Every finding on record at Horizons Community Care, Inc

This survey was for a federal and state licensure survey. Survey Dates: February 22nd, 23rd, and 24th of 2022. 12-month unduplicated census: 40 These deficiencies reflect State findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. QR Completed 3/8/2022 A4

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide contact information for the administrator to the patient and/or caregiver in 3 of 3 home visits observed. (Patient 1, 3, & 4) Findings Include: 1. A policy titled "Admission Process" dated December 1, 2018, revised November 2019 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated, but was not limited to, "In advance to providing care:" ... "Present and review the Need A Nurse, Inc., Service Guide/Admission Packet." ... "Written information to go the Client/Caregiver:" ... "Name and contact information for director/clinical manager (educate that contact information will be listed on home folder in multiple locations)." 2. An undated document titled "Need A Nurse Patient's Bill of Rights," was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The document indicated but was not limited to, "You and/or your representative have the right to be informed of the agency's administrator Susan Hall, RN (registered nurse) (812)-421-2002 2318 W Franklin St. Evansville, IN 47712. The administrator is available to receive questions, complaints, concerns regarding any aspects of services or care." 3. An undated policy titled "Notice of Rights: Grievance Procedure" was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "Information on Need A Nurse's Administrator will also be given as an additional contact for grievances." 4. A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "... "As a Medicare Certified [Home Health Agency...], Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." 5. During a home visit on 2/23/2022 at 10:35 a.m. Patient 1, a pediatric patient, was observed receiving care from RN J. Patient 1's parents/guardians were not present in the home. RN J could not provide a copy of the admission packet that included the administrator's contact information. Indicated that the family recently moved and the admission packet may have been lost in the move. 6. During a home visit on 2/23/2022 at 11:25 a.m. Patient 4 was observed receiving care from LPN T. Patient 4's patients/guardians were not present in the home. LPN T indicated that Patient 4's mother usually works from home but had an appointment today. LPN T was unable to provide an admission packet that included the administrator's contact information. 7. During a home visit on 2/23/2022 at 10:30 a.m. RN (registered nurse) L indicated he/she did not know where patient 3's admit packet was that contained patient rights, visit frequency, state hotline number, medication list, plan of care, agency contact information, transfer/discharge information, and federal / state funded entities. The parent of patient 3 was not at home during the visit. RN L provided a binder patient 3's parent made up that included the Administrator's name and phone number, list of chores, and which medications the nurse was to give. 8. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated the admit packet that contained patient rights, visit frequency, state hotline number, medication list, plan of care, agency contact information, transfer/discharge information, and federal / state funded entities that was not found in the patient's homes were "extraneous information that serves no purpose". The Administrator indicated Person B said the agency was a Medicaid agency and the home admit packet information was not required due to the size of the agency. The Administrator indicated patient's have moved and the agency tried to ensure the information was in the home but found that it was a financial burden to keep replacing the admit packet back in the patient's home. 17-12-3(3)(e)

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 record review and interview, the agency failed to provide a written copy advising the patients/caregivers of the state's toll-free home health hotline in 3 of 3 home visits observed. (Patient 1, 3, & 4) Findings Include: 6. During a home visit on 2/23/2022 at 10:30 a.m. RN (registered nurse) L indicated he/she did not know where patient 3's admit packet was that contained the state hotline number. The parent of patient 3 was not at home during the visit. RN L provided a binder patient 3's parent made up but did not include the state hotline number. 7. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated the admit packet that contained patient rights, visit frequency, state hotline number, medication list, plan of care, agency contact information, transfer/discharge information, advanced directives, and federal / state funded entities that was not found in the patient's homes were "extraneous information that serves no purpose". The Administrator indicated Person B said the agency was a Medicaid agency and the home admit packet information was not required due to the size of the agency. The Administrator indicated patient's have moved and the agency tried to ensure the information was in the home but found that it was a financial burden to keep replacing the admit packet back in the patient's home. 1. A policy titled "Notice of Rights: Grievance Procedure" was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "The client and/or representative shall be advised verbally and in writing (Notice of Rights) of their right to voice grievances and the method of contacting NAN (Need A Nurse) if dissatisfied. This shall include information about the Home Health Hotline (established by the state), including its contact information, hours of operation and that the purpose of the hotline is to receive questions or complaints about local home health agencies. Information on Need A Nurse's Administrator will also be given as an additional contact for grievances." 