Every finding on record at International Quality Homecare

On 10/15/25 a complaint survey was conducted. This resulted in a partial extended survey at International Quality HomeCare. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. The following complaints were reviewed: H80785302C iQIES intake: 2630928

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 document review, the facility failed to evaluate all medications at time of recertification and address provider concerns to ensure all ordered medications were documented correctly. This affected 1 of 3 (P1) patients reviewed for medication administration. Findings include: During a home visit on 10/15/25 at 9:18 a.m., register nurse (RN)-A was observed setting up P1's medication for a weeklong period. Glipizide 5 milligrams (mg) tablets were set up. Two glipizide tablets were placed into each day's holding slot for P1 to take at a future date. The date on the pill bottle was 9/25/25. P1's emergency medication setup was also reviewed and observed to have two 5 mg glipizide tablets in each slot. There was no date on the holder to indicate when they were set up. P1's plan of care (POC) dated 5/26/25 to 7/24/25, identified a current medication list that included glipizide (a medication for diabetes to control blood sugars) 5 mg tablet, 2 tablets by mouth daily. A provider order dated 4/18/25, indicated P1 was started on glipizide 5 mg, 1 tablet by mouth daily. A provider order dated 9/25/25, indicated P1 was started on glipizide 5mg, 2 tablets by mouth daily. P1's skilled nursing progress note dated 4/25/25, indicated P1 was started on glipizide, and glipizide was added to the current medication list. Education included to take medication as ordered. P1's medical record indicated a letter from Mayo clinic dated 9/19/25, was received which reported a concern P1 was receiving two tablets of 5 mg glipizide and not one tablet as ordered. The letter included a current medication list which included glipizide 5mg tablet, take 1 tablet by mouth daily. The medical record lacked documentation the letter was reviewed and addressed by the facility. During an interview on 10/15/25 at 9:32 a.m., RN-A stated the agency set up P1's medication one week at a time. There was also an emergency week set up in case there was some reason staff could not make it out that week. P1 was not to take that setup week unless advised to by the agency. RN-A was the nurse to set up P1's emergency medication supply and it was done around a month ago. The emergency pill box contained two 5 mg tablets, which would have not been correct per the order at that time. The new bottle and order was received on 9/25/25, when a request for refill was sent to the pharmacy. During an interview on 10/15/25 at 10:26 a.m., the pharmacist stated P1 had been on one 5mg tablet of glipizide by mouth daily since the order was written on 4/18/25. There was a new order received on 9/25/25, which increased her glipizide does from one 5mg tablet to two 5mg tablets by mouth daily. During an interview on 10/15/25 at 1:07 p.m., the administrator stated all medications on the current medication list and used to set up weekly medications should match what the provider order states. If one tablet is all that is ordered, then only one tablet should be placed in each holding slot for the med setup. If there are discrepancies between the orders, the current medication list or what is on the bottle then the nurse should call the provider to clarify the correct order and follow the correct order. The administrator reviewed all of P1's medical records and confirmed P1 should have only received one tablet of 5mg glipizide until the order was changed on 9/25/25. The administrator was unsure if anybody addressed the letter received from Mayo clinic related to the medication errors. During an interview on 10/15/25 at 1:48 p.m., the provider stated a home visit was performed and the medication errors were found at that time. My staff attempted to notify the agency by phone several times but never able to get in contact with anyone. The letter was then sent and faxed to the provider. They never did reach back out as requested. Facility policy Medication Administration dated 2/25/21, indicated a comprehensive medication assessment of all patient's medications would be completed at admission and each recertification. The medications the client were on would be entered accurately onto the care plan.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 10/30/23- 11/2/23, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 10/30/23-11/2/23, a recertification survey was conducted. This resulted in a partial extended survey at Intergrated Quality Homecare. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. In addition to the recertification, the following complaints were reviewed. As a result: No deficiency was issued for complaints: H8078045C (21583), H8078046C (21576 and 21578), H8078038C (21716 and 21717), H8078044C (21585), H8078035C (21805), H8078042C (21628). Deficiencies were issued for complaints: H8078041C (21722), H80786722C (70744), H8078043C (21600), H8078037C (61098), H8078036C (61701), H8078040C (21767). Unduplicated census previous 12 months: 504 Total home visits conducted: 4 Parent Location visited: Rochester 3900 Fairway Pl NW Rochester, MN 55901 All other branch offices for this agency: Record review: Austin 701 W Oakland Ave Ste B Austin, MN 55912 Mankato 1750 Commerce Drive Ste 30 North Mankato, MN 56003 Owatonna 115 Landmark Drive NE Ste 3 Owatonna, MN 55060 Visited: La Crescent 306 Main St. Ste 4 LA Crescent, MN 55947 Shakopee 1127 Shakopee Town Square Shakopee, MN 55379 Worthington 1607 N McMillan St. Ste 3 Worthington, MN 56187 List Hours of Operation: 8:00 a.m.- 5:00 p.m. List total number of records reviewed: 19

