Every finding on record at Lorian Health

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from May 3, 2022 through May 10, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness plan every 2 years. Findings include: On 5/04/2022 in the morning, the agency provided an appendix A Hazard Vulnerability Assessment. The last review date for the assessment was dated January 2020. The Administrator indicated the assessment would not have changed due to the Covid-19 focus still currently take place.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures at least every 2 years. The Director of Patient Care Services indicated the agency provided all the documents located.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying patients in need of home evacuation at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding identifying patients needing evacuation from their residences at least every 2 years. The Director of Patient Care Services indicated the agency provided all the documents located.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying on duty staff or patients the agency was unable to contact at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding identifying on duty staff or patients the agency was unable to contact and report to state and local officials at least every 2 years. The Director of Patient Care Services indicated the agency provided all the documents located.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing/maintaining availability of records at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding a system of medical documentation preserving patient information, protecting confidentiality of patient information, and securing/maintaining availability of records at least every 2 years. The Director of Patient Care Services indicated the agency provided all the documents located. A document entitled Emergency Visit Notes was provided without any policies or procedures addressing all of the above.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years. The Director of Patient Care Services indicated the agency provided all the documents located.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. The Director of Patient Care Services indicated the agency provided all the documents located.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. The Director of Patient Care Services indicated the agency provided all the documents located.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Agency] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. The Director of Patient Care Services indicated the agency provided all the documents located.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically to include all of the following: A method for sharing information and medical documentation for patients under the [agency's] care, as necessary, with other health providers to maintain the continuity of care, and the means for providing information about the general condition and location of patients under the [agency's] care as permitted under 45 CFR 164.510(b)(4). The Director of Patient Care Services indicated the agency provided all the documents located.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: A means of providing information about the [agency's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. The Director of Patient Care Services indicated the agency provided all the documents located.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its emergency preparedness training and testing program at least every 2 years. Findings include: On 5/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its emergency preparedness training and testing program. The [agency] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The Director of Patient Care Services indicated the agency provided all the documents located.

This Statement of Deficiencies was generated as a result of the Medicare Recertification survey, Healthcare Worker (HCW) Vaccine Mandate, and a complaint investigation conducted at your agency from May 03, 2022, through May 10, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. Seventeen clinical records were reviewed. Seven home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 93.1% compliance with Healthcare Worker vaccination requirements. Three complaints were investigated. Complaint NV00061548 with the following allegations was substantiated. Allegation 1) During an identified Physical Therapy (PT) visit, patient told the PT of not feeling well and the PT did not investigate further could not be substantiated because there was no documented evidence of a PT visit on the day in question. The next closest visit lacked documented evidence the patient said anything about not feeling well, and the assessment documentation did not differentiate itself from other visits. Allegation 2) During an identified Skilled Nurse (SN) visit, patient told the nurse of not feeling well and even though patient had a weight gain, no additional assessment or call to the physician was made could not be substantiated because the weight gain did not exceed documented parameters requiring physician notification. The assessment itself was not substantially differentiated from other visits, and there was no documented evidence the patient verbalized not feeling well. Allegation 3) No individualized care plan in home was substantiated based on the requirement for written instructions to be provided to patients in the home regarding care and treatment. Interview and policy revealed the agency provided the plan of care upon