2. A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "... "As a Medicare Certified [Home Health Agency...], Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." 3. During a home visit on 2/23/2022 at 10:35 a.m. Patient 1, a pediatric patient, was observed receiving care from RN J. Patient 1's parents/guardians were not present in the home. RN J could not provide a copy of the admission packet that included the state's toll-free home health hotline. 4. During a home visit on 2/23/2022 at 11:25 a.m. Patient 4 was observed receiving care from LPN T. Patient 4's patients/guardians were not present in the home. LPN T indicated that Patient 4's mother usually works from home but had an appointment today. LPN T unable to provide an admission packet that included the state's toll-free home health hotline. 5. During an interview on 2/23/2022 at 4:01 p.m. the administrator was advised that admission packets containing the state's home health hotline information was not found in the home. The administrator stated that the patients observed in the home by surveyors recently moved and indicated that this information may have been misplaced in the move. Indicated that this information was not important. 17-12-3 (C)

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide a copy of written instructions to the patient and caregiver for 3 of 3 home visit observations (Patient 1, 3, & 4), with the potential to affect all patients. Findings Include: 6. During a home visit on 2/23/2022 at 10:30 a.m. RN L was unable to locate Patient 3's admission packet or a copy of the current plan of care and medication list with instructions. RN L indicated Patient 3's parent typed up his/her own information that included a list of contacts, medications, and chores. 7. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated the admission packet that contained patient rights, visit frequency, state hotline number, medication list, plan of care, agency contact information, transfer/discharge information, advance directives, and federal / state funded entities that was not found in the patient's homes were "extraneous information that serves no purpose". The Administrator indicated Person B said the agency was a Medicaid agency and the home admit packet information was not required due to the size of the agency. The Administrator indicated patient's have moved and the agency tried to ensure the information was in the home but found that it was a financial burden to keep replacing the admit packet back in the patient's home. 17-12-3(3)(d)(e) 1. A policy titled "Admission Process" dated December 1, 2018, revised November 2019 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated, but was not limited to, "Written information to go to the Client/Caregiver:" ... "Plan of Care, Medication schedule/instructions (in plain language, avoiding the use of medical abbreviations). Information on any treatments to be administered by the agency staff. Any other pertinent instruction related to the client's care and treatment-specific to the client's needs. Visit schedule, including frequency of visits for all NAN (Need A Nurse) personnel. Name and contact information for director/clinical manager..." 2. A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "... "As a Medicare Certified [Home Health Agency...], Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." 3. During a home visit on 2/23/2022 at 10:35 a.m. for Patient 1, RN (registered nurse) J was unable to locate the patient's admission packet including the most recent plan of care. RN J indicated that patient and family recently moved to new home and did not know where this information was. 4. During a home visit on 2/23/2022 at 11:25 a.m. for Patient 4, LPN (Licensed Practical Nurse) T was unable to provide an admission packet including the most recent plan of care. LPN T indicated that mother typically works from home but is not home today due to an appointment. 5. During an interview with the Administrator on 2/23/2022 at 4:01 p.m., the administrator indicated that a written copy of the plan of care, initial and revised (minimum of every 60 days), advising patient of services, were no longer being mailed to the patients due to patient complaints of receiving in the mail and due to lack of staff because of the COVID-19 pandemic. This practice of mailing the plan of care to each patient stopped in March of 2020.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received a visit schedule, including the frequency of visits, during observations in 2 of 3 home visits observed. (Patient 1 & 4) Findings Include: 1. A policy titled "Admission Process" dated December 1, 2018, revised November 2019 was provided by the Alternate Administrator on 2/24/2022 at 9:34 a.m. The policy indicated but was not limited to, "Written information to go to the Client/Caregiver:" ... "Visit schedule, including frequency of visits for all NAN (Need A Nurse) personnel." 2. A policy titled "Care Plans" dated December 1, 2017, was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "A written plan of care (POC) that conforms with the physician's orders shall be developed for each home care patient and shall include the following:" ..."4. The frequency and duration of visits to be made." 3. An undated document titled "Patient's Bill of Rights" was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, " Patient has the right to the following:" ... "Participate in, be informed about, and consent or refuse treatment of care that is or fails to be furnished based on the comprehensive assessment, establishing and revision the plan of care, the disciplines that will furnish care, the frequency of the visits..." 