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview and document review the facility failed to ensure a thorough investigation and ensure protection of patients during the investigation occurred for 2 of 3 patients (P20, P21) reviewed for allegations of misappropriation of property. Findings include: P20 P20’s Plan of Care for certification period 6/26/21-8/26/21, indicated P20 received skilled nurse visits once a week and had diagnoses of heart failure, kidney disease, and lung disease. A facility complaint document dated 8/8/21, indicated a complaint was filed against registered nurse (RN)-B. One of allegations was RN-B accepted personal items and furniture from P20. The complaint was filed by licensed practical nurse (LPN)-A. A facility document titled Internal Investigation Report dated 8/6/21, indicated the above complaint was received by the compliance department on 8/10/21 and was added to the internal investigation report already in place from a separate email. The clinical operations manager (COM) was asked to investigate the allegations as the COM had already been made aware of the allegations. The investigative report lacked any indication proactive protective measures had been placed to ensure patients were not at risk of maltreatment during the facility investigation. The compliance manager (CM) interviewed LPN-A on 8/13/21 addressing several other complaints but lacked information pertinent to allegations related to R20. Furthermore, the report lacked follow up information from the COM, to show interviews with P20 and RN-B had taken place, or further investigation of the allegation had taken place until 10/26/21, when R20’s county social worker notified the facility of concerns. When interviewed on 11/1/23 at 2:38 p.m. CM stated during a facility investigation, if staff were involved, they were removed from caring for the patient who was involved. CM further stated if an allegation of abuse or mistreatment came in, the team determined if the staff was removed from the client involved or placed on a formal administrative leave during the investigation. The COM had done the investigation and had determine what occurred and the COM would have investigative notes as well. CM believed RN- B had been instructed not to be in contact with P20 and was informed by P20’s county social worker on 10/26/21, and that was when the investigation resumed. CM verified the facility’s investigation report lacked indication if other patients who received care from RN-B had been interviewed and stated not all interviews were included, only those who had relevant information. When interviewed on 11/1/23 at 3:34 p.m., COM stated she had heard about the investigation with P20 and RN-B but was not involved in the investigation. COM stated she had no notes or follow up on any concerns as the compliance department was responsible for the investigations and worked with human resources if disciplinary action was needed. When interviewed on 11/2/23 at 9:19 a.m., RN-B verified she had not been placed on leave during the investigation involving P20 as she had was already working at a different branch. P21 P21’s POC for certification period 1/30/23-3/30/23, indicated P21 received skilled nurse visits and had diagnosis of diabetes. A facility document, no title and no date, listed facility complaints. The list indicated a phone call was received on 1/12/23. The document further indicated a concern of theft involving LPN-A taking money from P21. A facility document titled Internal investigation Report dated 1/12/23, indicated an investigation had occurred regarding R21 and an allegation of missing money. The report indicated the initial report was received on 1/12/23. However, the first documented interview was on 2/7/23. Furthermore, LPN-A who was listed as staff involved on a complaint report, was not interviewed about the allegation and there was no indication protective measures for other patients had been put in place. When interviewed on 11/1/23 at 3:55 p.m. CM verified P21’s complaint was received on 1/12/23 and the interview was not initiated until 2/7/23. He did not recall how P21’s complaint was received and wasn’t sure how LPN-A was involved as LPN-A was not the primary nurse for P21. CM stated P21’s medical helper was called and identified herself as P21’s power of attorney (POA), which was not truthful. CM further stated he could not discuss the allegation with P21’s medical helper as she wasn’t the POA. P21 was interviewed on 2/7/23, and had no complaints of missing money, and referred CM to talk to P21’s medical helper about further concerns. CM stated he had not followed up with P21’s medical helper because P21 was no longer a patient of the facility and the medical helper had already lied about being the POA. Furthermore, CM verified LPN-A was not interviewed as she had only cared for the patient one or two times and the main nurse for P21 was RN-B. RN-B was interviewed as RN-B was P21’s nurse. When interviewed on 11/2/23, at 9:19 a.m., RN-B stated she was P21’s main nurse. RN-B stated she filed the complaint as R21’s caretaker friend had called her and verified LPN-A had filled in for a visit or two. RN-B couldn’t remember if the complaint was called to the compliance office or a report was filed. When interviewed on 11/2/23 at 12:11 p.m., the operations manager (OM) stated the compliance office was responsible for investigations and unless directly involved, other leaders would not be involved. OM expected staff to be suspended while the investigation took place to ensure other patients were protected. OM further expected all aspects of the investigation, including the initial report and all interviews to be documented timely and to be included in the investigative report or file. A facility policy titled Reporting of Maltreatment of Vulnerable Adults revised 2/25/21, directed staff to remove any employee suspected of maltreatment to be removed from the home and any other scheduled visits during the investigation. Furthermore, the policy directed the CM and investigative team will complete the internal investigation, however lacked direction on documentation of investigation.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and document review the facility failed to ensure allegations of misappropriation of property was reported to the state authority (SA) for 2 of 3 patients (P20, P21) reviewed for abuse. Findings include: P20 P20’s Plan of Care for certification period 6/26/21-8/26/21, indicated P20 received skilled nurse visits and had diagnoses of heart failure, kidney disease, and lung disease. A facility complaint document dated 8/8/21, indicated a complaint was filed against registered nurse (RN)-B. One of the allegations was RN-B accepting personal items and furniture from P20. The complaint was filed by licensed practical nurse (LPN)-A. A facility document titled Internal Investigation Report dated 8/6/21, indicated the complaint involving R20 was received by the compliance department on 8/10/21. The investigation report lacked indication the allegation was reported to the SA. When interviewed on 11/1/23 at 2:38 p.m. the compliance manager (CM) stated complaints can be sent through a variety of ways including email, phone calls or an online submission. Once received, the CM determined if the complaint can be handled at the branch level or warranted state reporting. CM stated examples of times state reporting was required included abuse, fraud, boundaries, and