Every finding on record at Loving Care Agency Inc

This visit was for a Federal complaint survey of a Deemed Home Health Provider. Survey Dates: 1/22/2024, 1/23/2024, and 1/24/2024 Complaint: 103870 with related deficiencies cited. 12-Month Unduplicated Skilled Admission: 63 QR on 01/29/2024 by A4

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received all home health aide visits as ordered, and failed to ensure all interventions were provided as ordered on the plan of care for 2 of 5 active clinical records reviewed. (Patients #1, 7) Findings include: 1. A review of agency policy 04.40.05 "Staffing and Scheduling," last revised 02/22/23, indicated "Care and services will be rendered based on ... physician orders ... 2. A review of agency policy 4.27.04 "Physician Orders/Plan of Care," last revised 12/07/23, indicated "Care and services will be provided in accordance with physician's (or authorized prescriber's) orders ... " 3. A review of the comprehensive assessment for Patient #1, dated 01/11/24, indicated a primary diagnosis of post laminectomy syndrome (a condition where the individual continues to feel pain after undergoing a laminectomy, or removal of vertebrae to reduce pressure on the spinal cord) and secondary diagnoses of encounter for attention to tracheostomy (an artificial opening into the windpipe through the neck), cerebral palsy (a group of disorders affecting the ability to move and maintain balance), neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems), microcephaly (smaller than normal head at birth or due to growth failure of the head after birth), other deforming dorsopathies (a group of diseases of the spine caused by impaired blood supply or shock/trauma to the spine), vascular myelopathies (damage to the spinal cord due to impaired blood supply), paralytic syndrome (symmetric, ascending weakness that progresses over days), convulsions (rapid, involuntary muscle contractions and twitching, often seen during a seizure), encounter for attention to gastrostomy tube (G-tube, a tube placed through an artificial opening from the abdomen to the stomach and used to provide nutrition, medication, and hydration), and dependence on supplemental oxygen. The assessment indicated Patient #1 was dependent on the ventilator (breathing machine), required frequent trach tube suctioning, required intermittent in and out catheterization (insertion of a tube via the urethra into the bladder to drain urine) every 3 hours and as needed, and required placement of a Foley catheter (a type of tube placed into the bladder to drain urine and stabilized with an inflated balloon tip to prevent dislodgement) at bedtime and removal of the Foley catheter the next morning. The patient received all nutrition and hydration, except peanut butter crackers, via G-tube, was bedfast and totally dependent for all needs, required repositioning every 2 hours, required incontinence care for bowel movements, required a specialized vest to assist with coughing up to 4 times per day, utilized orthotics, braces, and splints applied for various contracted extremities, and was dependent for all care and medications. A review of the plan of care for certification period 01/16/24 - 03/15/24 indicated a history of a wound which was healed as of 11/12/23. Skilled Nurse interventions included, but were not limited to, completing a comprehensive assessment with pain assessment every (q) shift and as needed, turn q 2 hours, G-tube feedings and water flushes 3x/day, oximetry spot checks q shift, medication administration via G-tube multiple times per day, intermittent urinary catheterization every 3 hours and as needed, placement of a Foley catheter at bedtime and removal of the catheter in the morning, assessment and monitoring of migraine, seizure activity, and spastic behavior, application of braces, orthotics, and splints to contracted limbs daily as tolerated, verification of ventilator and oximeter (non-invasive device for monitoring oxygen levels) settings and alarms, trach care q shift including change of trach ties and trach dressing, stoma cleaning, and changing/cleaning of the inner cannula (daily), G-tube care twice daily, output monitoring q shift, passive range of motion (PROM) every shift if patient did not perform active range of motion during the shift, bathing, dressing, and personal care, and incontinence care as needed. Review of the active feeding orders indicated a daily feeding plan of Kate Farms (a brand of G-tube feeding) 375 milliliters (ml), 4 packages of peanut butter crackers, and 2 packages of Prosource Water 960ml (see interview with patient caregiver concerning Prosource Protein vs Prosource Water) divided up to 3 meals/day via gravity bolus, and may have oral diet per patient or patient caregiver request for comfort or taste. Skilled nurse to give 5-8 ounces of cranberry juice with 8 ounces of water per G-tube daily for signs/symptoms of urinary tract infection including fever, cloudy urine, foul-smelling urine, pain, or agitation. Ordered safety