Every finding on record at Fountain Home Health Inc

The following reflects the findings of the California Department of Public Health during Recertification Survey. Representing the Department of Public Health: Surveyor ID #43979, RN, Health Facilities Evaluator Nurse Surveyor ID #43929, RN, Health Facilities Evaluator Nurse Unduplicated Census: 175 Active Patients: 49 Sample Size: 7 Home Visits: 3 One Condition of Participation not met: 484.60 Condition of Participation: Care planning, coordination of services, and quality of care Old Address: 4430 Fountain Avenue Suite 4, Los Angeles, California 90027. New Address: 8349 Foothill Blvd. Sunland, California 91040

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure one of seven patients (Patient 4) was informed of the availability of the home health hotline telephone number for 1 of 7 sampled patients (Patient 4). This deficient practice has the potential for the patient's complaints or concerns will not be reported, investigated, and resolved timely. Findings: A review of Patient 4’s Patient Information sheet indicated the patient was admitted to the HHA on 11/21/21, with diagnoses including hypertensive heart disease without hear failure (high blood pressure). During an observation of the home visit on 8/13/22, at 11:00 a.m., with the Director of Patient Care Services (DPCS), Patient 4 was observed receiving care. Patient 4’s primary caregiver (PCG) was present during the visit. During an interview on 8/13/22, at 11:53 a.m., the PCG stated she did not know how to contact the state or public health department if there were any issues or concerns with the agency. The PCG did not refer to the patient handbook for reference. A review of the HHA’s policy and procedure titled, “Patient Complaint Policy” dated 1/1/2020 indicated “During the initial evaluation visit, the Case Manager will inform the patient and/or family of the Agency’s system for receiving, reviewing, and resolving complaints ie. Agency complaint process and DHS hotline”.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review all the medications the patient is currently using for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice placed patients at risk for medication error and adverse drug reaction. Findings: 1. A review of “Recertification” for Patient 1 was admitted on 7/14/2021. Patient 1 was oriented to person, place, time and is forgetful. The admitting diagnosis was Diabetes Mellitus (DM)Type II (sugar in blood) and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD – Difficulty breathing). It indicates to notify physician of: Oxygen (02) Saturation (Sat) less than 90%. It lists dyspnea as a functional limitation and stated P1 is a heavy smoker. Skilled Nurse (SN) to visit once a week for 9 weeks. Under Physical Therapy (PT) it states, “Evaluation and follow up”. The plan for next visit is to follow POC. A review of “Home Health Certification and Plan of Care” 7/13/2022 indicated for certification period from 7/9/2022 to 9/6/2022, indicated SN was to visit once a week for 9 weeks and PT evaluation and follow up treatment. Is also indicated the SN was to check oxygen saturation every visit for shortness of breath (SOB) and to report to the primary medical doctor the parameters of the Oxygen saturation less than 90%. During a concurrent observation, interview, and record review on 8/12/2022, at 6:20 p.m., with License Vocational Nurse 1 (LVN1) of Patient 1’s “Medication Profile” indicated a bottle of Lactulose 10 milligrams (mg) / 15 milliliters (ml), give 30 ml by mouth (PO) twice a day (BID) as needed (PRN). The medication Lactulose was not written in the patient's medication profile. LVN 1 stated that the Lactulose was discontinued a long time ago and did not know why the medication was still in the medication box. 2. A review of “Recertification” for Patient 2 indicated start of care date of 10/15/2020 with an admitting diagnosis of Diabetes Mellitus (DM)Type II (sugar in blood) and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD – Difficulty breathing). Skilled Nurse (SN) to visit once a week for 9 weeks with one of her interventions to be: SN to remove any duplicate or expired medications to prevent confusion with medication regimen. A review of Patient 2's “Home Health Certification and Plan of Care” from 6/7/2022 to 8/5/2022 included SN visit once a week for 9 weeks and to report to the primary medical doctor the parameter of ters: 4. Oxygen saturation less than 90%. A review of “Home Health Certification and Plan of Care” indicated P2’s certification period was from 8/6/2022 to 10/4/2022. It also indicated SN was to visit once a week for 9 weeks and to report to the primary medical doctor the parameters of Oxygen saturation less than 90%. A concurrent observation, interview, and record review on 8/12/2022 at 6:40 p.m., with LVN1 stated Patient 2 was taking Gabapentin 100 mg give 1 capsule PO at bedtime (HS), 2. Atorvastatin Calcium 10 mg give 1 tablet PO QHS, 3. Cetirizine Hydrochloride 100 mg 1 tablet PO every day (QD). The Gabapentin, Atorvastatin Calcium or Cetirizine Hydrochloride were not written on Patient 2’s medication profile. LVN1 stated that the medications should not have been inside the patient's medication box. An interview on 8/12/2022, at 7 p.m., with LVN1, stated, “I check their medications at every other visit. It takes a lot of time and I only have 45 minutes. I have to do wound care. I don’t check the medications at every visit.” An interview on 8/14/2022 ,at 12 p.m., with the Director of Patient Care Services (DPCS), DPCS stated, “Medication reconciliation is done by the Registered Nurse (RN) when opening the case, we do 4 times for sure. If there is a forgetful patients, definitely, the nurse has to check the medications. If patient is forgetful or confused, she should check it every day”. A review of facility’s policy titled, “Administration of Medication Policy” dated 1/1/2020 indicated “Medications… will be recorder in the patient’s clinical record. The medication profile will be updated whenever a new mediation is prescribed, changed or discontinues”.