theft. CM stated there was not a facility report filed to the SA, as he believed P20’s county social worker had filed a report. P21’s POC for certification period 1/30/23-3/30/23, indicated P21 received skilled nurse visits and had diagnosis of diabetes. A facility document no title and no date, indicated a phone call was received on 1/12/23. The document further indicated a complaint of facility staff taking money from P21. A facility document titled Internal investigation Report dated 1/12/23, indicated R21 was investigated for a complaint of theft. The report indicated the facility investigation occurred from 1/12/23- 2/16/23. Furthermore, the investigation report lacked indication a allegation was reported to the SA. When interviewed on 11/1/23 at 3:55 p.m., the CM was not sure how R21’s complaint was received. COM verified the investigation started on 1/12/23, however the first interview of the complainant occurred on 2/7/23. CM verified the allegation was not reported to the SA and further stated the term “immediately” had always been hard to determine, as the facility did have a window of opportunity to investigate before reporting to the SA. When interviewed on 11/2/23 at 12:11 p.m. the operations manager (OM) stated all staff were mandated reporters and can call in any allegations of abuse or theft. Furthermore, the OM stated the CM or leadership may not be available and that was why staff are educated to report themselves. The OM had not been aware of P20 and P21’s allegations and further expected their allegations to be reported to the SA. A facility policy titled Reporting of Maltreatment of Vulnerable Adults revised 2/25/21, directed any mandated reporter (any employee) who had a reason to believe a vulnerable individual has been maltreated shall immediately report to the compliance department. If unable to reach the compliance department the administrator shall be contacted. If unable to contact either, staff with call the Minnesota Adult Abuse Maltreatment Center (MAARC) to file a report. Furthermore, the policy identified immediately as “as soon as possible, but no longer than 24 hours from the time initial knowledge of the incident”.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and document review the facility failed to admit within 48 hours of receiving referral or have physician order to change admit date for 4 of 17 (P4, P6, P7, P13) patients reviewed for admit. P4's facility referral sheet undated, indicated a referral was received from P4's provider on 3/3/23. P4's plan of care (POC) for certification period 9/30/23 to 11/28/23, indicated the start of care (SOC) was dated 4/3/23. P4's delayed admission form undated, indicated it was dated and sent to the provider on 4/7/23, and signed by the provider and sent back on 4/11/23. P6's facility referral sheet undated, indicated a referral was received from P6's provider on 5/9/19. P6's POC for certification period 4/23/23 to 6/21/23, indicated the SOC was dated 5/14/19. The facility did not provide a delayed admission form for P6. P7's facility referral sheet undated, indicated a referral was received from P4's provider on 3/17/22. P7's POC for certification period 9/27/23 to 11/25/23, indicated the SOC was dated 4/5/23. The facility did not provide a delayed admission form for P7. P13's facility referral sheet undated, indicated a referral was received from P13's provider on 10/7/21 P13's POC for certification period 12/23/21 to 2/20/22, indicated the SOC was dated 12/23/21. P13's delayed admission form undated, indicated it was dated and sent to the provider on 12/10/21, and was signed by the provider and sent back on 1/4/22. During an interview on 11/1/23 at 8:24 a.m., registered nurse (RN)-A stated it was difficult to get admission done within 48 hours of receiving the referral, especially for the branches that only had one nurse available. During an interview on 11/1/23 at 10:48 a.m., the branch operations coordinator (BOC)-A stated all admissions should be done within 48 hours of receiving the referral from the provider. If the admission could not take place within 48 hours then a delayed admission form would also be sent within 48 hours. BOC-A acknowledged it was difficult to get the delayed admission form sent within 48 hours because the nurse had to sign the form prior to sending to the provider. Obtaining the nurse signature could sometimes takes days if not weeks to get it.

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 document review, the agency failed to ensure medication regimen reviews were completed to ensure medications identified on the plan of care (POC) were available and set up as ordered by physician for 1 of 3 patients (P5) observed with home visit for medication set up. P5's Home Health Certification and Non-Medicare Plan of Care (POC) for certification period of 10/22/23-12/20/23, identified a start of care as 6/11/14. The POC identified P5 medical diagnoses included bipolar disorder, hypertension, peripheral vascular disease (a disease which affects your vessels outside of your heart), generalized anxiety disorders, and mild intellectual abilities. The POC identified P5 was to receive skilled nurse visits weekly for administration of medication, medication set up, and assessment of medication compliance. On 11/1/23 at 10:00 a.m., during the medication set up process, the medications were tracked by registered nurse (RN)-D as she set up medication. RN-D stated she had printed a current medication profile that morning to review with medication set up. As medications were set up by RN-D, she would document the entries for medication set up. A review of medications set up identified the following discrepancies: The medication lorazepam 1mg was identified on the POC to be set up daily, however, this was observed being set up as twice daily. The label on the prescription bottle identified the order was to be twice daily. RN-D set this up for twice daily. The medication cephalexin 500mg was identified on the POC to be given daily, and was set up as such, however the prescription label identified the medication was to be given three times a day for 14 days. This prescription label indicated this was dispensed on 9/27/23, with an order date of 6/11/14. RN-D set this up for daily dosing. The POC identified the medication Celebrex 100mg was ordered for one capsule as needed two times daily for joint pain. This was set up by RN-D as twice daily. This medication is a non-steroidal anti-inflammatory drug (NSAID). RN-D set up this medication for twice daily on a routine basis. RN-D stated P5 requested this frequency. RN-D stated she had not advised the