Every finding on record at Madelia Community Hospital Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements was conducted on 12/5/22-12/7/22, during a recertification survey. The agency is NOT in compliance with the Appendix Z Emergency Preparedness Requirements.

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 interview and policy review, the agency failed to develop and implement emergency preparedness policies and procedures that included a system to inform state and local emergency preparedness officials of the need for patient evacuations from their residences, during an emergency. This had the potential to affect all patients receiving home care services from the agency. The agency's undated Emergency Preparedness Plan, included several policies related to emergency preparedness, however, lacked documentation to include a system for informing state and local emergency preparedness officials about 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. During an interview on 12/7/22, at 1:45 p.m. the home care director stated the agency did not have this system however in each patient home all patients had the individual emergency plans.

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 interview and policy review, the agency failed to develop and implement emergency preparedness policies and procedures that included a system to address what action would be required due to the inability to make contact with staff or patients and reporting capabilities to the local and State emergency officials during an emergency. This practice had the potential to affect all 79 patients currently receiving services from the agency. During an interview on 12/7/22, at 1:45 p.m. the home care director stated the emergency plan did not include information regarding the inability to make contact with staff or patients during an emergency and how this information would be reported to local and state officials. The administrator stated each patient had a plan developed for emergencies in the home however, verified the agency did not have a policy or procedure of how it would report to local and state officials.

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 interview and document review, the agency failed to develop a policy and procedure for protecting medical records as part of the emergency preparedness program (EPP). This had the potential to affect all 79 patients currently being served by the agency. On 12/7/22, the EPP, 2/2021, and policies and procedures pertaining to the EPP were requested and reviewed. The agency's policy and procedure for the protection of exiting medical records was not provided. During an interview on 12/7/22, at 2:15 p.m. the home care director stated discussion of what to do with medical records of past patients and current patients to protect them happened and the plan was to have the portion of charts that were in paper form would be scanned into the electronic record. At this time, paper charts were stored in boxes in an unlocked office in the agency. A timeframe to decide when the paper charts would be scanned had not been decided. The EEP did not include protecting the medical records of current and past patients.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and policy review, the agency failed to ensure emergency preparedness policies and procedures addressed the use of volunteers in an emergency. A review of the agency Emergency Preparedness Policy and Process revised 2/2021, revealed the written plan for emergency lacked policies and procedures to facilitate volunteer support for individuals with varying levels of skills and training, and the use of volunteers in it's emergency plan. During an interview on 12/7/22 at 2:15 p.m. the home care director verified the agency plan lacked integration of volunteers in an emergency.

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 interview and document review, the agency failed to develop an Emergency Officials Contact (EOC) Information list as part of the emergency preparedness plan communication plan. This had the potential to affect all 79 patients currently being served by the agency. The communication plan was reviewed on 12/7/22, and no EOC information list was found.. During an interview on 12/7/22, at 2:15 p.m. the home care director stated there had been no collaboration with the community emergency officials and no EOC information list had been developed.

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 interview and document review, the agency failed to ensure their emergency preparedness plan addressed primary/alternative means of communication with Federal, State, tribal, regional, and local emergency management agencies. This had the potential to affect all 79 patients receiving services from the agency. Review of the facility's EPP dated 12/7/22, revealed the communication plan lacked procedures addressing primary/alternative means of communication with Federal, State, tribal, regional, and local emergency management agencies. On 12/7/22, at 2:15 p.m. the home care director confirmed the EPP lacked the above information.

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 interview and document review, the agency failed to ensure their communication plan included; a method for sharing protected health information and medical documentation with other providers; and release patient information. This had the potential to affect all 79 patients receiving services from the agency. A review of the agencies Emergency Preparedness plan, dated 2/2021, indicated the communication plan did not address how the HHA was going to share protected health and medical information with other providers. On 12/7/22, at 2:15 p.m. the home care director confirmed there was no a communication plan in place addressing the above information.

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 interview and document review, the agency failed to ensure their communication plan included a means of providing information about the facility's needs, and ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This had the potential to affect all 79 patients receiving services from the agency. A review of the agency emergency preparedness plan (EPP), dated 2/2021, indicated the EPP lacked any documentation regarding communicating with the authority having jurisdiction, the Incident Command Center, or designee about the agencies ability to provide assistance. During interview on 12/7/22, at 12:15 p.m., the director of home care verified the information was lacking in the EPP.