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, the Home Health Agency (HHA) failed to meet the Condition of Participations for Care Planning, Coordination, and Quality of Care as follows: The HHA failed to follow the plan of care (POC) for 1 of 7 sampled patients (Patient 5).The HHA did not weigh the patient weekly, as per the patient POC. This failure resulted in the patient had not weighed and could cause unidentified significant weight change (a minimum 5 percent of usual body weight within 6 months) . (Refer to G572) The HHA failed to ensure the POC for physical therapy (PT, a non invasive discipline that helps individual develop, maintain, and restore maximum body movement and physical function), occupational therapy (OT, an intervention to develop, recor, and maintain meaningful ), and speech therapy (ST, assessment and treatment of communication problem and speech disorder) services, included frequency of therapy visit, for five of five patient provided therapy services, out of 7 sampled patients (Patient 1, 3, 4, 5, and 7). This failure could result in insufficient and lack of therapy services provided to patients to meet patients' care goals. (Refer to G574). The HHA failed to ensure the physician was notified promptly of the patient's change of condition, for 1 of 7 sampled patients (Patient 5), when Patient 5 decline to eat and drink. (Refer to G590). The HHA failed to revise and update the patient's POC for one of seven sampled patient (Patient 4), when Patient 4's blood sugar check was discontinued, and was not indicated on the patietn's POC. This deficient practice had a potential for patient's progress and decline in health status , not identify to meet the patient's care goals. (Refer to G 592) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal regulations for Care Planning, Coordination of services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

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, the Home Health Agency (HHA) failed follow the plan of care (POC) for one of seven patients (Patients 5). The HHA did not weigh the patient weekly per the patient POC. This failure had the potential to result in patients not receiving the identified needs and services, significant weight change, and decline in health status, that could affect their quality of care and well being. A review of “Recertification” for Patient 1 indicated Patient 1 was oriented to person, place, time and is forgetful. Patient 1's start of care date was on 7/14/2021 with an admitting diagnosis of Diabetes Mellitus (DM)Type II (sugar in blood) and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD – Difficulty breathing). It indicated to notify physician of: Oxygen (02) Saturation (Sat) less than 90%. It indicated dyspnea as a functional limitation and stated Patient 1 was a heavy smoker. Skilled Nurse (SN) to visit once a week for 9 weeks, Physical Therapy (PT) for “Evaluation and follow up”. The plan for next visit is to follow POC. A review of “Home Health Certification and Plan of Care” 7/13/2022 indicated Patient 1’s certification period was from 7/9/2022 to 9/6/2022. It also indicated SN was to visit once a week for 9 weeks and PT evaluation and follow up treatment. Is also indicated the SN was to check oxygen saturation every visit shortness of breath (SOB) and to report to the primary medical doctor the following parameters: 4. Oxygen saturation (measure oxygen level in the blood) less than 90%. An interview on 8/12/2022 at 7 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that she believed Patient 1 complained of SOB due to his lower back pain. LVN1 stated, “There is a rule that we shouldn’t check the oxygen saturation if they are not on oxygen.” An interview on 8/14/2022 at 12 p.m. with the Director of Patient Care Services (DPCS), DPCS stated that a patient’s oxygen saturation (02 Sat) should be checked if the patient complains of shortness of breath (SOB). DPCS stated, “Yes, anytime the patient complains of SOB the 02 sat should be checked because you don’t know if it is from pain, or a respiratory issue”. A review of facility’s policy titled, “Identification and Reporting of Significant Changes in Patient’s Condition Policy” dated 1/1/2020 indicated “Clinical findings that are found to be outside the parameters indicated by the physician on the Plan of Care or any observed or assessed adverse observation must be reported to the patient’s physician immediately”. A review of Patient 5’s Patient Information sheet indicated the patient was admitted to the HHA on 6/4/22, with diagnoses including hypertensive heart and chronic kidney disease with heart failure (heart and kidney failure). During an interview on 8/14/22, at 