provider of routine use of Celebrex. Upon review of P5's medication listing by RN-D, P5 stated he was no longer using Cetaphil, Sarna, HC (hydrocortisone) cream, HC with pramoxine rectal cream, and Ciprofloxacin and dexamethasone ear drops, and had not for a while. Additionally, P5 brought out Albuterol solution for nebulization (a fine mist produced with a nebulizer machine to help breathing). P5 stated he had not used this recently. Current supply of the solution is outdated. P5 also stated when he was seen by the provider this morning, they had ordered a muscle relaxer and a medication, which P5 looked up on his clinic profile to be a non-steroidal anti-inflammatory drug (NSAID). RN-D stated the medication profile should have been reviewed with every medication set up (weekly) and with recertification. RN-D stated the medication profile was to reflect accurately what was set up and was to correspond with the prescription labels as well. RN-D stated if there was a discrepancy, the provider was to be notified and clarification sought as to what was to be given. RN-D stated this was important and referenced her setting up the Celebrex twice daily per patient request and new orders this morning for another NSAID. On 11/2/23, at approximately 2:30 p.m., the RN-E /Branch Professional Services Manager. stated when recertifications are completed, there is to be a review of the medication profile. If there are discrepancies, the provider is to be contacted. The POC is to be reviewed every 60 days with recertification. When completing medication set up for patients, if there was a discrepancy on the label to the orders, the nurse was to contact the pharmacy and provider for clarification. The orders would then be amended as ordered by the provider. If there was a discrepancy with set up medications, the clarification was to be obtained before setting up the medication. The agency policy titled D.16(a) Medication Management, reviewed and updated on 2/25/21, identified "A comprehensive medication assessment of all patients' medications will be completed by the professional clinician completing the comprehensive assessment upon admission, with each recertification, and with any changes in the medication regimen. The physician will be notified of any concerns regarding the medication review and any patient noncompliance."

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure the individualized plan of care (POC) was reviewed and revised by the provider every 60 days, beginning with the start of care for 6 of 13 patients reviewed (P6, P13, P18, P5, P14 and P9) for home care services. P9's POC for the certification period 8/8/23-10/6/23, indicated the form was signed by the provider on 10/10/23 and returned to the facility on 10/10/23. When interviewed on 11/1/23 at 3:00 p.m., the operations manager (OM) stated patients'' POC was sent out for signatures from the main branch and expected POC's to be signed within 20 days. The OM acknowledged there were challenges with obtaining the signatures promptly and was working on tracking and following up with providers to help the POC's be returned promptly. A facility policy titled Care Planning, Coordination of Services revised 2/25/21, required the individualized POC to be reviewed no less frequently than 60 days. P5's plan of care (POC) for the certification period 6/24/23 to 8/22/23, indicated the form was signed by the provider on 11/2/23, and returned to the home health agency (HHA) on 11/2/23. P5's plan of care (POC) for the certification period 8/23/23 to 10/21/23, indicated the form was signed by the provider on 11/2/23, and returned to the home health agency (HHA) on 11/2/23. P5's plan of care (POC) for the certification period10/22/23 to 12/20/23, indicated the form was signed by the provider on 11/1/23, and returned to the home health agency (HHA) on11/1/23. P14's plan of care (POC) for the certification period 12/4/21 to 2/1/22, indicated the form was signed by the provider on 10/31/23, and returned to the home health agency (HHA) on 11/1/23. P6's plan of care (POC) for the certification period 4/23/23 to 6/21/23, indicated the form was signed by the provider on 9/1/23, and returned to the home health agency (HHA) on 9/1/23. P6's POC for the certification period 6/22/23 to 8/20/23, indicated the form was signed by the provider on 9/1/23, and returned to the HHA on 9/1/23. P13's POC for the certification period 12/23/21 to 2/20/22, indicated the form was signed by the provider on 8/30/22, and returned to the home HHA on 9/6/22. P13's POC for the certification period 2/21/22 to 4/21/22, indicated the form was signed by the provider on 8/30/22, and returned to the HHA on 9/6/22. P13's POC for the certification period 4/22/22 to 6/20/22, indicated the form was signed by the provider on 8/30/22, and returned to the HHA on 9/6/22. P13's POC for the certification period 6/21/22 to 8/22/22, indicated the form was signed by the provider on 8/30/22, and returned to the HHA on 9/6/22. P18's POC for the certification period 1/24/20 to 3/23/20, indicated the form was signed by the provider on 9/13/22, and returned to the HHA on 9/14/22. During an interview on 11/1/23 at 10:248 a.m., the branch operations coordinator (BOC)-A stated the clinical management team out of the cooperate office were responsible to get the provider signatures on the plan of care in a timely manner. She was not sure what the time from was but new it had to be reviewed and signed by the provider in the current 60-day certification period.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and document review, the facility failed to ensure documentation of measurable progress achieved on the quality improvement project. This had the potential to impact all patients receiving home care services. Findings include: A facility document titled quality assessment and performance improvement (QAPI) written plan dated 2023, indicated a goal to improve and educate staff on writing the client’s plan of care (POC) timely and accurately with a goal of 100% by 6/30/2023. The plan indicated all departments will work together to achieve the goal but lacked indication of any implementation of interventions or changes, data monitoring or audits. A facility document titled QAPI quarter 1 meeting minutes dated 3/7/23, did not reflect who attended the meeting. The minutes indicated incident and other reports reviewed with no indication for performance improvement. The minutes further indicated continued an analysis of the facilities POC process required more detail and would meet in May to evaluate POC data in relation to goals. A facility document titled QAPI quarter 