Every finding on record at Medcore Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 08/01/24. Standard level deficiencies cited. Abbreviation: Pts. = Patients

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness plan. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last updated 01/2023 was reviewed on 07/30/24. The plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness plan in 2021, 2022, 2023 and 2024. 2. During an interview with the Agency Supervisor on 07/31/24 at 2:45 PM, the Agency Supervisor confirmed the Agency lacked documentation of participation in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness plan, since the initiation of COVID-19 (Coronavirus disease 2019) in March 2020.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined that in 505 of 505 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 01/01/2023 to 12/31/2023 (12 months) was reviewed on 07/31/24. The report included a warning for 505 of 505 (100 %) assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview with the Agency Supervisor on 7/31/24 at 2:45 PM, the Agency Supervisor confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, clinical records, observation during home visits, and staff interview, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to inform the Pt./representative in advance of treatment, the service(s) to be provided and frequency of the visits. Findings include: 1. The patient's admission folder was reviewed on 07/30/24 and contained a form titled, "Client Plan of Care". The Agency required the SN to complete the form during the SOC visit, the RN places a check mark next to the “Service” to be provided and “Frequency/Duration” of the visits. 2. The following clinical records were reviewed from 07/30/24 to 07/31/24: Pt. #1. SOC 03/23/24. Pt. #2. SOC 07/02/24. Pt. #3. SOC 04/26/24. Pt. #4. SOC 07/15/24. Pt. #5. SOC 07/05/23. Pt. #6. SOC 12/06/23. Pt. #7. SOC 06/18/23. The clinical records lacked a completed "Client Plan of Care" form, and/or other documentation indicating the Pt./representative was notified of the service(s) to be provided, and the frequency of each service. 3. Home visits were conducted on the following Pts. on 7/30/21 and 7/31/24: Pt. #1. SOC 03/23/24. Pt. #2. SOC 07/02/24. Pt. #3. SOC 04/26/24. During the home visits, the patient's admission folder was observed, and lacked a completed "Client Plan of Care" form, and/or other documentation indicating the Pt./representative was notified of the service(s) to be provided, and the frequency of each service. 4. During an interview with the Agency Supervisor on 07/31/24 at 2:45 PM, the Agency Supervisor confirmed the Agency failed to inform the Pt./representative in advance of treatment, the service(s) to be provided and frequency of the 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 review of a clinical record, Agency policy, and staff interview, it was determined in 1 of 1 (Pt. #6) clinical record reviewed, wherein Home Health Aide services are provided, the Agency failed to ensure the RN provide accurate written instructions to the Home Health Aide. Findings include: 1. Pt. #6 was admitted to Home Health services on 12/06/23 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The closed clinical record was reviewed on 07/30/24. The clinical record contained the “OASIS-E Start of Care” comprehensive assessment form that included: “Musculoskeletal - Weakness, Ambulation Difficulty, Joint Pain/Stiffness knees, back shoulders; Poor Balance… Patient noted with gait abnormalities, muscle weakness, difficulty in walking and imbalance. The “Aide Care Plan” completed by the RN for the certification period of 12/06/23 to 02/03/24, required the Home Health Aide the option to choose a bath for Pt. #6 which included; “Complete Bath, Partial Bath/Sponge, shower every visit; and “Tub as needed”. The Home Health Aide visit note dated 12/22/23 included the Home Health Aide provided a complete bath, partial bath, and shower. The Home Health Aide visit notes dated 12/18/23 and 12/29/23 included the Home Health Aide provided a complete bath, partial bath, tub, and shower. The Aide Care Plan lacked appropriate and safe bathing instructions for the Home Health Aide, based on RN’s musculoskeletal assessment of Pt. #6. 2. The Agency’s policy titled; “Home Health Aide Services” was reviewed on 07/31/24. The policy required, “…2… A specific care plan is developed documenting the Aide services to be provided…” 3. During an interview with the Agency Supervisor on 07/31/24 at 2:45 PM, the Agency Supervisor confirmed the RN failed to provide accurate and safe written bathing instructions for the Home Health Aide.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Transfer summary and Discharge summary. Findings include: 1. Pt. #6 was admitted to Home Health services on 12/06/23 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The closed clinical record was reviewed on 07/30/24. The clinical record contained the Transfer Summary competed by the RN and dated 01/11/24. The record lacked documentation that the Transfer summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health services on 06/18/23 with the diagnosis of Sepsis, Unspecified Organism. The closed clinical record was reviewed on 07/31/24. The clinical record contained the Discharge Summary competed by the RN and dated 07/24/23. The record lacked documentation that the Discharge summary was sent to the Physician. 3. During an interview with the Agency Supervisor on 07/31/24 at 2:45 PM, the Agency Supervisor confirmed the Agency failed to ensure the Physician was sent a copy of the Transfer summary and Discharge summary.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(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: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 7/7/21 at 12:30 PM. The Plan included documentation the Agency last reviewed and updated the plan in "Dec 2017". As of 7/7/21, the Agency failed to review and revise the plan every 2 years. 2. During an interview with the DON on 7/8/21 at 11:45 AM, the DON confirmed the above finding.