request. Patients were not required to request the instructions (see Tag G0612). Allegation 4) No PT exercise/strengthening instructions for patient to do on non-visit days could not be substantiated because there was documented evidence the patient was provided a home exercise plan. Allegation 5) No signs regarding oxygen in use could not be substantiated because the agency was not responsible for providing oxygen. The agency documented teaching regarding oxygen use several times, including signage. The clinician(s) did not recall whether there was signage or not, but it would normally be provided by the Durable Medical Equipment (DME) company, not the agency. Allegation 6) No schedule of planned visits; they just call the morning of and ask if they could come today was substantiated because there was no documented evidence of written visit schedules during home visits as required. This could be through utilization of the calendar templates in the patient booklet or some other hand out. The agency's practice was to call patients the evening before (see Tag G0614). Allegation 7) No signed consents could not be substantiated because consents were obtained and signed. Allegation 8) State toll free hotline number (to lodge complaints) was buried at the bottom of Page 49 of the magazine/” workbook”. No circle or highlight to indicate that patient was told about it. When asked if patient was aware, denied any knowledge of it. This allegation could not be substantiated because the signed consents obtained highlighted the patient acknowledged being instructed about the State toll free hotline number. Allegation 9) No increase in visit frequency after hospitalizations between July and December even though Outcome and Assessment Information Set (OASIS) assessments indicated a need for frequent monitoring could not be substantiated because the plans of care showed the opposite. Visit frequency increased from every other week to weekly after the September hospitalization. Although the visit frequency increased, the order for reporting weight changes was out of sync with the ordered visit frequency for the plans of care. The agency was cited for coordination of care because there was no way the agency could either effectively monitor the patient's weight changes or be held accountable for those changes because of the orders written in conjunction with the visit frequencies (see Tag G0962). Allegation 10) Patient not instructed regarding 1,500 cubic centimeter (cc) fluid per day restriction (per hospital discharge instructions) could not be substantiated because no such specific discharge instructions were identified, and the agency documented fluid management teaching. Teaching and understanding of the signs and symptoms of congestive heart failure was emphasized and documented during multiple visits before and after the September hospitalization. The teaching tool used emphasized low sodium diet, fluid intake management, monitoring weight changes and measurements of lower extremities as measures to take to lessen signs and symptoms of congestive heart failure. The agency was already cited for written instructions which often accompany fluid restrictions. Allegation 11) Instructions in magazine/ “workbook” indicate patient to voice grievances to manager (not administrator) could not be substantiated because there was no requirement to voice grievances to an Administrator above everyone else. The agency had an organized process where upon grievance issues were funneled to the administrative hierarchy as a complaints/grievances came in. Examples were reviewed. There was no documented evidence the patient complained or filed a grievance. Complaint NV00061666 with the following allegations could not be substantiated. Allegation 1) A staff member used a wound application with sulfa in it, for which the patient had a known allergy could not be substantiated based upon reviewing the clinical record. The Nurse Practitioner ordered the product for which the patient had a sulfa allergy. The agency requested the order. The clinical record lacked documented evidence of an order, and the patient had not picked up the product at the pharmacy. A week later, the Nurse Practitioner told the patient a week after ordering not to pick up the product, realizing the allergy. The patient complained about the nurse's wound care the day before, and the Nurse Practitioner reported the nurse for using a sulfa product when the nurse did not use a sulfa product. Although the product was not used, the agency was cited for coordination of care because there was no copy of the order despite a request for it, and nobody realized for a week about the allergy. The Nurse Practitioner blamed an agency nurse for using a sulfa product, knowing the product was not picked up from the pharmacy. The agency acted as if it had no knowledge about the wound care referral initially and was unable to facilitate interviews with the nurse and Nurse Practitioner. The agency was cited at Tag G0962. Allegation 2) The wound site was burning with reinfection. The patient was in a lot of pain and having issues walking could not be substantiated as far as being caused by the agency. The patient was admitted with an infected wound and was on antibiotics. The wound documentation was reviewed for the entire stay. The descriptor of burning pain with redness surrounding the wound was present on nearly every visit since admission. There was a possible right calcaneus ankle fracture identified by home x-ray at the point in time of this allegation which