2 meeting minutes no date, did not reflect who attended. The meeting minutes indicated no concerns with data reports or infection control issues reported from the compliance department. Survey results were discussed from a survey in Hayward, WI. The meeting minutes lacked indication of discussion of data or progression of the POC performance improvement plan. A facility document titled QAPI quarter 3 review no date, indicated continued effort with timely initiation of care. Staff education continued and educational webinar being developed. The meeting minutes lacked indication of discussion of data or progression of the POC performance improvement plan. A list of QAPI team members was requested however was not received. Facility information regarding QAPI plan data, status, progress or revisions to plan was requested however was not received. Upon entrance on 10/30/23 at 9:30 a.m., the operations manager (OM) verified they were the acting administrator as the primary administrator was out. A follow up interview on 11/2/23 at 2:46 p.m., the (OM) stated she was not part of the QAPI committee. OM had been working on a data base to help track the timeliness of plan of care signatures and was going to support education in 2024 to develop education and goals around the plan of care. OM was not sure how involved the branches and staff were in QAPI and any updates would go to the department leaders to be talked about within their departments as information pertains to them. When interviewed on 11/2/23 at 3:09 p.m., the clinical operations manager (COM) verified she was part of the QAPI team. COM stated there were no set meeting schedules and the team met if an issue was noticed in a process or area. That was when the team would get together to discuss and determine a plan. If the issue was focused on one area or department, the focus would be in that department or area. The COM stated there had been some facility wide education on the accuracy and timeliness of them being completed. COM stated the clinical management department was tracking data and wasn’t sure where it was at, but acknowledged there hadn’t been much improvement and it was not at a point of being able to take it off the plan. facility policy titled Quality Assessment and Performance Improvement revised 2/25/21, directed staff to develop, implement, evaluate, and maintain an effective ongoing data driven QAPI program which included activities identified in the quality improvement plan will be completed and documented.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure the plan of care was updated with medication dosage and frequency for 1 of 3 clients (C5) who were observed during home visits for medication set up. In addition, the facility also failed to ensure the coordination twice daily wound care was in place for 1 of 1 client (C10) who was reviewed with closed record review for wound care provision. C5's Home Health Certification and Non-Medicare Plan of Care (POC) for certification period of 10/22/23-12/20/23, identified C5's medical diagnoses included bipolar disorder, hypertension, peripheral vascular disease (a disease which affects your vessels outside of your heart), generalized anxiety disorders, and mild intellectual abilities. The POC identified C5 was to receive skilled nurse visits weekly for administration of medication, medication set up, and assessment of medication compliance. During home visit observation on 11/1/23, at 10:00 a.m. C5's medication set up was observed as completed by registered nurse (RN)-D, who stated she had printed a current medication profile that morning to reference with medication set up. As medications were set up by RN-D, the medications were documented as having been set up for the following week. Upon observation during med set up, the following discrepancies were identified: The medication lorazepam 1 mg was identified on the POC as being ordered daily, however, this was observed as set up twice daily. The label on the prescription bottle identified the order was to be twice daily, however, this did not match the POC. Lorazepam 1 mg was set up twice daily in C5's med set up. The narrative note reflected: "Medications set up in caddy x 7 days by RN. RN Calls in all refills as well. No missed doses in the last 7 days." This note did not reflect medication was set up twice daily, versus the daily set up as ordered on the POC. The POC identified the medication Celebrex 100 mg was ordered for one capsule as needed, two times daily, for joint pain. This was set up by RN-D as twice daily. RN-D set up this medication for twice daily on a routine basis as C5 had requested this frequency. The documentation reflected "Medications set up in caddy x 7 days by RN. RN Calls in all refills as well. No missed doses in the last 7 days." This documentation lacked identification this medication was set up routinely for twice daily administration, which was what was set up by RN-D. RN-D stated the orders should have been clarified before filling the medication set up and the POC should accurately reflect what is being set up for C5. C10's Home Health Certification and Non-Medicare POC for certification period of 10/21/20-12/19/20, identified C10's medical diagnoses included chronic venous hypertension with ulcerations and inflammation of bilateral (both) lower extremities, with non-pressure ulcers of both left and right calves, with fat layer exposed. The initial POC identified C10 was to receive zero to one skilled nurse visits weekly for 60 days for wound care education, infection control, and assessment. On 10/27/20, a Client/Physician Communication Form was written which advised the provider C10 required dressing changes bilaterally to lower legs twice daily with a request made to increase home health aide (HHA) visits to 13 times a week, in conjunction with registered nurse visit weekly starting 10/23/20. This was authorized by the provider on 10/28/20. A review of the document HHA Time and Activity Documentation was completed, and the following dates were identified as C10 having received HHA services for provision of wound care in the morning on the following days; 10/24/20, 10/25/20, 10/27/20, 10/28/20, 10/29/20, 10/30/20, and 10/31/20. The documents reviewed for November identified C10 received services on the daily on 11/1/20, 11/3/20, 11/4/20, 11/5/20, 11/7/20, 11/8/20, 11/9/20 and 11/10/20. The documentation identified "Client cancelled" on 11/11/20, 11/12/20, 11/13/20, 11/14/20, and 11/15/20. The HHA Time and Activity Documentation identified services resumed on the following days; 11/16/20, 11/17/20, 11/18/20, 11/19/20, 11/21/20, 11/22/20, and 