Development of EP Policies and Procedures CFR(s): 484.102(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. *[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: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan policies and procedures biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 7/7/21 at 12:30 PM. The Plan lacked documentation the Agency had reviewed the Plan's policies and procedures since "Dec 2017". As of 7/7/21, the Agency failed to review and revise the Emergency Preparedness Plan policies and procedures every 2 years. 2. During an interview with the Administrator and DON on 7/8/21 at 11:45 AM, the DON confirmed the above finding.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) [(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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: . A. Based on review of the Pt. admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to ensure Pts. received an individualized Emergency Preparedness Plan, in the event of an emergency or disaster. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 7/6/21 at 1:00 PM and included a form titled "Emergency Preparedness Plan" "Emergency Phone Numbers" which required the staff to enter the Contacts Person's Name/Phone Number, Physician Name/Number, Pharmacy Name/Number, and Home Medical Equipment Number in the event of a disaster. 2. The clinical records of the following Pts. were reviewed from 7/6/21 at 2:15 PM to 7/7/219 at 3:45 PM and lacked documentation of an individualized Emergency Preparedness Plan: Pt. #1. SOC 6/21/21. Pt. #2. SOC 5/10/21. Pt. #3. SOC 5/12/21. Pt. #4. SOC 5/25/21. Pt. #5. SOC 4/20/21. Pt. #6. SOC 9/12/20. Pt. #7. SOC 1/22/21. 3. Home visits were conducted on the following Pts. from 7/6/21 at 4:30 PM to 7/7/21 at 3:00 PM. Pt. #1. SOC 6/21/21. Pt. #2. SOC 5/10/21. Pt. #3 SOC 5/12/21. During the home visits, Pt. #1 folder was not available. For Pts. #2 and #3 home folders were reviewed, and the form titled "Emergency Preparedness Plan" "Emergency Phone Numbers" were left blank. 4. During an interview with the DON on 7/8/21 at 10:15 AM, the DON stated staff are required to complete the form with the Pt./patient's representative during the initial comprehensive assessment upon admission, then place this form in the patient's clinical record, admission folder in their home. The DON and Administrator confirmed Agency staff failed to complete the Emergency Preparedness forms, ensuring the Pt. received an individualized emergency preparedness plan, as required by the Agency.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, in-service binder, personnel files and staff interview, it was determined the Agency failed to conduct Emergency Preparedness testing biannually. This has the potential to affect all Pts. receiving services. Findings include: 1. The Emergency Preparedness Plan last updated on "Dec 2017" was reviewed on 7/7/21 at 12:30 PM. The Agency presented documentation that a facility-based exercise was conducted on 11/21/17, the Agency failed to conduct any testing exercises after 11/21/17. 2. The Agency's in-service binder for 2018, 2019, 2020, 2021 and lacked documentation the Agency conducted any testing exercises. 3. During an interview with the DON on 7/8/21 at 11:45 AM, the DON confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 7/8/21. Standard level deficiencies written. Abbreviations: & = and x = times # = number w/wk = week O2 = Oxygen AM = morning freq = frequency Dec = December SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients DON = Director of Nursing PT = Physical Therapy/Therapist COVID-19 = Coronavirus disease 2019 PPE's = Personal Protective Equipment CDC = Centers for Disease Control and Prevention QAPI = Quality Assessment Performance Improvement