would certainly be cause for significant pain increase. There was no documented evidence as to the possible cause, source, or timing of the possible fracture. Complaint NV00061697 with the following allegations was substantiated. Allegation 1) The agency made no attempt to schedule and conduct a start of care OASIS within 24 to 48 hours of discharge/referral was unsubstantiated because the agency made contact on 01/01/2022. According to 2 different referenced documents, the agency received the home health referral on 12/31/2021: The Patient Information Report and the Client Coordination Note Report. The Scheduling Coordinator completed both documents. On 01/01/2022, the Scheduling Coordinator documented contact with the patient’s family, confirmed the family member as the point of contact, confirmed the patient's doctor, confirmed the patient's address and phone number, and confirmed the agreed upon start of care date as 01/03/2022. This date was written on the Plan of Care as patient-requested and therefore physician-ordered as well which was acceptable per policy. Allegation 2) The agency's nurse inaccurately assessed/documented aspects in the start of care OASIS were substantiated (see Tag G0526). Allegation 3) The agency failed to provide copies of signed admission documents could not be substantiated, as this was not a requirement. The patient's signed consent was obtained. The last sentence of the agreement read "by signing below, I agree that I have been instructed, reviewed and understand all the above. I have received a hard copy for my records." The patient signed the document 01/03/2022. Allegation 4) The agency failed to provide a copy of the plan of care to the patient was substantiated (see Tag G0612). Allegation 5) Failing to provide a hard copy written schedule of planned visits was substantiated (see Tag G0614). The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the agency's nurse failed to accurately assess a patient's medication administration ability and whether a patient used a walker for 1 of 17 sampled patients (Patient 15). Findings include: Patient 15 was discharged on 12/31/2021, from an acute care hospital with a case management documented assessment showing independent management of home medication and no durable medical equipment. The agency admitted Patient 15 on 01/03/2022 with diagnosis of status post-surgery for carotid endarterectomy. A Registered Nurse (RN) conducted an Outcome and Assessment Information Set (OASIS) Start of Care assessment on 01/03/2022. The RN documented the patient was unable to take medication unless administered by another person for Question M2020. On 5/06/2022, the RN did not recall specific rationale as to why the patient was assessed as needing medication assistance in the home during the Start of Care assessment on 01/03/2022. The RN documented the patient used a walker prior to the hospitalization referred to for Question GG0110. On 5/06/2022 at 9:30 AM, the RN indicated a possible error regarding the walker used prior to hospitalization, although there was a possible anticipated need for a walker in the discharge summary.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide ordered treatment in relation to a physical therapy visit for 2 of 17 sampled patients (Patient 1 and 14). Findings include: Patient 1 was admitted to the agency on 11/26/2021 with diagnoses including diabetes mellitus II with gangrene. A Physician Order dated 11/28/2021 documented physical therapy visits once weekly for two weeks and then twice weekly for the next six weeks. For the week of 12/26/2021 through 1/01/2022, the agency conducted one documented physical therapy visit dated 12/30/2021. The clinical record lacked documented evidence the twice weekly visit frequency was changed or discontinued. The clinical record lacked documented evidence of a missed visit or communication note explaining the absence of a second visit for the week. Patient 14 was admitted to the agency on 09/23/2021 with diagnoses including chronic congestive heart failure and chronic obstructive pulmonary disease. The Plan of Care dated 09/23/2021 documented a physical therapy evaluation for the week of 09/26/2021. The clinical record lacked documented evidence of a physical therapy evaluation, missed visit or order change or discontinuation. On 5/06/2022 in the afternoon, the Director of Patient Care Services indicated a 5-day expectation for secondary discipline evaluations and confirmed there was no documented evidence the aforementioned visits were conducted, documented, or otherwise explained as missed, changed, or discontinued.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure treatments were administered only as ordered by a physician or allowed Nurse Practitioner for 1 of 17 sampled patients (Patient 8). Findings include: Patient 8 was admitted to the agency on 12/03/2021, with diagnoses including open wound and cellulitis of right lower extremity. A Physician order dated 12/03/2021, documented med honey application to a right lateral ankle wound. A Nurse Practitioner Wound Specialist ordered 1% Sulfa Silvadene Cream to a right lateral ankle wound on 12/23/2021. A Licensed Practical Nurse documented the use of AG (silver antimicrobial) Gel in the patient's wound on 12/24/2021. The clinical record lacked documented evidence a provider ordered AG Gel for the patient's wound. The clinical record lacked documented evidence of the 1% Sulfa Silvadene order. On 05/06/2022 in the afternoon, the Director of Patient Care Services confirmed the findings.