11/23/20 on a daily basis. The documentation identified services were provided by the nurse on 11/24/20. HHA documentation was again resumed on 11/25/20, 11/26/20, 11/27/20, 11/28/20, and 11/29/20. The agency lacked documentation any documentation for 11/30/20. The agency failed to provide any documentation for dressing changes on 10/26/20, 11/2/20, and 11/6/20. A request was made for documentation to reflect the second dressing change of the day for the above listed dates, however, none was provided. The agency had provided ongoing wound care orders from 11/9/20 and 12/4/20, which indicated wound care was to be continued twice daily. On 11/2/23, at 3:15 p.m. an interview was completed with RN-E /Branch Professional Services Manager who stated the POC should be reviewed with every medication set up. If there are discrepancies, clarification is to be obtained prior to completion of the medication set up. RN-E stated she did not recall C10 without record review, however, stated if there were the number of cancelled visits as outlined, the discussion should have occurred if ongoing services were indicated, and a review should have been completed for the potential reduction or discontinuation of services. The facility policy, A.10 Physician's Orders identified orders are obtained for all treatments, procedures, and equipment as required by laws, regulations, and third-party requirements. The policy identified the homecare nurse will verify that the medications are up-to-date, current, and stored as appropriate during each visit of medication check and/or review. The policy identified the home care nurse will physically check each medication during this time. Additionally, the policy identified the orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services. The policy further identified the physician is notified of any significant changes in client condition and any of the changes in the plan of care. The policy goes on to identify if the patient progresses to the point where it is no longer reasonable and necessary to continue services because the patient's medical, nursing, and rehabilitative needs have been adequately met by the agency, the agency notifies and discharges the patient, even though the certification period had not ended.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on interview and document review, the facility failed to report all branches of the agency to the state authority and at the time the parent branch added the branch. This had the potential to impact all patients who received home care services at the unreported branches. Centers for Medicare and Medicaid Services (CMS) CFR 484.2 defines a branch as “an approved location or site from which a home health agency serves within a portion of the total geographic area served by the parent branch. A branch services under the same CMS certification number as it’s parent agency”. A facility document titled Summary Office Designation by Company revised 11/4/22, indicated Rochester, MN was the parent office for following Minnesota branches: Owatonna, Mankato, Worthington, Shakopee, Austin, and La Crescent. The document further identified the Worthington branch had an affiliate office in Fairmount, MN who shared the same Medicare identification (ID) number as the Worthington branch. The Shakopee branch had an affiliate office in Eagan, MN who shared the same Medicare ID number as the Shakopee branch. The La Crescent branch had three affiliate offices in the Wisconsin cities of La Crosse, Whitehall, and Ellsworth, in which all shared the same Medicare ID number as the Le Crescent branch. A facility document titled Patient duplicated and unduplicated admission report dated 10/30/22-10/30/23, indicated patients were admitted and received care from the above-named branch locations and all affiliate offices except for Eagan. An employee listing document, no date, indicated the branches of Mankato, Austin, Shakopee, Worthington, La Crescent and the affiliate offices of Ellsworth, La Cross, and Whitehall were staffed with branch operations coordinators and clinical managers. Furthermore, the list indicated staff were assigned to all branches and affiliate offices listed above except for the affiliate offices of Eagan and Fairmount. A facility document untitled and undated, indicated the affiliate offices La Crosse, and Whitehall opened in 2015; Eagan and Fairmount opened in 2016, and Ellsworth in 2020. When interviewed on 10/30/23 at 9:30 a.m., the operations manager (OM) stated she was currently the acting administrator. OM verified the Minnesota branches of Owatonna, Mankato, Worthington, Shakopee, Austin, and La Crescent. OM further stated there were also office affiliations that were tied to the branches. These affiliate offices were in Eagan, Fairmount, La Cross, Whitehall, and Ellsworth. Affiliate offices were a place where staff could document, make phone calls, fax and schedule visits. OM explained some clients were spread out and these offices made it easier for staff to have a place to document and work. OA stated medical records were not stored in affiliate offices as these offices were extensions of the branch office. OA further explained staff and patients were assigned under both branch offices and affiliate offices and affiliate offices either had a branch operations manager or an assistant branch operations manager depending on the size of the office. OA verified all branches and affiliate offices worked under the same Medicare license. When interviewed on 10/31/23 at 3:15 p.m., the assistant branch operations manager (ABOM)-A stated she had access to all files for the Minnesota branches. The Wisconsin branches had a different ABOM as Wisconsin state laws were different. ABOM-A stated they understood the Wisconsin offices, Fairmount and Eagan offices were branches as clients, staff, and some managers were assigned to them. When interviewed on 11/1/23 at 3:00 p.m., ABOM-B stated they managed the administrative side of the Wisconsin offices of Ellsworth and Whitehall. ABOM-B verified the Wisconsin offices were all licensed under the Medicare license for the Minnesota International Quality Homecare Agency. A follow up interview on 11/2/23 at 2:46 p.m., the OM stated the affiliate offices were more for convenience as some client locations were rural and spread out. OA was not aware of the definition of a branch and acknowledged the affiliate offices fit the definition from provided from CMS. A facility policy titled General Administrative Policy revised 2/25/21, directed staff to provide written notification to the commissioner, of changes including branch locations.