measures included, but were not limited to, aspiration precautions, equipment safety, seizure precautions, and side rails up. A review of a skilled nursing flow sheet, dated 01/17/23, evidenced RN 3 clocked in at 8 AM and clocked out at 5 PM. The flow sheet indicated the following were checked: emergency equipment, go bag, infection control kit, O2 tank, all alarms on and audible, ambu bag/extra trach on site, safety precautions, fall precautions, aspirations precautions, standard precautions, and respiratory precautions. No time was indicated. Vital signs were obtained at 8:20 AM and 4:25 PM and an untimed comprehensive assessment was documented on the flow sheet. The record failed to evidence the patient's blood pressure was obtained during the shift. The patient received 150 ml juice and crackers at 9 AM, 150 ml of water and crackers at 12 PM, 250 ml of formula mixture and crackers at 12:15 PM, 200 ml water and crackers at 12:55 PM, 170 ml water and crackers at 2 PM, and 170 ml water and crackers at 5 PM. The record failed to evidence the amount of crackers consumed, failed to evidence they were divided into 3 meals, failed to evidence the patient received 960 ml Prosource Protein packets vs water (see interview below concerning Prosource Protein vs water), failed to evidence the patient received Kate Farms feedings of 375 ml divided into 3 feedings (125 ml each feeding), failed to evidence the type of juice given, and failed to evidence signs and symptoms of urinary tract infection indicating the need for juice. The patient was turned at 9 AM, 11 AM, and 3 PM. The record failed to evidence the patient was turned q 2 hours, failed to evidence G-tube care was done, failed to evidence active or passive range of motion was completed, failed to evidence orthotics, braces, or splints were applied or why they were not applied, failed to evidence trach care was completed or the inner cannula was changed/cleaned. The flow sheet indicated the patient was intermittently catheterized at 12 PM and a Foley catheter was inserted at 3 PM. The record failed to evidence the patient was intermittently catheterized every 3 hours and a Foley was placed at bedtime. The record failed to evidence ventilator settings and alarms were assessed and documented throughout the shift. On 01/24/24 at 3:44 PM, Person K, a relative and primary caregiver for Patient #1, indicated the patient received feedings of Kate Farms Regular which comes in an 11.5 ounce (oz.) per container. Mix 375 ml, about 1 1/2 containers, with tap water to equal 32 oz. and divide to be given in 3 separate meals. Person K indicated Prosource is not water but is a liquid protein supplement. The patient receives a 30 ml packet of Prosource Protein supplement at 9 AM and another at 9 PM, flushed before and after with tap water because the Prosource Protein supplement curdles the Kate Farms formula if they come in contact. Person K indicated the peanut butter crackers were figured into the patient's calories and nutrition plan by a dietician to increase protein and promote healing of a now-healed pressure ulcer caused by the patient's cough assist vest and the crackers, which come 6/package, were required nutritional intake for the patient. On 01/23/24, the Nursing Director indicated all skilled nurse's caring for patients receiving mechanical ventilation should document using a skilled nurse flow sheet and an invasive ventilation flow sheet. The Nursing Director indicated RN 3 did not submit an invasive ventilation flow sheet on 01/17/24. On 01/24/24 at 3:10 PM, RN 3 indicated the ventilator and alarm settings should be documented at least every hour and the patient's interventions and treatments should all be documented on the nursing flow sheet as ordered on the plan of care. RN 3 indicated she gets busy and doesn't document things if they are going as they should. 4. A review of a complaint dated 01/18/24 indicated Person L, a relative and primary caregiver for Patient #7, spoke with RN 1 on 01/17/24 to ask if any other available HHAs were available to cover upcoming open shifts. A review of a care plan assessment for Patient #7, dated 01/08/24, indicated home health aide services were ordered for 4 hours/day, 7 days/week not to exceed 28 hours per week. A review of the plan of care for certification period 01/12/24 - 03/11/24 indicated home health aide services were ordered 4 hours/day, 7 days/week, not to exceed 28 hours/week. A review of the confirmed visit schedule (visits confirmed as provided based on clock in/clock out and submission of visit notes) indicated missed visits on 01/13/24, 01/14/24, and 01/18/24 - 01/24/24 due to "unassigned." 5. On 01/24/24 at 2:11 PM, HHA 3 indicated Patient #7 received 3 separate HHA shifts each day for an hour in the morning for dressing and toileting, an hour around noon for toileting, and 2 hours from 8 PM - 10 PM for bathing, personal care, and meal prep for the next day. HHA 3 indicated there were only 2 HHAs assigned to the case, and they had difficulty staffing all shifts. HHA 3 indicated they tried to fill in for the night shift but often couldn't and the second aide was currently on vacation with no one to fill the shifts. 