10:00 a.m., RN 1 stated she was unable to weight Patient 5 during the initial assessment and subsequent visits because it was not safe for the patient to get out of bed. RN 1 stated she could see the patient was loosing weight. RN 1 stated if patients cannot get weighed, there are other ways to monitor weight such as measuring arm, ankle, and abdomen circumference. RN 1 stated she did not do any of the mentioned alternatives because she only did that if she noticed the patient gaining weight, not loosing weight. RN 1 stated she did not notify the physician she was unable to weigh the patient because “I am negligent in that. I should’ve weighed her because of her CHF (congestive heart failure).” During an interview on 8/14/22, at 10:56 a.m., the Director of Patient Care Services (DPCS) stated if nurses were unable to weigh the patient, “we definitely” needed to notify the doctor. The DPCS stated if the doctor was notified of the inability to weight the patient, she would expect the doctor to order lab test or give a different order on how to monitor the patient’s weight. A review of Patient 5’s record titled “Home Health Certification and Plan of Care”, for certification period 6/4/22-7/3/22, indicated “Orders and treatments…SN (skilled nursing) 1wk1 (1 visit for 1 week), 2wk1 (2 visits for 1 week), 1wk7 (1 visit for 7 seeks)…SN to perform every visit…3. Weigh patient weekly. Patient’s current weight is 92 lbs…SN to report to the PMD (primary medical doctor) the following parameters:…4….significant changes in clinical status…Goals and outcomes…14. Time frame: within 9 weeks, patient will consistently demonstrate safety measures on transfer/ambulation as evidenced by absence of incident of fall/injury/hospitalization and patient will remain safe at home.” A review of Patient 5’s medical record titled “RN-Skilled Nursing Visit” was reviewed: 6/7/22, the record did not indicate a weight assessment. 6/10/22, the record did not indicate a weight assessment. 6/13/22, the record did not indicate a weight assessment. 6/22/22, the record did not indicate a weight assessment. 6/24/22, the record did not indicate a weight assessment. Further review of the record did not indicate the doctor was notified of the observed weight loss by RN 1. A review of Patient 5’s record titled “Discharge Summary”, dated 6/29/22, indicated “Patient was taken to the hospital on 6/28/22 due to generalized weakness”. A review of HHA’s policy and procedure titled, “Plan of Care Policy”, dated 1/1/2020 indicated “The professional person responsible for any specific treatment will notify the attending physician, dentist, podiatrist, or other health professionals and responsible agency staff of significant changes in the patient’s condition. Significant changes mean those changes that suggest the need to modify or develop a plan of care… Changes in the patient that want changes in the Plan of Care include but are not limited to the following: a. Changes in physical condition, diagnosis prognosis… d. Lack of achievement of goal =s in the specific time frame…

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 interview and record review, the Home Health Agency (HHA) failed to the ensure the plans of care (POC) for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services, included frequency of therapy visits, for five of five patients provided therapy services (PT, OT, ST) in a sample of seven patients (Patients 1, 3, 4, 5 and 7). This failure had the potential for the patients therapy goals will not be met that could lead to the decline in the patients physical status and quality of life. 4. A review of “Recertification” for Patient 1 indicated start of care date of 7/14/2021, with an admitting diagnosis of Diabetes Mellitus (DM)Type II (sugar in blood) and secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD – Difficulty breathing). A review of Patient 1 “Home Health Certification and Plan of Care” for certification period of 7/9/2022 to 9/6/2022, indicated PT serivices for “evaluation and follow up treatment”. The POC did not indicate and identify the reason Patient 1 was receiving PT services. There was no documented evidence PT services included frequency of visits to meet the patient's therapy needs. 