Wound care treatments are provided within an individualized plan of care under the direction of a physician." c. Every nursing note from 01/25/2021 through 03/26/2021 was reviewed. There was no documented evidence the nurse performed measurement of length, width, depth and undermining and tunneling if present, of the wound, at least weekly. d. For time period of 01/25/2021 through 03/18/2021, there was no documented evidence of a complete assessment that contained all of the following as required per agency policy: a description of the wound bed, drainage, signs and symptoms of infection, healing and/or wound condition. The following are excerpts from the nursing clinical notes: 01/25/2021: Met with patient to dress wound on right lower extremity (RLE). Patient had supplies in his home from previous care provided. He has a stasis ulcer that is on his right lower shin. We undressed the wound and placed a new dressing with nonstick gauze and a padding with coban around. After placing the dressing on I helped him with his compression stockings. 01/28/2021: Old wound dressing removed. Wound cleansed with wound cleanser. Pat dried. Dressing applied to wound with ointment and mesh. Legs wrapped with compression wraps. No complaints of pain. No falls since last visit. No further concerns at this time. Will continue to monitor. 02/01/2021: Patient was up and ready upon arrival. We took vitals and changed the bandage on his right leg. The wound is healing well. We replaced the old bandages. We applied neosporin, cutimed sobact dressing, with gauze padding and coban 2 bandage. 02/04/2021: Wound care visit. Patient was just getting out of bed upon arrival. I undressed the wound, took the compression bandage as well as the gauze and wound mesh off. We cleaned the wound and placed neosporin on the wound. Placed new wound mesh, then gauze padding with the compression coban 2. After the bandage was placed we applied his compression stockings. Patient tolerated well. 02/08//2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 02/11/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 02/15/2021: Wound continues to look better. Old dressing removed. Site cleansed with wound cleanser. New dressing applied. Leg wrapped per physician orders. No further concerns at this time. Will continue to monitor. 02/18/2021: Old dressing removed. Wound cleansed with wound cleanser and pat dried. Gauze applied and wraps applied to legs. Wound is red and beefy. It continues to heal slowly. No further concerns at this time. Will continue to monitor. 02/22/2021: Old dressing removed. Wound cleansed with wound cleanser. Pat dried wound. Gauze applied to wound. No drainage. No infection noted. Wound is red and healing well. Wraps applied to legs. No further concerns at this time. Will continue to monitor. 02/25/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 03/01/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 03/04/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 03/08/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 03/11/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. 03/15/2021: RLE stasis ulcer. Dressed with nonstick gauze and coban. The OASIS recertification 03/18/2021: "...Current Number of Stasis Ulcer(s) that are Observable: One. Status of Most Problematic (Observable) Stasis Ulcer: Not healing." There was no other defining documentation about the wound on the recertification assessment. e. In an email correspondence with the administrator on 04/07/2021 at 12:36 PM the administrator was asked if the surveyors had been provided with the medical records in their entirety. The administrator responded that it was her understanding that we had complete access to the medical record. On 04/07/2021 at 1:51 PM the office manager confirmed the surveyors had been given access to the entire medical record that was in their current EMR. f. The agency failed to provide evidence wound care was performed according to the policy and accepted standards of practice, and per an individualized written plan of care that contained wound care orders, interventions, and measurable outcomes and goals, and had been reviewed and approved by a physician.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure each patient received home health services that were written in an individualized plan of care (POC) that identified interventions and patient-specific measurable outcomes and goals; and, was established, periodically reviewed, and signed by a physician, for 7 of 7 sampled patients. (Patient identifiers: 1, 2, 3, 4, 5, 6 and 7) Findings include: A review of six active patients (1, 2, 3, 4, 5 and 6) and one discharge patient (7) was completed on 04/08/2021. 1. A review of the individualized care plans for each of the patients revealed that the plans of care did not include patient specific interventions and measurable outcomes and goals. 