6. On 01/23/24 at 4:09 PM, Person L indicated Patient #7 received a 1-hour morning shift, a 1-hour shift around noon, and a 2-hour shift in the evening where most of the personal care occurred. Person L indicated being concern about scheduling because the scheduler worked out of the Indianapolis office and the patient was in the Valparaiso area. Person L indicated the scheduler doesn't return their calls and no one had not called about the unscheduled shifts. 7. On 01/24/24 at 1:31 PM, the Client Services Supervisor indicated RN 1 notified him the patient had been moved to a relative's house due to a flood in the apartment and the relative would provide care. The Client Services Representative also indicated an aide scheduled to fill in starting 01/17/24 was asked not to return and there was no one else to schedule. 8. On 01/24/24 at 4:48 PM, the Nursing Director indicated Patient #7 received 3 visits each day and they were unable to find coverage for all 3 shifts. No further information was available related to care coordination.

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 all medications were administered according to physician's orders for 1 of 5 active patient records reviewed. (Patient #1) Findings include: A review of agency policy 4.27.04 "Physician's Orders/Plan of Care," last revised 12/07/23, indicated "Care and services will be provided in accordance with physician's … orders … " A review of the plan of care for Patient #1, for the certification period 01/16/24 - 03/15/24, evidenced the patient received Sodium Chloride 0.9% inhalation every 4 hours, Sodium Chloride 3% Inhalation twice daily and as needed every 6 hours for increased secretions, Albuterol Sulfate 2.5mg/3ml inhalation every 3 hours as needed for wheezing/shortness of breath/cough/increased work of breathing (start date 12/03/08), and Tobramycin Sulfate 80 mg via nebulizer twice/day as needed x 28 days for respiratory illness (effective date 09/19/22). The plan of care failed to evidence the Tobramycin Sulfate was discontinued 28 days after the effective date of 09/19/22. A review of a skilled nurse flow sheet, dated 01/22/24, evidenced an entry at 6:30 AM which indicated " 3L [Liters] continuous O2 [oxygen] nebs [refers to inhaled medication delivered via a nebulizer or device used to create a fine spray of an inhaled medication] started per order by mom 0715 started tobi [Tobramycin - an inhaled antibiotic] per order due to psudeomonous [sic pseudomonas - a type of bacteria] smell … " The record failed to evidence a current order for inhaled Tobramycin. On 01/24/24 at 9:08 AM, the Nursing Director indicated a patient's parent may choose to give different medications, treatments, or care but the nurse should verify all medications, care, and treatments against the plan of care or updated physician's order or by speaking with the physician's office.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained all clinical notes and all documentation of communication with and about patients and their care and services for 2 of 5 active clinical records reviewed. (Patients #1, #2) Findings include: 1. A policy received from the Agency on 01/23/2024 at 12:06 PM titled " General Communication" indicated but was not limited to " Regular communication with physicians, patients, staff, payers, case managers, supervisors or others providing and/or overseeing care or service to patients will be documented . . . Any communication . . . will be documented in the patient's medical record . . . ." 2. During an interview with Registered Nurse (RN) # 1 on 01/23/2024 at 2:30 PM, they reported having a document from 12/19/2023 related to Patient #2 explaining the education and information provided to the caregiver of Patient #2. When queried if this was in the clinical record, they replied, " . . . I do my best but I am checking . . . " The RN failed to include the document in the Patient’s clinical record and failed to follow agency policy. 3. A review of the comprehensive assessment for Patient #1, dated 01/11/24, indicated the patient had a tracheostomy (an artificial opening through the neck and windpipe) and was dependent on mechanical ventilation for breathing. Review of the skilled nurse visits evidenced a skilled nurse flow sheet was submitted for 12/06, 12/07, 12/09, 12/16, 12/20, 12/21, 12/24, 12/27, 12/30/23 and 01/03, 01/04, 01/06, 01/11, and 01/13/24. The record failed to evidence an Invasive Ventilation Flow Sheet was submitted with the skilled nurse visit note for the specified days. On 01//23/24 at 2:46 PM, the Nursing Director indicated the nurses document ventilator settings and information on the Invasive Ventilation Flow Sheet and it was expected to be submitted with every visit. On 01/24/24 at 3:10 PM, RN 3 indicated she had not submitted Invasive Ventilation Flow Sheets for Patient #1 but should have done so.