5. A review of “Start of Care OASIS” for Patient 3 indicated a start of care date of 7/23/2021 with diagnosis of pressure ulcer (skin wound) of right and left buttocks. A review of Patient 3's “Home Health Certification and Plan of Care” for certification period of 7/23/2022 to 9/20/2022, included PT services for evaluation and follow up treatment. There was no documented evidence the POC identified the patient's need for therapy services. There were no frequency of PT visits. On 8/14/22, at 12:45 p.m., during an interview with the DPCS stated, the POC should include frequency of PT services to be provided to the patients. A review of facility’s policy titled, “Plan of Care Policy” dated 1/1/2020 indicated “The plan of Care will include: d. Frequency of services…" A review of facility’s policy titled, “Care Planning Process” dated 1/1/2020 indicated based on these assessments and conclusions, the plan of care will include, but is not limited to c. Specific services to be provided. e. Type, frequency and duration of above actions”. Findings: 1. A review of Patient 4’s Patient Information sheet indicated the patient was admitted to the HHA on 11/21/21, with diagnoses including hypertensive heart disease without hear failure (high blood pressure). A review of Patient 4's clinical record for certification period of 7/19/22 to 9/16/22, indicated PT services for PT evaluation and follow-up treatment. There was no documented evidence the POC identified the need for PT services to be provided to the patient and frequency of visits to attain the patient care goals. 2. A review of Patient 5’s Patient Information sheet indicated the patient was admitted to the HHA on 6/4/22, with diagnoses including hypertensive heart and chronic kidney disease with heart failure (heart and kidney failure). A review of patient's POC for certification period of 6/24/22 to 7/3/22, indicated PT evaluation and follow-up treatment. It also indicated OT evaluation and follow-up tretment. There was no documented evidence the POC contained frequency of visits and the needs identified for the patient to be provided PT and OT services. 3. A review of Patient 7’s Patient Information sheet indicated the patient was admitted to the HHA on 8/8/22, with diagnosis hemiplegia following cerebral vascular accident right dominant side (weakness on the right side of the body due to a brain attack, stroke). A review of Patient 7’s record titled, “Home Health Certification and Plan of Care”, for certification period 8/8/22-10/06/22, indicated PT evaluation and follow up treatment; OT (occupational therapy) evaluation and follow up treatment; ST (speech therapy) evaluation and follow up treatment. The POC did not indicate frequency of visits and did not identify the need for these services (PT, OT, and ST) to be provided to the patient. During an interview with DPCS on 8/14/22, at 12:45 p.m., staed the plan of care need to include the frequency of visits and the need for these visits. A review of the HHA’s policies and procedures titled, “Care Planning Process” dated 1/1/2020, indicated, “C. Procedures…3. Based on these assessments and conclusions, the plan of care will include, but is not limited to… c. Specific services to be provided…e. Type, frequency and duration of above actions…”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to notify the physician promptly of the patient's change of condition for 1 of 7 sampled patients (Patient 5), when Patient 5 decline to eat and drink. This deficient practice resulted in the decline of the patient's health status leading to patient's admission to the general acute care hospital (GACH). Findings: A review of Patient 5’s Patient Information sheet indicated the patient was admitted to the HHA on 6/4/22, with diagnoses including hypertensive heart and chronic kidney disease with heart failure (heart and kidney failure). During an interview on 8/14/22, at 10:00 a.m. with Registered Nurse 1 (RN 1) she stated signs of change of condition included changes in nutritional status such as not eating as much, not drinking enough fluids, or not being able to drink. RN 1 stated she would report to the physician (doctor) if the patient was not drinking or eating as much, especially if it was something new. RN 1 stated Patient 5 initially was doing better, “but turned for the worse” on 6/22/22. RN 1 stated she did not notify the doctor about the change of condition for Patient 5 because her daughter, who is also a registered nurse was going to report the changes of condition to the doctor. RN 1 stated she was the responsible nursing staff and it was her responsibility to call the doctor. RN 1 stated “I did not call the doctor because the daughter was the one who wanted to report the patients condition. If I called the doctor, I would’ve documented it in the communication note…the only thing I would have reported is that she’s unable to take food and fluids in and that is unable to go in to the doctor’s office for a visit.” During an interview on 8/14/22, at 10:56 a.m., the Director of Patient Care Services (DPCS) stated “patient decline in eating and drinking that is a change of condition and should be reported to the