2. The agency was unable to provide documented evidence they were providing care under the direction of a physician. During review of the the medical records for the seven sampled patients none of the plans of cares had been signed by a physician or other qualified practitioner. After repeated requests the agency was unable to provide documented evidence of plans of care that had been reviewed by a physician at least every 60 days, or signed within 31 days by a person lawfully authorized to give the orders (per Utah state licensing rule R432-700-25. Medication and Treatment), as follows: a. Patient 1 was admitted on 03/03/2021 with diagnoses of congestive heart failure and chronic kidney disease. The POC dated 03/03/2021 to 05/01/2021 was reviewed. The nurse digitally signed the POC on 03/03/2021; the POC did not contain a physician's signature, a period of 36 days after completion. Additionally, there was no evidence of an attached physician signed POC in the medical record. b. Patient 2 was admitted on 02/23/2021 with a diagnosis of Type 2 diabetes mellitus with diabetic neuropathy. The POC dated 02/23/2021 to 04/23/2021, was reviewed. The nurse digitally signed the POC on 02/23/2021; the POC did not contain a physician's signature, a period of 44 days after completion. Additionally, there was no evidence of an attached physician signed POC in the medical record. c. Patient 3 was admitted on 01/21/2021 with a diagnosis of chronic venous insufficiency. The POC dated 01/21/2021 to 03/21/2021, was reviewed. The nurse digitally signed the POC on 01/21/2021; the POC did not contain a physician's signature, a period of 78 days after completion. Additionally, there was no evidence of an attached physician signed POC in the medical record. d. Patient 4 was admitted on 12/30/2016 with a diagnosis of chronic obstructive pulmonary disease. The POC dated 02/07/2021 to 04/07/2021, was reviewed. The nurse digitally signed the POC on 02/07/2021; the POC did not contain a physician's signature, a period of 61 days after completion. In addition, the POCs for the following certification periods were reviewed: 10/16/2019 to 12/14/2019; 04/13/2020 to 06/11/2020; 06/12/2020 to 08/10/2020; 08/11/2020 to 10/09/2020; 10/10/2020 to 12/08/2020; and 12/09/2020 to 02/06/2021. There was no evidence in the medical record of a physician signed POC, either digitally signed or attached hard copy, for any of the POCs reviewed. e. Patient 5 was admitted on 12/19/2016 with a diagnosis of left-sided hemiplegia following cerebral infarction. The POC dated 01/27/2021 to 03/27/2021, was reviewed. The nurse digitally signed the POC on 01/25/2021; the POC did not contain a physician's signature, a period of 74 days after completion. In addition, the POCs for the following certification periods were reviewed: 12/04/2019 to 02/01/2020; 02/02/2020 to 04/01/2020; 04/02/2020 to 05/31/2020; 06/01/2020 to 07/30/2020; 07/31/2020 to 09/28/2020; 09/29/2020 to 11/27/2020; and 11/28/2020 to 01/26/2021. There was no evidence in the medical record of a physician signed POC, either digitally signed or attached hard copy, for any of the POCs reviewed. f. Patient 6 was admitted on 07/30/2019 with a diagnosis of hypertensive heart disease with heart failure. The POC dated 01/20/2021 to 03/20/2021, was reviewed. The nurse digitally signed the POC on 01/20/2021; the POC did not contain a physician's signature, a period of 79 days after completion. In addition, the POCs for the following certification periods were reviewed: 11/27/2019 to 01/25/2020; 01/26/2020 to 03/25/2020; 03/26/2020 to 05/24/2020; 05/25/2020 to 07/23/2020; 09/222/2020 to 11/20/2020; and 11/21/2020 to 01/19/2021. There was no evidence in the medical record of a physician signed POC, either digitally signed or attached hard copy, for any of the POCs reviewed. g. Patient 7 was admitted on 11/03/2020 with a diagnosis of Parkinson's disease. Patient 7 was discharged on 01/20/2021. The POC dated 11/03/2020 to 01/01/2021, was reviewed. The POC did not contain a physician's signature, a period of 157 days from admission, and 79 days after discharge. Additionally, there was no evidence of attached physician signed POCs in the in the medical record. h. In an email correspondence with the administrator on 04/07/2021 at 12:36 PM the administrator was asked if the surveyors had been provided with the medical records in their entirety. The administrator responded that it was her understanding that we had complete access to the current electronic medical record (EMR). On 04/07/2021 at 1:51 PM, the office manager confirmed the surveyors had been given access to the entire medical record that was in their current EMR. On 04/07/2021 at 11:26 AM and on 04/08/2021 at 9:38 AM the surveyor requested signed POCs for the last two certification periods, from the administrator. On 04/08/2021 at 10:42 AM the surveyor asked the administrator what the hold up was on the signed POCs. At 10:45 AM the administrator responded, "We are waiting for (name of a