This visit was for a federal complaint investigation at a deemed home health agency. Complaint #: IN 00345786; substantiated with findings Survey Dates: 3-30 and 3-31-2021 Facility #: 007136 CCN #: 157606 MCD #: 200869820 Quality Review Completed on 4/6/21 by Area 3

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the frequency and hours of care visits were individualized on the plan of care to meet the patients needs as identified in the comprehensive assessment for 2 of 3 (Patients #1 and 2) patients whose clinical record was reviewed. The findings included: 1. Review of a policy, "Plan of Care," last reviewed/ revised 5-28-2020, evidenced the policy stated, " ... An individualized care plan will be developed by the appropriate personnel to ensure that care and services are appropriate to the patient's specific needs/ problems ... It is developed based on the initial assessment, goals, problems, and patient care needs .... " 2. Review of the clinical record of patient #1, evidenced a start of care date of 10-12-2020, and contained a plan of care for certification periods 10-12-2020 to 12-10-2020, and 12-11-2020 to 2-8-2021. Patient #1's primary diagnosis was quadriplegia, and plan of care orders included home health aide (HHA) care visits 7-9 hours a day, 4-7 days a week to perform activities of daily living, to include bed bath and incontinence care, and instrumental activities of daily living. Review of the comprehensive assessments dated 10-12-2020 and 12-4-2020, evidenced patient #1 was bedbound, and lived with only an elder mother who was unable to provide patient #1's care. Diagnoses included quadriplegia, generalized anxiety disorder, cystitis (bladder infection), and suprapubic catheter (a catheter placed through the abdominal skin into the bladder to drain urine.) Patient #1 had sensation to mid-chest and used a mouth stick to operate remote controls for telephone and television, and patient #1 was totally dependent on caregivers for all needs/ care. Patient #1's mother was identified as a caregiver, but was noted not to be able to reposition or bathe patient #1. The plan of care failed to be individualized to meet patient #1's needs as a quadriplegic for care visits 7 days a week to provide continence care, bed bath several times each week, repositioning patient each 2 hours during care visits to ensure relief of pressure from left buttock wound & dressing, to provide hydration and meals, linen changes, and to assist patient #1 with oral care, etc. Review of the prior authorization document, dated 10-15-2020, evidenced 8 hours a day of home health aide visits, 7 days a week, were authorized by Medicaid. On 3-31-2021, at P.M., when the administrator and acting clinical manager, employee B, were queried about the agency's choice in the plan of care for HHA visits 4-7 days a week, rather than 7 days a week, the administrator stated the agency had often used ranges of visits per week, rather than a discrete number. Neither disagreed with the determination based on patient #1's comprehensive assessments, the appropriate care visits were at the maximum permitted by the prior authorization of 8 hours, 7 days a week. 3. Review of the clinical record for patient #2, evidenced a start of care date of 5-31-2017, date of birth of 1-3-1998, evidenced diagnoses to include, congenital deformity of spine and cerebral palsy, and contained plans of care for certification periods 1-18- to 3-18-2021, and 3-19 to 5-17-2021, each with orders for home health aide 3-9 hours per visit, 2-5 days per week "to assist with ADLs (activities of daily living) and personal care tasks and follow aide care plan ... Hygiene and grooming; assist with shower, shampoo hair, hair care, mouth care set up, shave legs, underarms, and bikini area with electric razor, assist with dressing, clean/file nails, foot care, skin care; elimination: assist with toileting, assist with toilet transfers ... Transfers: mobile wheelchair, transfers pivot, pt. able to reposition self, HHA may provide gentle PROM (passive range of motion) to extremities as requested by patient ... Meals: prepare meal, set up meal, patient may assist with meal prep ... Housekeeping: change bed linens, make bed, tidy room where care provided, clean/dust surfaces, laundry ... Medications: med reminders ... Safety: fall precautions, hip precautions, glasses, regular diet." Review of the recertification comprehensive assessment