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on interview and record review, the agency, which elected to have a unified and integrated emergency preparedness program as part of a healthcare system, failed to ensure an individual facility-based risk assessment for each separately certified facility within the health system utilizing an all-hazards approach. This had the potential to affect all 79 patients receiving services from the agency. On 12/7/22, at 2:15 p.m. the director of home care (DHC) stated the home care agency (HHA) was part of an integrated health system and fell under the umbrella of a hospital. The DHC stated the HHA participated in drills and training with the hospital and staff were trained in the hospital's emergency preparedness program (EPP), as well as the HHA's specific EPP. The DHC stated she was involved in the development of the EP for the HHA. A review of the 2022 risk assessment revealed the risk assessment was completed for the hospital, clinics, pharmacy and ambulance. There had been no individual agency-based risk assessment completed for the HHA. On 12/7/22, at 2:15 p.m. the DHC verified there was no separate risk assessment specific to the home health agency.

Federal initial comments in IQIES: On 12/5/22-12/7/22 a recertification survey was conducted. This resulted in partial extended survey at Madelia Community Hospital Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 127 Total home visits conducted: 3 List Hours of Operation: 8:00 a.m.-4:30 p.m. List total number of records reviewed: 7

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the primary care provider was updated when a home visit was missed for 6 of 7 patients (P1, P2, P3, P4, P5, and P6) whose records were reviewed for home visits. P1's face sheet printed 12/6/22, indicated diagnoses included: type 2 diabetes, with chronic kidney disease, bipolar disorder, heart failure, history of falling, anxiety disorder, asthma, noncompliance with medication regimen. P1's plan of care (POC) dated 10/10/22 to 12/8/22, indicated skilled nursing; 2 wk (week) 8wk 3 PRN (as needed); additional visits as need to assess emergent situations; 1wk 1wk, skilled nurse visits 2x per week, may be done by RN (registered nurse) or LPN (licensed practical nurse. Aide; 3wk 9wk; HHA (home health aide) 3x per week. P1's visit management document printed 12/6/22, included the following missed visits: 11/29/22, 11/25/22, 11/24/22, 11/17/22, 9/15/22, 9/8/22, and 6/30/22. P1's Record review of missed visit/physician notification did not show any missed visit notifications to the primary provider. P6's face sheet printed 12/7/22, indicated start of care date 5/13/22, diagnoses included: type 2 diabetes, neurocognitive disorder with Lewy bodies, Parkinson’s disease, major depressive disorder, osteoarthritis, hypertension, vascular demotion with behavioral disturbances. P6's plan of care (POC) dated 9/10/22 to 11/8/22, indicated skilled nursing; every 2 wk 8wk 3 PRN (as needed); additional visits as need to assess emergent situations; Aide; 1wk 8wk., P6's visit management document printed 12/6/22, included the following missed visits: 10/21/22, 10/7/22, 9/30/22, 9/23/22, 9/16/22, 9/9/22, 9/2/22, and 7/22/22. P6's Record review of missed visit/physician notification did not show any missed visit notifications to the primary provider. On 12/6/22, at 3:56 p.m. agency scheduler stated missed visits were marked in the electronic medical record system as missed and confirmed provider communication regarding the missed visit was not sent. On 12/6/22, at 4:11 p.m. homecare director (HCD) indicated the agency procedure prior to the new EMR was to send the provider a paper copy of the patient missed visit, Holly further indicated when the agency changed to the new EMR system a procedure was not developed and HCD verified the agency current practice did not include communication to the provider regarding patients missed skilled nurse visits or HHA visits. HCD indicated she expected staff to communicate to the provider the patients missed visits and follow provider orders P2’s face sheet printed 12/7/22, indicated diagnoses included diabetes mellitus and major depression. P2’s record included the following plans of care (POC) with orders: 7/24/22-9/21/22- skilled nursing 1 visit each week for 9 weeks with 3 as needed visits to assess for emergent cares; aide 3 weeks each week for 8 weeks and 2 visits each week for 1 week 9/22/22-11/20/22- skilled nursing 1 visit each week for 7 weeks and 3 as needed visits for emergent care; aide 1 visit per week for 1 week then 3 visits per week for 9 weeks 11/21/22-1/19/23- skilled nursing 1 visit each week for 9 weeks; aide 3 visits per week for 8 weeks then 2 visits per week for 1 week. P2’s visit management document printed 12/7/22, included the following missed visits 9/22/22 skilled nurse and aide, 9/23/22 aide visit, 9/28/22 aide visit, 12/2/22 nurse and aide visits. P2’s record failed to indicate communication with P2’s provider to update on the missed visits and the reason for the missed visits. P3’s face sheet printed 12/7/22, indicated diagnoses included hypertension and chronic obstructive pulmonary disease (a lung disease). P3’s record included the following POC with orders: 7/11/22-9/8/22 skilled nursing 1 visit each week for 9 weeks and 3 visits as needed for emergency care 9/9/22-11/7/22 skilled nursing 1 visit each week for 8 weeks and 3 visits as needed for emergency care then 1 visit each week for 1 week 11/8/22-1/6/23 skilled nursing 1 visit each week for 9 weeks; physical therapy 2 visits each week for 2 weeks P3’s visit management document printed 12/7/22, included the following missed visits: 10/25/22 for physical therapy, 11/7/22 for nursing, 11/8/22 for physical therapy, 11/21/22 for physical therapy, 11/29/22 for nursing, 12/2/22 for physical therapy P3’s record failed to indicate communication with P3’s provider to update on the missed visits and the reason for the missed visits. P4’s face sheet printed 12/7/22, indicated diagnoses included abdominal aortic aneurysm (bulge in the major blood vessel- aorta) and heart disease. P4’s record included the following POC with orders 10/21/22 to 12/19/22 skilled nursing 2 visits per week for 8 weeks and 3 as needed visits for emergent care; aide 2 visits per week for 8 weeks then 1 visit per week for 1 week. P4’s visit management document printed 12/7/22, included the following missed visits: 11/8/22 for physical therapy and 11/22/22 for physical therapy. P4’s record failed to indicate communication with P5’s provider to update on the missed visits and the reason for the missed visits. P5’s face sheet printed 12/7/22, indicated diagnoses included absence of left toe and diabetes mellitus. P5’s record included the following POC with orders 10/28/22-12/26/22 skilled nursing daily visit. 11/20/22-12/24/22 skilled nursing 3 visits each week for 5 weeks. P5’s visit management document printed 12/7/22, included the following missed visits 11/17/22 for nursing and 12/2/22 for nursing. P5’s record failed to indicate communication with P5’s provider to update on the missed visits and the reason for the missed visits.