different certified agency) to grant access to (name of employee's) old desktop so we can send them. We found that we have an issue with our EMR. (Name of employee) pulled a report last night that showed when they were marked signed and returned but we are missing the majority of uploads into Kinnser (current EMR) this is one of the many reasons we are moving to PCC (different EMR). We are working on getting them to you as soon as we are granted access." During exit on 04/08/2021 at 11:05 AM, the facility was given until the end of business to provide the signed POCs. By the end of the day the surveyors received POCs that had been faxed from another Medicare certified entity for 3 of the 7 sampled patients, as follows: h(i). For patient 4, the surveyors received a physician signed POC for the certification period of 04/13/2020 to 06/11/2020. No current POC was received. h(ii). For patient 5, the surveyors received a POC for the certification period of 01/27/2021 to 03/27/2021, which had been signed by the physician during the survey on 04/07/2021. h(iii). For patient 6, the surveyors received physician signed POCs for certification periods 11/27/2019 to 01/25/2020 and 01/26/2020 to 03/25/2020. No current POC was received. No other signed POCs were received.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the agency did not ensure infection control education was provided to agency employees. Specifically, the agency could not provide documented evidence that 3 of 4 employees had infection control training. (Employee identifiers: 2, 3 and 4) Findings include: A review of 4 employee files was completed on 04/08/2021. There was no documented evidence of infection control training for 3 out 4 employees upon hire and at least once per year. Hire dates for each employe were as follows: Employee 2: March, 2016 Employee 3: October, 2014 Employee 4: September, 2015 Through email correspondence with the administrator on 04/08/2021 at 9:38 AM, the surveyor requested the infection control training for the 4 sampled employees. At 10:06 AM the administrator responded, "We do not have these...".

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to provide necessary oversight and supervision of the HHA. Findings include: 1. The HHA failed to ensure each patient received home health services that were written in an individualized plan of care that identified patient-specific measurable outcomes, interventions and goals, and was established, periodically reviewed, and signed by a physician. (Refer to tag G-0572) 2. The HHA failed to ensure infection control education was provided to agency employees. (Refer to tag G-0686) 3. The HHA failed to ensure the governing body assumed full legal authority and responsibility for the agency's overall management and operation. Specifically, the agency was commingling with another entity and could not show separateness between the 2 agencies. (Refer to tag G-0942) 3. The HHA failed to ensure individual emergency plans were developed for the HHA's patients during a natural or man-made disaster or emergency. (Refer to tag E-0017) 4. The HHA failed to maintain an emergency preparedness training and testing program that was based on the emergency plan, risk assessment, and policies and procedures. Specifically, the agency could not provide documented evidence that employees had been trained on the agency's emergency preparedness plan. (Refer to tag E-0036)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure the governing body assumed full legal authority and responsibility for the agency's overall management and operation. Specifically, the agency was commingling with another entity and could not show separateness between the two agencies; did not provide care planning, coordination of services, and quality of care as required; could not provide evidence employees had training on infection control and emergency preparedness; and could not provide evidence of individual emergency preparedness (IEPs) plans for each patient. (Patient identifiers: 1, 2, 3, 4, 5, 6 and 7) and (Employee identifiers: 1, 2, 3 and 4) Findings include: 1. On 04/06/2021, the surveyor attempted a recertification survey at Brighton Home health at the address on file. There was an unaffiliated Medicare-certified hospice (this hospice agency will be referred to as Unnamed Hospice throughout the remainder of tag G942) at the same address with no identifying signage for the agency to be surveyed. In the state system, it was found that Brighton Home health and Unnamed Hospice were both listed at the same location with no difference in address, including suite number. Surveyors entered Unnamed Hospice and were told Unnamed Hospice would contact the administrator of Brighton Home health. Entrance was conducted shortly thereafter. After the entrance, surveyors were provided with the following commingled documents: An activation of an emergency preparedness plan for earthquake dated 03/18/2020, it had several agency names at the top, none of the names listed were of the agency being surveyed. Two separate documents both titled, "Emergency Management Plan Evaluation Form" both were dated 09/07/2020. One was for high winds power outage and the other was for fires. Both documents were for Unnamed Hospice, and not the agency being surveyed. 