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the initial POC was reviewed and signed by the Physician within 30 days, as required by the Agency's policy; and staff provide service as indicated in the POC. This was found in 3 of 7 (Pts. #3, 4, and 5) clinical records reviewed. Findings include: 1. Pt. #3. SOC 5/12/21. Diagnoses: Essential (Primary) Hypertension and Recurrent Personal History of Pneumonia. The clinical record was reviewed on 7/7/21 at 1:30 PM. The record contained the initial POC effective 5/12/21. As of 7/7/21, the POC lacked the Physician's signature (56 days from the SOC), verifying the Physician reviewed and approved the initial POC. 2. Pt. #4. SOC 5/25/21. Primary Diagnosis: Varicose Veins of Bilateral Lower Extremities with Other Complications. The clinical record was reviewed on 7/7/21 at 2:00 PM. The record contained the POC effective 5/25/21. As of 7/7/21, the POC lacked the Physician's signature (43 days from the SOC), verifying the Physician reviewed and approved the initial POC. 3. Pt. #5. SOC 4/20/21. Diagnoses: Lumbar Region Radiculopathy and Unspecified Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 7/7/21 at 2:45 PM. The record contained the record contained the POC for the certification period of 4/20/21 to 6/18/21. As of 7/7/21, the POC lacked the Physician's signature (78 days from the SOC), verifying the Physician reviewed and approved the initial POC. The POC effective 4/20/21 required: "...SN to assess O2 saturation on room air (freq) every visit..." The weekly SN visit notes dated: 5/11/21, 5/18/21, 5/25/21, 6/8/21 and 6/23/21 lacked documentation the SN assessed O2 saturation. The POC effective 4/20/21 required: "...SN to assess pain level... every visit". The SN visit note dated 5/18/21 lacked documentation the SN assessed for pain. 4. The Agency policy titled, "Medical Supervision" was reviewed on 7/8/21 at 10:10 AM. The policy required: "...2. A Physician Plan of Care is developed for each client at the time of admission and signed by the physician within an appropriate time frame... If the physician is unwilling to... sign the plan of care orders, services will not be provided to the client ..." 5. During an interview with the DON on 7/78/21 at 9:50 AM, the DON stated the Agency require the Physician to review and sign the initial POC, within 30 days after the SOC date. 6. During an interview with the DON on 7/8/21 at 1:20 PM, the DON confirmed the Agency failed to ensure the initial POC was reviewed and signed by the Physician.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC contained instructions for the care of all open wounds. This was found in 1 of 3 (Pt. #4) clinical records reviewed, wherein Pts. required wound care. Findings include: 1. Pt. #4. SOC 5/25/21. Primary Diagnosis: Varicose Veins of Bilateral Lower Extremities with Other Complications. The clinical record was reviewed on 7/7/21 at 2:00 PM. The record contained the SOC comprehensive assessment completed by the SN, and dated 5/25/21 which contained documentation the Pt. had 2 open wounds. The first wound was located on the "left lower leg", the POC effective 5/25/21 included instructions for care of this wound. The second wound was located on the "left inner leg" with a description of: "Left inner leg wound... had a blister and opened up... Wound appears red, with moderate amount of serous discharges..." The POC effective 5/25/21 did not include the second wound (Left inner leg) and lacked wound care instructions for this wound. 2. During an interview with the DON on 7/8/21 at 1:20 PM, the DON confirmed the POC for Pt. #4 lacked wound care instructions for the care of the "left inner leg" wound.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff conducted Pt. immunization screening at the SOC, as required by the Agency. This was found in 6 of 7 (Pts. #3, 4, 5, 1, 2 and 7) clinical records reviewed. Findings Include: 1. Pt. #3. SOC 5/12/21. Diagnoses: Essential (Primary) Hypertension and Recurrent Personal History of Pneumonia. The clinical record was reviewed on 7/7/21 at 1:30 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 5/12/21. The assessment form included a section titled "Most Recent Immunizations" with checkmarks indicating the Pt. received the Pneumonia and Flu vaccines. The assessment form lacked the dates the Pt. received the vaccines. The Agency was unable to provide a separate immunization form indicating when the Pt. received the vaccines. 