physician”, when asked what a significant change meant. A review of Patient 5’s record titled “Home Health Certification and Plan of Care”, for certification period 6/4/22-7/3/22, indicated “Orders and treatments…SN (skilled nursing) 1wk1 (1 visit for 1 week), 2wk1 (2 visits for 1 week), 1wk7 (1 visit for 7 seeks)…SN to report to the PMD (primary medical doctor) the following parameters:…4….significant changes in clinical status such as increasing weakness…inability to tolerate food/fluid intake…Goals and outcomes…14. Time frame: within 9 weeks, patient will consistently demonstrate safety measures on transfer/ambulation as evidenced by absence of incident of fall/injury/hospitalization and patient will remain safe at home.” A review of Patient 5’s record titled “RN-Skilled Nursing Visit”, dated 6/22/22, indicated “GU urine is diminishing in amount…PCG reports patient not reaching for the glass of water and drinking by self anymore and has to be spoon fed solid food. Is sleeping more and has little energy…patient wants to sleep during SN visit…Daughter, pcg will call PMD (primary medical doctor)…to discuss patients condition and not able to get patient into the office for follow up visit.” Further review of the record did not indicate the doctor was notified of patient 5’s condition. A review of Patient 5’s record titled, “RN-Skilled Nursing Visit”, dated 6/24/22, indicated, “Only took approximately ½ can of ensure (nutritional supplement) and 240 ml of water. Eating very little rice, banana for breakfast…”. Further review of the record did not indicate the doctor was notified of Patient 5’s condition. A review of Patient 5’s record titled “Discharge Summary”, dated 6/29/22, indicated “Patient was taken to the hospital on 6/28/22 due to generalized weakness”. A review of HHA’s policy and procedure titled, “Communication with a Patient’s Physician Policy” dated 11/1/2020 indicated, “1. Communication with a patient’s physician is required when: a. significant changes in the patient’s condition and/or changes in the patient’s expected response to treatment and/or medications… 2. Staff members communication with a patient’s physician will document the communication via one or more of the following forms which are filed in the patient’s clinical record: Plan of Care, Physician orders forms, nurses visit noted…” A review of facility’s policy titled, “Identification and Reporting of Significant Changes in Patient’s Condition Policy” dated 1/1/2020 indicated “Clinical findings that are found to be outside the parameters indicated by the physician on the Plan of Care or any observed or assessed adverse observation must be reported to the patient’s physician immediately”.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to revise the plan of care to reflect the current patient’s updated comprehensive assessment for 1 of 7 sampled patients (Patient 4), when Patient 4's POC did not indicated the patient's blood sugar check was discontinued. This deficient practice has the potential for the patients progress or decline of health status will not be identified in order to meet the patient care goals. Findings: A review of Patient 4’s Patient Information sheet indicated the patient was admitted to the HHA on 11/21/21, with diagnoses including hypertensive heart disease without hear failure (high blood pressure). During an observation of the home visit on 8/13/22, at 11:00 a.m., with the Director of Patient Care Services (DPCS), Patient 4 was observed receiving care from the DPCS. The DPCS did not check Patient 4’s blood sugar level. During an interview on 8/13/22, at 12:10 p.m., the DPCS stated she did not check Patient 4’s blood sugar because the patient was no longer on insulin (a medication that helps control high blood sugar levels). The DPCS stated the order to check blood sugar was from her previous recertification period when the patient was on insulin. The DPCS stated she forgot to update the plan of care (POC) and she should have updated the POC to reflect the current treatment. The DPCS stated she understood the importance of updating the POC. A review of Patient 4’s record titled “Home Health Certification and Plan of Care”, for certification period 7/19/22-9/16/22, indicated “Orders and Treatments…SN (skilled nursing) every 2 weeks times 5…SN to continue to perform every visit…3. Blood sugar checking/recording…proper Insulin preparation/administration…and safe storage of Insulin.” Further review of the record did not indicate the patient was taking Insulin. A review of the HHA’s policy and procedure titled, “Plan of Care Policy”, dated 1/1/2020, indicated “C. Procedure…3. The Plan of Care will include…c. Types of services and equipment required”.