4. A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "... "As a Medicare Certified [Home Health Agency...], Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." 5. During a home visit on 2/23/2022 at 10:35 a.m. of Patient 1, RN J was unable to provide the admission packet detailing the visit schedule, including frequency. RN J indicated that Patient 1 recently moved and was not sure where this packet/information could be found. 6. During a home visit on 2/23/2022 at 11:25 a.m. of Patient 4, LPN T indicated that parent/caregiver usually works in the home but is not here at this time due to an appointment. Unable to provide admission packet containing this information. 7. During an interview on 2/23/2022 at 4:01 p.m., the Administrator indicated the patients observed had recently moved and may have contributed to the missing admission packets.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received written information regarding the patient's medication regimen in plain language which also identified who was responsible for giving each medication for 3 of 3 home visits observed, with the potential to affect all patients. (Patient 1, 3, & 4) Findings Include: 1. A policy titled "Admission Process" dated December 1, 2018, revised November 2019 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated, but was not limited to, "Written information to go to the client/caregiver:" ... "Medication schedule/instructions (in plain language, avoiding the use of medical abbreviations)." 2. A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated but was not limited to, "... "As a Medicare Certified [Home Health Agency...], Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." 3. During a home visit on 2/23/2022 at 10:35 a.m. with Patient 1, RN J was asked if the admission packet could be reviewed to ensure all required information was present, including the medication list/schedule. RN J indicated that the family had recently moved and was unsure where this information was. The patient's parents/guardians were unavailable and not present in the home during the home visit. 4. During a home visit on 2/23/2022 at 11:25 a.m. with Patient 4. LPN T was unaware of where the admission packet was. Indicated that Patient 4's mother typically works from home but had left to go to an appointment. 5. An interview with the administrator was completed on 2/23/2022 at 4:01 p.m. The administrator was advised of medication schedules/instructions were not found in the homes of visits completed by surveyors. The administrator indicated that they do not provide medication schedules/instructions to the clients/representatives, the medication instructions/schedules are provided to the agency from the patients via medication prescription bottles and hospital discharge summaries. Indicated that an updated plan of care used to be mailed to each patient's home, which included the medication list, but due to patient complaints of receiving this information via mail and and lack of staff due to the COVID-19 pandemic, this practice was eliminated in March of 2020. 6. During a home visit on 2/23/2022 at 10:30 a.m. RN (registered nurse) L indicated he/she did not know where patient 3's admit packet was that contained the medication list / instructions and the plan of care. RN L provided a binder patient 3's parent made up that included which medications the nurse was to give. 7. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated the admit packet that was not found in the patient's homes were "extraneous information that serves no purpose". The Administrator indicated patient's have moved and the agency tried to ensure the information was in the home but found that it was a financial burden to keep replacing the admit packet back in the patient's home.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure additional precautions were implemented to mitigate the spread of COVID-19 for unvaccinated staff that provide direct patient care and aerosol (suspension of liquid droplets in the air) procedures for 1 of 1 home visit observation. (RN L) Findings include: A January 17, 2022 policy titled Mandatory COVID-19 Vaccine Policy and Procedure 42 C.F.R. 484.60 (d)(2)/418 C.F.R. 418.70 (d)(2)1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated, but was not limited to, " ... As a Medicare Certified [Home Health Agency ...], Need a Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation. ... 2 On Friday, January 14, 2022, CMS issued Memorandum QSO-22-09-ALL which announced enforcement deadlines for the states that had, prior to the Supreme Court Ruling been subject to the injunction issued by the Federal Court ... 7. Additional Precautions for Exempt Staff ... 7.1.2 Weekly COVID-19 Testing. [NOTE: CMS suggests that weekly testing for unvaccinated HCP [health care professionals] is a measure for agencies to consider ... 7. Additional Precautions for Exempt Staff ... When in the presence of other staff or patients, the Covered Staff Member will wear either: ... or (iii) a well fitting surgical mask. ... 