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure patient visits completed by a licensed practical nurse (LPN) were supervised by a registered nurse (RN). This deficient practice affected 4 of 7 patients (P1, P2, P3, and P5) reviewed for supervision of LPN visits by a RN. P2’s review of skilled nursing visits completed 8/1/22-12/7/22, indicated P2 received nursing visits from a LPN on 8/1/22, 8/22/22, 10/10/22 and 11/7/22. All other nursing visits received were completed by a RN. P2’s medical record failed to include completion of supervision of LPN visits by a RN. P3’s review of skilled nursing visits completed 7/12/22-12/7/22, indicated P3 received nursing visits from a LPN on 7/12/22 and 9/20/22. All other nursing visits reveived were completed by a RN. P3’s medical record failed to include completion of supervision of LPN visits by a RN. P5’s review of skilled nursing visits completed 10/29/22-12/6/22, indicated P4 received nursing visits from a LPN on 10/29/22, 10/30/22, 10/31/22, 11/4/22, 11/21/22, 11/23/22, 11/25/22 and 11/28/22. All other nursing visits received were completed by a RN. P5’s medical record failed to include completion of supervision of LPN visits by a RN. On 12/6/22, at 2:35 p.m. director of home care (DHC) confirmed LPN visits were not monitored or supervised by a RN. DHC stated LPNs discuss their patients with the team, which included RNs, but their nursing visit notes and other patient documentation was not reviewed by DHC or other RNs. A policy on supervising LPNs was requested. DHC stated the agency did not have a policy. P1's face sheet printed 12/6/22, indicated diagnoses included: type 2 diabetes, with chronic kidney disease, bipolar disorder, heart failure, history of falling, anxiety disorder, asthma, noncompliance with medication regimen. P1's plan of care (POC) dated 10/10/22 to 12/8/22, indicated skilled nursing; 2 wk (week) 8wk 3 PRN (as needed); additional visits as need to assess emergent situations; 1wk 1wk, skilled nurse visits 2x per week, may be done by RN (registered nurse) or LPN (licensed practical nurse. Aide; 3wk 9wk; HHA (home health aide) 3x per week. P1's skilled nursing notes dated 12/1/22 to 7/15/22, indicated licensed practical nurse (LPN) visits included: 11/15/22, 11/1/22, 10/28/22, 10/18/22, 9/27/22, 9/20/22, 9/13/22, 9/6/22, 8/30/22, 8/16/22, 8/5/22, and 7/15/22. P1’s medical record failed to indicate supervision of LPN visits by a RN.