dated 3-12-2021, evidenced patient #2 lived at home with parents and other siblings and required assistance with bathing, dressing, toileting, transfers, meals, and medication reminders. Review of HHA visit notes from 1-18-2021 to 3-29-2021, evidenced the home health aide was in the home of patient #2 to provide the above described care consistently for 8 hours, 5 days per week. A range of visit hours of 3-9 hours was not appropriate and individualized because it took the HHA 8 hours to complete the care. On 3-31-2021, at 10:58 A.M., the administrator and acting clinical supervisor (acting nursing supervisor), employee B, verified the plans of care were not individualized and established to meet the patients' identified needs. They indicated patient #1's quadriplegia warranted the maximum prior authorization permitted HHA hours and days per week of visits. They indicated for patient #2, the HHA visits took 8 hours to provide the ordered care, and the range of 3-9 hours was not individualized to meet patient #2's needs for care of 8 hour visits.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse failed to ensure the written care instructions included the frequency a patient with buttock wound and dressing should be repositioned for 1 of 1 patient with wound (Patient #1) and failed to ensure a minimum frequency for bathing was established in relation to hygiene for 2 of 3 patients (Patients #1 and 2) whose clinical record was reviewed. The findings included: 1. Review of a policy, "Care Plan," last reviewed/revised 5-28-2020, evidenced the policy stated, " ... When aide services are provided, written patient care instructions for the aide must be prepared by the registered nurse ... Assignments are designated based on patient need and the utilization of "prn" [as needed] is not to be associated with any task. Determination of when tasks are performed are out of the scope of practice for aides ... " 2. Review of the plan of care for patient #1, start of care date of 10-12-2020, evidenced patient #1 was quadriplegic and totally dependent on caregivers for ADLs (activities of daily living) and IADLs (Instrumental Activities of Daily Living.) Review of the home health aide (HHA) care plan updated 12-4-2020, evidenced bed bath was ordered "as requested." The HHA care plan failed to include a minimum frequency of bed bath for patient #1's hygiene needs. 3. Review of the plan of care for the certification period of 3-19 to 5-17-2021 for patient #2, evidenced diagnosis of congenital deformity of the spine and cerebral palsy, with durable medical equipment of bath/shower chair, and wheelchair. Review of the clinical record for patient #2, start of care date of 5-31-2017, evidenced a home health aide (HHA) care plan updated 9-15, 11-17-2020, 1-12, and 3-12-2021, with shower assistance to be provided "as requested." Other HHA tasks ordered "as requested" included mouth care set up, toilet, pivot transfer, change linens, make bed, tidy room, clean surfaces, and laundry. The HHA care plan failed to establish a minimum frequency for patient #2's hygiene needs and other HHA tasks. 4. On 3-31-2021, at 10:58 A.M., the administrator and acting clinical supervisor, employee B, verified the home health aide care plans included "as requested" for the frequency of bathing and repositioning, and all HHA instructions should have been specific to include a minimum frequency.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to establish written guidelines and a procedure in relation to when, how, and who must participate in the decision whether to accept patients to agency service for 1 of 1 governing body. The findings included: Review of the clinical record of patient #1, evidenced a start of care date of 10-12-2020, and contained a plan of care for certification periods 10-12-2020 to 12-10-2020, and 12-11-2020 to 2-8-2021. Patient #1's primary diagnosis was quadriplegia, and plan of care orders included home health aide (HHA) care visits 7-9 hours a day, 4-7 days a week to perform activities of daily living, to include bed bath and incontinence care, and instrumental activities of daily living. Review of the comprehensive assessment dated 10-12-2020, evidenced patient #1 was bedbound, and lived with an elder mother. Diagnoses included quadriplegia, generalized anxiety disorder, cystitis (bladder infection), and suprapubic catheter (a catheter placed through the abdominal skin into the