32 ... CMS states that providers should consider requiring staff who are not fully vaccinated to wear NIOSH approved N-95 masks. CDC only requires N-95 masks for HCP when they are involved in aerosol generating procedures ..." Review of the agency employee COVID Vaccine log indicated three religious exemptions that included RN L. During a home visit on 2/23/2022 at 10:30 a.m. RN L was asked what precautions were taught to prevent the spread of COVID-19 while providing care for Patient 3. RN L indicated he/she wears a blue mask that loops behind the ears while in the home and does hand hygiene. RN L indicated he/she would inform the office immediately if experiencing signs or symptoms of COVID-19. RN L indicated he/she does not have an N-95 mask. RN L was asked if he/she tests for COVID-19 weekly, performs self-screening, or any additional precautions to prevent the spread of COVID-19 to which he/she responded "no". At that time, RN L indicated he/she administers patient 3's nebulizer breathing treatments. The agency failed to implement additional precautions such as wearing an N-95 mask while administering a nebulizer treatment and weekly COVID testing for unvaccinated staff providing direct patient care. The complete clinical record for patient 3 was reviewed on 2/23/2022, start of care date 10/23/07, for the certification period of 1/3/2022 to 3/3/2022, with orders for respite nursing services 4-12 times a month for 2 months. The Plan of Care indicated "SN [skilled nurse] Respiratory Interventions: Administer nebulizer treatments per med [medication] profile." Review of the Medication Profile indicated "Albuterol Sulfate [medication for shortness of breath] (2.5 mg/ML) 0.083% ml [milliliters] inhalation 1 tube three times a day." Patient 3's diagnoses included respiratory failure with unspecified hypoxia (low oxygen level in tissue) or hypercapnia (too much carbon dioxide in the blood that causes difficulty breathing). Review of the nurse visit notes dated 1/3/22, 1/10/22, 1/17/22, 1/24/22, 1/31/22, 2/7/22, 2/14/22 indicated RN L administered nebulizer (breathing machine used to deliver medication in the form of a mist into the lungs) treatments according to the medication profile. During an interview on 2/23/2022 at 4:01 p.m. the Administrator was asked how the agency mitigates the spread of COVID-19 infections regarding unvaccinated employees that provide direct patient care. The Administrator indicated unvaccinated employees do not perform additional precautions. The Administrator indicated that staff are to follow CDC guidelines but do not test weekly for Covid-19, do not wear N-95 masks, nor work remotely. The Administrator indicated Person B (non-employee) informed him/her that unvaccinated staff could wear the regular blue mask while providing patient care. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated Person B wrote the agency Mandatory COVID-19 Vaccine Policy and Procedure dated January 17, 2022 based on the QSO 22-07 memorandum and indicated it was okay to use regular masks, no additional precautions were needed for unvaccinated staff, and everyone was treated the same. The Administrator did not provide additional information as to how the blue surgical mask meets the guideline for a well-fitted mask such as an N-95 mask. The Administrator indicated Person B wrote the COVID-19 policy and was not a member of the governing body when asked and did not state the governing body adopted the policy. 17-12-1(m)

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the administrator failed to ensure the agency met all rules and regulations for recertification for 1 of 1 home health agency. Findings include: A January 17, 2022 policy titled "Mandatory COVID-19 Vaccine Policy and Procedure C.F.R. 484.60 (d)(2)/C.F.R 418.70 (d)(2) 1 was provided by the Alternate Administrator on 2/24/2022 at 9:45 a.m. The policy indicated, but was not limited to, " ... Need A Nurse, Inc (the "Agency") is required to comply with all of the Medicare Conditions of Participation." The agency Administrator failed to provide contact information for the administrator was provided to the patient and/or caregiver. (see tag G414) The agency Administrator failed to provide a written copy advising the patients/caregivers of the state's toll-free home health hotline. (see tag G444) The agency Administrator failed to provide a copy of written instructions to the patient and caregiver. (see tag G612) The agency Administrator failed to ensure patients received a visit schedule, including the frequency of visits. (see tag G614) The agency Administrator failed to ensure that patients received written information regarding the patient's medication regimen in plain language that also identified who was responsible for giving each medication. (see tag G616) The agency Administrator failed to ensure additional precautions were implemented to mitigate the spread of COVID-19 for unvaccinated staff that provide direct patient care and aerosol (suspension of liquid droplets in the air) procedures. (see tag G687) During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated the admit packet that contained patient rights, visit frequency, state hotline number, medication list, plan of care, agency contact information, transfer/discharge information, advanced directives, and federal / state funded entities that was not found in the patients homes was "extraneous information that serves no purpose". The Administrator indicated Person B (non-employee) said the agency was a Medicaid agency and the home admit packet information was not required due to the size of the agency. The Administrator indicated patients have moved and the agency tried to ensure the information was in the home but found that it was a financial burden to keep replacing the admit packet back in the patient's home. During an interview on 2/24/2022 at 11:35 a.m. the Administrator indicated Person B wrote the agency Mandatory COVID-19 Vaccine Policy and Procedure dated January 17, 2022 based on the QSO 22-07 memorandum and indicated it was okay to use regular masks, no additional precautions were needed for unvaccinated staff and everyone was treated the same. The Administrator did not provide additional information as to how the blue surgical mask meets the guideline for a well-fitted mask such as an N-95 mask. The Administrator indicated Person B wrote the COVID-19 policy and was not a member of the governing body when asked and did not state the governing body adopted the policy. 17-12-3(b)(2)(C) 17-12-3(d) 17-12-3(e) 17-12-1(m) 17-12-3(a)(1) & (2)