On 5/9/22 through 5/12/22 a complaint survey was conducted. This resulted in a partial extended survey at International Quality Homecare. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. H8078034C/62961 was substantiated, deficiencies were issued at G430, G482 and G488 as a result of the complaint investigation. H8078033/62817 was substantiated with no deficiencies cited. The Condition of Participation: Patient Rights 42 CFR 484.50 at G406 was found not met. An Immediate Jeopardy (IJ) was identified on 5/10/22, at G430. The IJ began on 4/26/22 when P1's county case manager observed home health aide (HHA)-A verbally abusing P1 at her home. The IJ was removed on 5/12/22, at 12:00 p.m. when it was verified the agency implemented a system for investigation of abuse allegations and trained staff on the process.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to meet the Condition of Participation 484.50, Patient Rights. The HHA failed to ensure 1 of 1 patients (P1) was free from abuse when the agency was informed home health aide (HHA)-A was verbally abusive to P1. Refer to G430, G482, and G488: Based on interview and document review, the home health agency (HHA) failed to ensure abuse did not occur for 1 of 1 patient (P1) who was verbally abused by HHA-A who was providing care for P1. The facility further failed to ensure a system to report and investigate allegations of abuse to determine other patients who may have been abused by HHA-A.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interview and document review, the home health agency (HHA) failed to ensure abuse did not occur for 1 of 1 patient (P1) who was verbally abused by home health aide (HHA)- A who was providing care for P1. The IJ began on 4/26/22 when P1's county case manager observed home health aide (HHA)-A verbally abusing P1 at her home. The compliance manager was notified of the IJ on 5/10/22, at 4:00 p.m. The IJ was removed on 5/12/22, at 12:00 p.m. it was verified the agency implemented a system for investigation of abuse allegations and trained staff on the process. P1's Home Health Certification And Plan Of Care (POC) for the certification period 3/23/22- 5/01/22, indicated diagnoses of major depression and lower back pain. The POC further indicated that P1 was to receive 0-3 visits each week x 60 days for bathing, dressing, grooming, skincare, ambulation, transfers, and light housekeeping. A report to the state agency (SA) dated 4/26/22, at 3:30 p.m. indicated P1's case manager was at her home while HHA-A arrived at P1’s home and argued with P1 about why she did not receive her shower due to her being passed out on 4/25/22. And, when HHA-A offered the shower, P1 wanted to eat instead. P1 denied she was passed out, the HHA-A continued to yell at P1 and stated look at all the empty bottles, you’re an alcoholic. HHA-A then stormed out of P1’s home and stated the staff (unknown) will not be coming back either on 4/27/22. The reporter was unsure if P1 was dropped as a client from the agency. During interview on 5/9/22, at 4:00 p.m. the branch office coordinator (BOC) stated she was informed of the incident around 4/28/22, by the county case manager. The BOC stated it was on her list to speak to the staff involved home health aide (HHA)-A but she has not yet and should have. The BOC stated typically with abuse investigations the compliance department is informed and they complete the investigations. The BOC stated she did not inform the compliance officers of the incident and HHA-A continues to work with other patients. During interview on 5/9/22, at 8:30 p.m. P1 stated HHA-A did yell and scream at her on 4/26/22 when her case manager was present, and it was very upsetting that she blows up at me and screams at me, and slams the door and she makes me cry all the time. P1 stated she has been grieving due to the loss of her husband six weeks ago and admitted she had been drinking more than usual but did not feel it was appropriate for her to be treated that way. P1 stated she felt HHA-A was being verbally abused and in fact, her family member (FM)-A has also heard HHA-A yell at her too. During interview on 5/9/22, at 9:00 p.m. FM-A stated HHA-A has had boundary issues for a long time and did not appreciate how HHA-A would yell at P1. FM-A stated this was not the first time this has occurred. FM-A stated it hurt so bad to see P1 cry and felt HHA-A was pushing her to drink more. During interview with the compliance manager (CM) on 5/10/22, at 12:00 p.m. the CM stated the incident should have been immediately reported to him and HHA-A should have been removed from the schedule pending an investigation. The CM stated he was never informed of the incident and should have so a thorough investigation could have been completed. Facility policy International Quality Homecare Reporting Of Vulnerable Adults updated 2/25/21, indicated a person who has a reason to believe that a vulnerable individual is being or has been maltreated, or who has knowledge that a vulnerable individual has sustained a physical injury that is not reasonably explained shall immediately report the information to the Compliance Manager and/or the Compliance Director at the corporate office. If unable to reach either, contact should then be made to the Administrator. In addition, the policy indicated if an employee is the suspected abuser, the employee is removed from the home and will be removed from any other scheduled home care services during the investigation. The Immediate Jeopardy that began on 4/26/22, was removed on 5/12/22 when all staff were trained on vulnerable adults reporting, investigating, and taking action in response to allegations of abuse.