2. In an email correspondence with the administrator on 04/07/2021 at 2:22 PM the administrator stated that the Unnamed Hospice was doing business as (DBA) Brighton Home Health. All of the agency documents would have either the name of Unnamed Hospice or Brighton Home Health on them. She then attached two licenses to show they all have the same license number. Additionally, she also stated that a healthcare group was currently managing the agency until October when a change of ownership could be completed; she provided the management agreement. The management agreement was dated 07/29/2020. The agreement was between Brighton Home Health and a healthcare group, with no mention of any other agency. The first license provided was for Brighton Home Health with an issue date of 02/01/2019 and the expiration date as 01/31/2021. The second license provided was for Bristol Home Health with an issue date of 05/07/2019 and the expiration date as 01/31/2021. The license had the ownership as an affiliated hospice agency that was not affiliated with Brighton Home Health. Additionally, at the time of survey there was no Bristol Home Health, licensed or certified, on file with the state of Utah. In the federal Automated Survey Process Environment (APSEN), which is a suite of software applications designed to help State Agencies collect and manage healthcare provider data, the current license on file for the agency being surveyed was originally issued on 01/10/2012, and was renewed on 02/01/2021 and had an expiration date of 01/31/2023. The name and legal names were listed as Brighton Home Health and Brighton Home Health, LLC, respectively. Ownership was listed as Brighton Home Health with a start date of 01/10/2012 and no end date was listed. No DBA was listed. NOTE: Brighton Home Health did not operate a Medicare-certified hospice. 3. During chart review none of the seven sampled patient records contained admission consents. On 04/07/2021, the surveyors requested the legal consents for admission. On 04/08/2021, the admission Consents for patients 1, 2, 6 and 7 were received and reviewed. They were signed and dated as follows: Patient 1, 03/03/2021 Patient 2, 02/23/2021 Patient 6, 07/30/2019 Patient 7, 11/03/2020 The admission consents were for Unnamed Hospice, and not the HHA being surveyed. The surveyors were informed that the patient admission consents for patients 4 and 5 needed to be retrieved from a separate electronic medical record (EMR) system that was no longer being used. The administrator stated that she would need to request them from Unnamed Hospice. Later that day on 04/08/2021, the surveyors received the consents with no concerns noted. No consent was provided for patient 3, who was admitted to the agency on 01/21/2021. 4. Surveyors were informed that the personnel files for employees 3 and 4 needed to be retrieved from the Unnamed Hospice. Once received the files were commingled with documents from the agency being surveyed and Unnamed Hospice. 5. After interview and review of documents, it was determined that separateness was not occurring between the two agencies. Commingling of Medicare-certified entities is not permitted - each entity must show "separateness." In addition to commingling of the two agencies, problems were identified with the following: a. The HHA could not provide documented evidence they were providing wound care according to their policy and accepted standards of practice, and per an individualized written plan of care that contained wound care orders, interventions, and measurable outcomes and goals, and had been reviewed and approved by a physician, for 1 of 7 patients, refer to tag G570. (Patient identifier: 3) b. The HHA did not ensure each patient received home health services that were written in an individualized plan of care that identified interventions and patient-specific measurable outcomes and goals, and was established, periodically reviewed, and signed by a physician for 7 of 7 patients, refer to tag G572. (Patient identifiers: 1, 2, 3, 4, 5, 6 and 7). c. The HHA could not provide documented evidence that 3 out of 4 employees had any infection control training, refer to tag G686. (Employee identifiers: 2, 3, and 4) d. The HHA could not provide IEP plans for each patient as part of the comprehensive assessment for 7 of 7 patients, refer to tag E-0017. (Patient identifiers: 1, 2, 3, 4, 5, 6 and 7) e. The HHA could not provide documented evidence that 4 out of 4 employees had been trained on the agency's emergency preparedness plan, refer to tag E-0036. (Employee identifiers: 1, 2, 3, and 4)