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 observation, interview and policy review, the agency failed to ensure patients received written instructions outlining services provided to patients in the plan of care for 2 of 7 sampled patients visited (Patient 9 and 2). Findings include: Patient 9 On 05/03/2022 in the afternoon, a Physical Therapy Assistant conducted a home visit. During the visit, the patient's spouse provided the home health information left. Besides the booklet, there was no documented evidence of either a visit schedule or instructions regarding the agency services provided to the patient. Patient 2 On 05/05/2022 at 9:00 AM, a Licensed Practical Nurse conducted a home visit. Besides the booklet, there was no documented evidence of either a visit schedule or instructions regarding the agency services provided to the patient. On 05/06/2022 at 9:30 AM, a Registered Nurse indicated the assigned nurse contacted the patient the evening before, usually between 5 and 7 PM to confirm the appointment. The Registered Nurse confirmed the evening call made prior to appointments as a regular practice. The Director of Patient Care Services confirmed this as the agency's process. On 05/06/2022 at 9:30 AM, a Registered Nurse indicated patients did not typically receive a plan of care but could get a copy upon request. The Director of Patient Care Services indicated patients were provided the plan of care when requested and showed a policy which revealed patients had to request the plan of care to receive instructions on their services.

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 provide documented evidence of written visit schedules in the home for 1 of 7 sampled patients visited (Patient 9). Findings include: Patient 9 On 05/03/2022 in the afternoon, a Physical Therapy Assistant (PTA)conducted a home visit. During the visit, the patient's spouse provided the home health information left. Besides the booklet left, there was no documented evident of a visit schedule. The calendar area inside was left blank. The PTA indicated patients were called for appointments ahead of time. On 05/06/2022 at 9:30 AM, a Registered Nurse indicated the assigned nurse contacted the patient the evening before, usually between 5 and 7 PM to confirm the appointment. The Registered Nurse confirmed the evening call made prior to appointments as a regular practice. The Director of Patient Care Services confirmed this as the agency's process.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and policy review, the agency failed to follow its infection control practices when conducting home visits for 2 of 7 sampled patients visited (Patient 2 and 9). Findings include: Patient 2 On 05/05/2022 at 9:00 AM, a home visit was conducted with a Licensed Practical Nurse (LPN). The LPN did not verbalize any COVID screening of the patient at the door or throughout the visit. At the conclusion of the visit, the LPN acknowledged the agency contacted the patient directly for the home visit appointment, and the LPN did not contact the patient ahead of time. Pages 15-16 of the agency's COVID Plan revealed multiple pre-screening and screening assessment form questions for follow-up visits. Patient 9 On 05/03/2022 in the afternoon, a home visit was conducted with a Physical Therapy Assistant (PTA). The PTA did not wear a mask throughout the home visit. The PTA confirmed needing to wear a surgical mask. Page 6 of the agency's COVID Plan revealed field staff must use a surgical mask at all times while working.

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, record review and document review, the agency failed to update their staff vaccine policy and maintain a staff vaccination rate of 100%. Findings include: On 05/06/2022, in the afternoon, the Director of Patient Care Services (DPCS) confirmed the agency had no updated/revised staff vaccine policy which documented the following: -All staff have received at least a single-dose COVID-19 vaccine or the first dose of a multi-dose COVID-19 vaccine series prior to providing any care or services -All staff, except those granted an exemption or for whom the vaccine must be temporarily delayed, are fully vaccinated for COVID-19 -Those staff who are not fully vaccinated adhere to additional precautions in order to mitigate the spread of COVID-19 -Staff are able to request an exemption from vaccination for medical or non-medical reasons -Each staff member's vaccination status, including any boosters received -Each staff who requested and been granted an exemption to vaccination -Each staff for whom the vaccine must be temporarily delayed -Contingency plans for staff who are not fully vaccinated. On 05/06/2022 in the afternoon, the DPCS and the Human Resource Director confirmed the agency had 44 employees. Forty-one employees were fully vaccinated, two Licensed Practical Nurses were not vaccinated (with no exemptions or delay) and one Home Health Aid was partially vaccinated calculating the vaccine percentage rate at 93.1%.