Every finding on record at Coastal Nursecare of Florida Inc

During the re-licensure and recertification survey conducted 07/14/2025 through 07/16/2025 at Addus Homecare, a Home Health Agency, Emergency Preparedness was reviewed. Addus Homecare was not in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and staff interview the agency failed to provide or document emergency preparedness training of agency staff at least every 2 years. The Findings Are: Review of the agency's emergency preparedness policies and procedures revealed it is agency policy to provide initial emergency preparedness training upon hire, and to provide training on emergency preparedness for all staff at least every 2 years. During an interview with the State Director on 07/16/2025 at 2:25 PM, she confirmed she could not provide any documentation or other evidence that staff are receiving any kind of emergency preparedness training after their initial training which is provided during the orientation process upon hire of new staff.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(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, REHs at §485.542, 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 record review and staff interview the agency failed to conduct exercises to test their emergency plan or to document activation of their emergency plan in response to an actual emergency at least annually. The Findings Are: Review of the agency's emergency response manual revealed no documentation of any exercises to test the effectiveness of the emergency plan, nor any implementation of the plan in response to an actual emergency since the year 2022. During an interview with the State Director on 07/16/2025 at 3:15 PM she confirmed she can find no record of implementation of the disaster/emergency plan in response to an actual emergency, or participation in any table top/full scale community based exercises to test the effectiveness of the plan. She stated "I'm sure they had to have implemented the emergency plan in response to the unprecedented snowfall in January, but I can't find any documentation to that effect".

A recertification survey was conducted on July 14 through July 16, 2025 at Addus Homecare. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Requirements for Home Health Agencies.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record reviews and interview, the home health agency failed to provide services that were ordered by the physician and on the plan of care for 1 of 3 sampled skilled patients. (Patient #4) The findings include: A review of the medical record for sampled patient #4 revealed a plan of care for a certification period of 5/18/2025 through 7/16/2025. The orders were for Skilled nurse visits 3 times a week for a 60-day period to administer Wilate 980 units via port-a-cath. Beginning 5/18/2025 through 6/27/2025 the "Bleeding Disorder Visit Record" revealed the patient received the intravenous medication via peripheral Intravenous therapy and not through the implanted port-a-cath. An interview was conducted with the agency administrator on 7/15/2025 at approximately 10:35 AM. She related the patient had refused to let the nurse assess the port and there was no order for the change to a peripheral IV. An interview was conducted with the Director of Nursing on 7/15/2025 at approximately 10:45 AM. She related she had been employed about a month and had notified the nurse at the doctor’s office of the patient not letting them access the port and the nurse was doing peripheral IVs but confirmed there was no documentation of the conversation and no order for the change in the plan of care.

During the recertification survey conducted July 25, 2022 to July 28, 2022, at Carestaff, Emergency Preparedness was reviewed. The agency was in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies