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to investigate and take appropriate action regarding an allegation of abuse for 1 of 1 patients (P1), when the county case manager informed the facility branch office coordinator that a home health aide (HHA)-A was verbally and emotionally abusive. This had the potential to affect all five patients who received care from HHA-A. P1's Home Health Certification And Plan Of Care (POC) for the certification period 3/23/22- 5/01/22, indicated diagnoses of major depression and lower back pain. The POC further indicated that P1 was to receive 0-3 visits each week x 60 days for bathing, dressing, grooming, skincare, ambulation, transfers, and light housekeeping. A report to the state agency (SA) dated 4/26/22, at 3:30 p.m. indicated P1's case manager was at her home while HHA-A arrived at P1’s home and argued with P1 about why she did not receive her shower due to her being passed out on 4/25/22. And, when HHA-A offered the shower, P1 wanted to eat instead. P1 denied she was passed out, the HHA-A continued to yell at P1 and stated look at all the empty bottles you’re an alcoholic. HHA-A then stormed out of P1’s home and stated the staff (unknown) will not be coming back either on 4/27/22. The reporter was unsure if P1 was dropped as a client from the agency. During an interview on 5/9/22, at 4:00 p.m. the branch office coordinator (BOC) stated she was informed of the incident around 4/28/22, by the county case manager. The BOC stated it was on her list to speak to the staff involved home health aide (HHA)-A but she has not yet and should have. The BOC stated typically with abuse investigations the compliance department is informed and they complete the investigations. The BOC stated she did not inform the compliance officers of the incident and HHA-A continued to work with other patients. During interview with the compliance manager (CM) on 5/10/22, at 12:00 p.m. the CM stated the incident should have been immediately reported to him and HHA-A should have been removed from the schedule pending an investigation. The CM stated he was never informed of the incident and should have so a thorough investigation could have been completed. Facility policy International Quality Homecare Reporting Of Vulnerable Adults updated 2/25/21, indicated an if maltreatment, abuse, or neglect is suspected an internal investigation is started. The internal investigation is completed by the compliance manager and the investigative team. If an employee is the suspected abuser, the employee is removed from the home and will be removed from any other scheduled home care services during the investigation. The employee will be informed not to have any contact with the vulnerable adult or minor to prevent retaliatory issues from occurring.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to immediately report an allegation of verbal abuse to the state agency (SA) and administrator for 1 of 1 patient (P1) following an allegation of verbal abuse by a home health aide (HHA)-A. This had the potential to affect all 5 patients who received care from HHA-A. P1's Home Health Certification And Plan Of Care (POC) for the certification period 3/23/22 - 5/01/22, indicated diagnoses of major depression and lower back pain. The POC further indicated that P1 was to receive 0-3 visits each week x 60 days for bathing, dressing, grooming, skincare, ambulation, transfers, and light housekeeping. A report to the state agency (SA) dated 4/26/22, at 3:30 p.m. indicated P1's case manager was at her home while HHA-A arrived at P1’s home and argued with P1 about why she did not receive her shower due to her being passed out on 4/25/22. And, when HHA-A offered the shower, P1 wanted to eat instead. P1 denied she was passed out, the HHA-A continued to yell at P1 and stated look at all the empty bottles you’re an alcoholic. HHA-A then stormed out of P1’s home and stated the staff (unknown) will not be coming back either on 4/27/22. The reporter was unsure if P1 was dropped as a client from the agency. During an interview on 5/9/22, at 4:00 p.m. the branch office coordinator (BOC) stated she was informed of the incident around 4/28/22, by the county case manager. The BOC stated it was on her list to speak to the staff involved home health aide (HHA)-A but she has not yet and should have. The BOC stated typically with abuse investigations the compliance department is informed and they complete the investigations. The BOC stated she did not inform the compliance officers of the incident and HHA-A continues to work with other patients. Review of P1's record failed to indicate a report was made by the agency to the (SA) or the the administrator. During interview with the compliance manager (CM) on 5/10/22, at 12:00 p.m. the CM stated the incident should have been immediately reported to him and HHA-A should have been removed from the schedule pending an investigation. The CM stated he was never informed of the incident and should have so a thorough investigation could have been completed. Facility policy International Quality Homecare Reporting Of Vulnerable Adults updated 2/25/21, indicated a person who has a reason to believe that a vulnerable individual is being or has been maltreated, or who has knowledge that a vulnerable individual has sustained a physical injury that is not reasonably explained shall immediately report the information to the Compliance Manager and/or the Compliance Director at the corporate office. If unable to reach either, contact should then be made to the Administrator. In addition, the policy indicated if an employee is the suspected abuser, the employee is removed from the home and will be removed from any other scheduled home care services during the investigation.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and document review the facility failed to develop policies and procedures to mitigate the transmission risk of COVID 19 for unvaccinated employees with exemptions for 2 of 2 staff home health aide (HHA)-A and HHA-B whom had exemptions. In addition, the agency failed to ensure all staff were wearing personal eye protection (PPE) while caring for clients. This had the potential to affect all patients in the agency. The agencies vaccination rate was 100% with two approved religious exemptions. The community transmission rate was at high risk. Facility policy COVID-19 Vaccination updated 1/04/22 indicated unvaccinated staff who received exemption will be required to follow additional CDC-recommended precautions, such as adhering to universal source control and physical distancing. In addition, the policy indicated unvaccinated staff must remain in compliance with Prevention Strategies Provide Extra Layers Of Protection: -Masks -Handwashing -Respiratory Etiquette (surgical masks) -Social distancing -Cleaning and disinfecting and, -Screening for symptoms The policy only listed standard infection control practices and lacked any additional mitigating practices for unvaccinated staff to prevent the spread of COVID-19. In addition, the policy lacked to indicate staff were to be wearing eye personal protective equipment (PPE). During interview on 5/12/22, at 11:00 a.m. the branch office coordinator (BOC) stated the agency has two staff that have religious approved exemptions and they were to follow the same precautions as vaccinated staff which included wearing surgical masks and follow universal precautions. The BOC further stated the staff are not wearing eye PPE and was not aware they were supposed to be wearing them.