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care in a manner which the plan of care clearly reflected wound care orders skilled nurses could readily implement for 1 of 17 sampled patients (Patient 8) and failed to ensure a patient's changes in weight would be monitored and reported for significant changes within the plan of care as written for 1 of 17 sampled patients (Patient 14). Findings include: Patient 8 was admitted to the agency on 12/03/2021 with diagnoses including open wound and cellulitis of right lower extremity. A Physician order dated 12/03/2021, documented med honey application to a right lateral ankle wound. A Nurse Practitioner Wound Specialist (NPWS) ordered 1% Sulfa Silvadene Cream to a right lateral ankle wound on 12/23/2021. A Licensed Practical Nurse documented applying AG (silver antimicrobial) Gel in the patient's wound on 12/24/2021. The clinical record lacked documented evidence a provider ordered AG Gel for the patient's wound. The clinical record lacked documented evidence of the 1% Sulfa Silvadene order. Evidence of Lack of Care Coordination: On 5/05/2022 in the afternoon, the Director of Patient Care Services (DPCS) initially indicated the agency did not collaborate with the NPWS because the clinical record lacked documented evidence of any order for a NPWS to consult for wound care. However, after reviewing the skilled visit notes for wound care documentation, it was evident nurses used differing wound applications without orders and referenced the NPWS visit with an order change. The only orders in the chart were for med honey. After discussing the agency's lack of monitoring (being in charge) of the patient's care involving the NPWS with the DPCS, the DPCS retrieved copies of the NPWS consults. The consult documentation in conjunction with the plan of care became problematic for the following: 1) The NPWS conducted two consult visits on 12/23/2021 and 12/30/2021 respectively, but the clinical record lacked documented evidence a physician ordered the consults. There was no documented evidence the agency was accepting wound care orders from the NPWS, and the agency did not have a contract with the NPWS to provide services for patients. 2) Within the consult documentation for each visit, a section entitled General Wound Care Instructions stated "it is okay to obtain verbal permission for dressing changes based on nursing judgment from the consultant's office. Okay to use generic or equivalent products for wound care." The consult documentation and the clinical record lacked documented evidence as to what generic or equivalent products would be acceptable for this patient. 3) Within the consult documentation for each visit, a section entitled "frequency of dressing changes" stated home health registered nurse twice weekly, but the clinical record showed documented evidence several licensed practical nurses conducted wound care visits. 4) Within the consult documentation for the 12/23/2021 visit, the NPWS ordered 1% Sulfa Silvadene Cream to the wound bed despite the fact the patient had a known documented sulfa allergy. The clinical record lacked documented evidence of an order for 1% Sulfa Silvadene. On 12/24/2021, a skilled nurse visit documented a licensed practical nurse (LPN) used AG Gel on the wound bed, but the clinical record lacked documented evidence of an order for AG Gel. 5) Within the consult documentation for the 12/30/2021 visit, the NPWS discussed the patient's sulfa allergy upon arrival for the consult and advised the patient not to pick up the 1% Sulfa Silvadene from the pharmacy. The patient indicated not picking it up. Then the NPWS contacted the agency and reported the LPN for using 1% Sulfa Silvadene on the patient's wound due to the patient complaining about the LPN's visit, even though the NPWS knew the patient did not have the 1% Sulfa Silvadene in the home. The clinical record lacked documented evidence the NPWS faxed the order as requested, was aware of the allergy, communicated the awareness to the agency and discontinued the 1% Sulfa Silvadene order prior to 12/30/2021. The DPCS indicated an inability to facilitate interviews with either the LPN or the NPWS. Patient 14 was admitted to the agency on 03/24/2021 with diagnoses including chronic combined systolic and diastolic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The agency continuously recertified the patient. In the care episode 07/22/2021 through 09/19/2021, the patient had an acute on chronic exacerbation of congested heart failure (CHF) and chronic obstructive pulmonary disease (COPD) exacerbation and was hospitalized 09/18/2021 to 09/22/2021. The plan of care documented skilled nurse visits ordered every 2 weeks for 6 weeks in August and September 2021. A Registered Nurse documented a skilled nurse visit dated 09/15/2021, revealing a 5-pound weight gain compared to the previous skilled nurse visit dated 08/31/2021. The clinical record lacked documented evidence the weight gain was reported to a physician. On 9/18/2021, the patient went emergently to acute care