An unannounced recertification survey was conducted July 25, 2022 to July 28, 2022 at Carestaff. The agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the duration of visits was documented in the patient's record 1 of 7 sampled patients (#1). The findings include: A review of sampled patient #1's Home Health Certification and Plan of Care for certification period 6/22/22 to 8/20/22 was completed. The Home Health Certification and Plan of Care included the frequency of visits to be made but failed to reveal the duration of visits to be made. On 7/28/2022 at approximately 9:30 AM, an interview was conducted with the Director of Nurses (DON). The DON confirmed there was not a duration for services listed on the Home Health Certification and Plan of Care for sampled patient #1.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observation, record review and staff interviews, the agency failed to ensure conformance with written physician orders related to the Plan of Care for 1 of 7 sampled patients, #3. The findings include: During the home visit on 7/26/2022 between approximately 9:35 AM and 10:05 AM, the surveyor observed the Staff member C, a Registered Nurse (RN) conducing a visit with patient #3. During the visit the nurse failed to obtain the patient's vital signs. On 7/26/2022 at approximately 10:00 AM, a interview was conducted with staff C, RN. The RN confirmed that she did not do the vital signs today and stated that she did not do them every visit. A record review was conducted for patient #3, which revealed a physician ordered plan of care for recertification periods 04/21/2022-06/19/2022 and 6/20/2022 – 8/18/2022 for the skilled nurse to monitor vital signs every visit. Review of skilled nurses notes from 5/29/2022 through 7/26/2022 revealed there were no vital signs recorded on the following skilled nurse visits: 6/1/2022, 6/3/2022, 6/8/2022, 6/10/2022, 6/14/2022, 6/20/2022, 6/21/2022, 6/29/2022, 7/1/2022, 7/6//2022, 7/8/2022, 7/13/2022, 7/15/2022, 7/20/2022, 7/21/2022, 7/22/2022 and 7/23/2022. On 7/28/2022 at approximately 9:30 AM, an interview was conducted with the Director of Nurses (DON). The DON confirmed there were no vital signs recorded on the following skilled nurse visits: 6/1/2022, 6/3/2022, 6/8/2022, 6/10/2022, 6/14/2022, 6/20/2022, 6/21/2022, 6/29/2022, 7/1/2022, 7/6//2022, 7/8/2022, 7/13/2022, 7/15/2022, 7/20/2022, 7/21/2022, 7/22/2022 and 7/23/2022.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review and staff interviews, the home health agency failed to ensure the home health aide (HHA) provided services within their scope of practice by failing to ensure the HHA did not administer medications for 1 of 3 home visits conducted (#2). The findings include: On 7/27/2022 at approximately 8:45 AM, a home visit was conducted for Patient #2, in the presence of Staff members A, HHA and Staff C, a Registered Nurse (RN). During the visit an observation was made of a pill reminder/medication planner box (medication planner), that was on the kitchen counter. At this time an interview was conducted with Staff A, HHA, who stated that Patient #2 receives medications for tremors and spastic motions of all limbs, which makes it difficult for her to open the lids of the medication planner. Staff A, HHA, explained that the patient's sister sets up medication planner with all of the patient's pills arranged by day of week and time of day they are to be taken. Staff A said she takes the medication planner, removes the medications from the planner slot for the correct time of day (morning medications, or evening medications), pours them into a small cup and places the cup and a drink in front of the patient so she can take the medications. She acknowledged that, due to the patients tremors/spasms, she often has to raise the medication cup to the patient's mouth in order not to spill the medications. Both Staff A and Patient #2 acknowledged the patient is not steady enough to be able to open the medication planner or to remove pills from the box. Staff A stated that she does not fill the medication planner nor does she take medications out of any labeled prescription containers, stating "her sister does all of that". Staff A was asked how she knows she is providing the correct medication at the correct dosage and correct time. She again stated the medication planner is set up by the patient's sister. She stated she assumes the medication planner is set up correctly. On 7/27/2022 at approximately 11:40 AM, an interview was conducted with the Director of Nursing (DON), during which she stated the patient was unable to open medication containers, either a medication planner/reminder box or a prescription bottle and that the HHA must do that for her. She was asked whether the HHA's have had the 2 hour training required by state law to be able to assist with self-administration of medications. She stated she thinks they get this during the new hire orientation. On 7/28/2022 at approximately 11:24 AM, an interview was conducted with the agency Administrator, which revealed that the HHAs receive the required 2 hour training "the same as I had when I worked in an ALF (Assisted Living Facility)". She stated she was not aware of the procedure being used to assist Patient #2 with her medications, and stated she just assumed they were using the correct procedure since they have all had the required training. When this surveyor advised the Administrator of observations and staff interview obtained during the home visit, she acknowledged the procedure being used with Patient #2 did not fall within the parameters for assistance with self-administration of medications. She acknowledged that with the procedure being used, the HHA is not able to verify the medications in the medication planner. She also confirmed the HHAs do not maintain any type of record of what medications they are assisting with, or that the patients are receiving such assistance, as required by state regulations.