bladder.) Patient #1 was totally dependent on caregivers for all needs/care. Patient #1's mother was identified as a caregiver. Review of the recertification comprehensive assessment dated 12-4-2020, evidenced patient #1 was bedbound, and lived with an elder mother. Diagnoses included quadriplegia, generalized anxiety disorder, cystitis (bladder infection), and suprapubic catheter (a catheter placed through the abdominal skin into the bladder.) Patient #1 was totally dependent on caregivers for all needs/care. Patient #1's mother was identified as a caregiver. Review of a document, "Backup Caregiver Agreement," evidenced patient #1's brother and sister as alternate caregivers. The document stated, " ... I understand there may be times when the agency's employees or contractors may be unable to provide scheduled services ... " The document identified patient #1's brother and sister as alternate caregivers and was signed by patient #1's mother on 10-12-2020. On 3-30-2021, the acting clinical manager, employee B, indicated patient #1's brother and sister did not reside with patient #1, but lived in town. Employee B also stated patient #1's mother was elderly and unable to bathe or reposition patient #1. Review of HHA visit notes during the 1st certification period failed to evidence home health visits the week of November 22 to November 28, 2020. During the week of November 29 to December 5, a HHA care visit was made on 12-4-2020, from 12-5 P.M., and on 12-5-2020, from 9 to 10:30 P.M. The agency failed to meet the ordered hours of care per visit, and failed to meet the ordered frequency of visits. Review of HHA visit notes during the 2nd certification period failed to evidence home health visits the week of January 3 to January 9, 2021. The agency failed to meet the ordered hours of care per visit, and failed to meet the ordered frequency of visits. On 3-31-2021, at 12:51 P.M., when asked about the failure to provide visits, indicated patient #1's brother, a designated alternate caregiver, did not come to provide care when she requested due to lack of agency staffing. When the language on the Backup Caregiver Agreement, " ... I understand there may be times when the agency's employees or contractors may be unable to provide scheduled services ... " was read to the Administrator and the acting Clinical Manager, employee B, both concurred this notice was not intended to be used as an excuse for chronic missed care visits. On 3-31-2021, the administrator and acting clinical manager, employee B, when queried if the agency had established written guidelines and a procedure in relation to acceptance of patients to agency service, both replied, "No." When queried to explain the patient intake process, the acting clinical manager, employee B, indicated once the referral was received, a following physician was verified, and source of payment was confirmed, the registered nurse made an appointment with referred patient to establish a start of care, obtain consents, teach patient rights, COVID-19 and general infection prevention/control, and conduct a combined initial and comprehensive assessment. The acting clinical manager indicated often identifying important needs for service and aspects of care at the initial/comprehensive assessment, which had not been included in the patients' referral. In relation to patient #1, employee B stated discovering a lot about care needs only after going to the home to admit patient #1, to include observing mother of patient was not physically able to complete the tasks of repositioning and bathing patient #1. Employee B, the acting clinical manager, stated being unaware of any procedure or written guidelines to follow to determine if patients should be accepted to agency services, with the responsibility to then meet the patients needs for ordered care visits. The acting clinical manager, employee B, when asked if the agency had ever considered conducting an initial assessment, and then conferring with appropriate personnel, prior to establishing a start of care and accepting a patient to agency services, replied "No." When asked if the agency could again find itself having admitted a patient and then not having the staff to meet the ordered care visits, the administrator and the acting clinical manager, employee B, stated, "Yes." The administrator and the acting clinical manager, employee B, indicated the agency needs a way to address this concern.