for acute on chronic exacerbation of CHF and COPD. The agency's professed teaching tool entitled Heart Failure Patient Care, Home Care provided by the Director of Patient Care Services (DPCS) revealed rapid weight gain (2 pounds in 24 hours or 5 pounds per week) suggests fluid retention. The agency's Significant Change for Physician's Notification policy, dated August 2019, revealed to report a 2-pound weight gain or more in 24 hours or 3 pounds or more in a workweek. The plan of care documented to report a 2–3-pound gain or loss within 5 days. On 05/06/2022 at 9:30 AM, the assigned Registered Nurse and DPCS indicated the parameters were not met to notify a physician. Within the teaching tool itself, patients were encouraged or instructed to obtain a daily weight. The assigned Registered Nurse indicated there was no way to know if the patient was being weighed and probably was not weighed between agency visits. The clinical record lacked documented evidence the patient was assessed for being capable of weighing self or was able to keep a weight log. The clinical record lacked documented evidence of ordered daily weights or a weight log to be kept. Without a daily log or assurance, the patient was weighed daily, there was no way for the agency to actively monitor weight changes in a manner which would hold it accountable for unreported changes contributing to the patient's potential CHF hospitalizations. As it was, the 5-pound gain in the first 15 days of September 2021 could have occurred gradually over the 15 days (not requiring notification) or in the last couple days prior to the visit on 9/15/2021, requiring physician notification. The plan of care as written for reporting weight changes in conjunction with the ordered visit frequency would not require a clinician to report weight changes, unless weights were ordered in the home daily or at least every 5 days (since that was the weight change reporting period ordered). The agency readmitted the patient on 09/23/2021 with diagnoses including exacerbation of acute on chronic CHF and COPD. The plan of care ordered one visit times one week, two visits’ times two weeks, and then one visit times 6 weeks for skilled nurse visits. The plan of care documented the skilled nurse to obtain daily weights and notify weight gains of 2-3 pounds within 24 hours and/or 3-5 pounds within 7 days. The clinical record lacked documented evidence how the nurse or agency would obtain daily weights without ordering the patient to keep a weight log for self-weighing or ordering daily visits. The clinical record lacked documented evidence of daily weights. From 11/19/2021 to 11/21/2021, the patient was hospitalized again for CHF and COPD exacerbation with shortness of breath worse upon exertion. On 11/22/2021, the agency recertified the patient through 01/20/2022. The plan of care and clinical record lacked documented evidence of any physician order for monitoring weight changes. On 12/06/2021 to 12/10/2021, the patient was hospitalized again with shortness of breath. The patient was discharged to a SNF and did not return to the agency.

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview, record review and document review, the facility failed to confirm if their social workers were qualified for their positions for two of three Social Workers (Social Worker 1 and 2). Findings include: The State of Nevada Board of Examiners for Social Workers revealed Social Worker 1 was a Licensed Certified Social Worker, and Social Worker 2 was a Licensed Social Worker. On 05/04/2022 in the afternoon, a representative from the State of Nevada Board of Examiners for Social Workers indicated a master’s degree Social Worker would have to apply with the Board to verify if they were a master’s degree holder from a school accredited or approved by the council on Social Work Education and have their title changed to a Licensed master’s in social Worker when they receive transcripts from their schools. There was no verified documented evidence Social Worker 1 and 2 were master’s degree holders from a school accredited or approved by the council on Social Work Education. The agency Job description form for Medical Social Workers documented the social worker qualifications were to have a master’s degree from a school accredited or approved by the council on Social Work Education. The agency undated policy titled Licensing, Certification and Registration Verification indicated employees who hold such job classifications will have their license, certification, or registration verified through the issuing agency prior to providing services and at time of renewal. On 05/06/2022 in the morning, the Human Resources (HR) Director confirmed the two social workers licenses were not verified properly to identify if the two social workers were master’s degree holders from a school accredited or approved by the council on Social Work Education. The HR Director indicated the agency did not request educational transcripts from the Social Worker's schools to verify qualifications.