2. Pt. #4. SOC 5/25/21. Primary Diagnosis: Varicose Veins of Bilateral Lower Extremities with Other Complications. The clinical record was reviewed on 7/7/21 at 2:00 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 5/25/21. The assessment form included a section titled "Most Recent Immunizations" with checkmarks indicating the Pt. received the Pneumonia and Flu vaccines. The assessment form lacked the dates the Pt. received the vaccines. The Agency was unable to provide a separate immunization form indicating when the Pt. received the vaccines. 3. Pt. #5. SOC 4/20/21. Diagnoses: Lumbar Region Radiculopathy and Unspecified Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 7/7/21 at 2:45 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 4/20/21. The assessment form included a section titled "Most Recent Immunizations" with checkmarks indicating the Pt. received the Pneumonia and Flu vaccines. The assessment form lacked the dates the Pt. received the vaccines. The Agency was unable to provide a separate immunization form indicating when the Pt. received the vaccines. 4. Pt. #1. SOC 6/21/21. Diagnosis: Pressure ulcer sacral region, stage I. The clinical record was reviewed on 7/6/21 at 3:00 PM. The record/agency lacked documentation of the date of the Influenza and Pneumococcal vaccination status. 5. Pt. #2. SOC 5/10/21. Diagnosis: Marfan's Syndrome, unspecified. The clinical record was reviewed on 7/7/21 at 9:30 AM. The record/agency lacked documentation of the date of the Influenza and Pneumococcal vaccination status. 6. Pt. #7 SOC 1/22/21. Diagnosis: Alzheimer's disease with late onset. The clinical record was reviewed on 7/6/21 at 2:15 PM. The record lacked documentation of the date of the Influenza and Pneumococcal vaccination status. 7. During the entrance interview with the DON on 7/6/21 at 11:20 AM, the DON stated Pts. are screened for the need of the Pneumococcal Pneumonia and Influenza vaccine at the SOC. This form includes the date the Pt. received the vaccine(s), this information is documented on a separate immunization form, and is uploaded into the patient's medical record. 8. During an interview with the DON on 7/8/21 at 10:15 AM and 1:20 PM, the DON confirmed the staff failed to conduct Pt. immunization screening at the SOC, as required by the Agency.

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: 5. Pt. #1. SOC 6/21/21. Diagnosis: Pressure ulcer sacral region, stage I. The clinical record was reviewed on 7/6/21 at 3:00 PM. The record included documentation the SN provided service on 6/21/21, 7/2/21, and 7/6/21. The record/agency lacked documentation that the Pt. was screened for COVID-19, prior to the visits indicated above. 6. Pt. #2. SOC 5/10/21. Diagnosis: Marfan's Syndrome, unspecified. The clinical record was reviewed on 7/7/21 at 9:30 AM. The record included documentation the SN provided service on 5/10/21 and 6/1/21. The PT provided service on 5/18/21, 5/25/21, 6/01/21, 6/07/21, 6/14/21, 6/16/21, 6/21/21, 6/28/21, and 7/7/21. The record/agency lacked documentation that the Pt. was screened for COVID-19, prior to the visits indicated above. 7. Pt. #7 SOC 1/22/21. Diagnosis: Alzheimer's disease with late onset. The clinical record was reviewed on 7/6/21 at 2:15 PM. The record included documentation the SN provided service on 3/22/21, 3/29/21, 4/5/21, 4/12/21, 4/19/21, and 4/26/21, 5/3/2, 5/10/21 and 5/19/21. The record/agency lacked documentation that the Pt. was screened for COVID-19, prior to the visits indicated above. 8. During the entrance interview with the DON on 7/6/21 at 11:20 AM, the DON stated: "Patients are screened prior to the visit. They (field staff) call the day before the visit and ask the Pt./family the COVID-19 screening questions from the CDC. The staff document this on a COVID form and the forms are maintained in the office..." 9. During an interview with the DON on 7/8/21 at 10:15 AM and 1:20 PM, the DON confirmed the above findings. . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff screened Pts. for COVID-19, prior to providing Pt. care and services. This was found in 7 of 7 (Pts. #3, 4, 5, 6, 1, 2 and 7) clinical records reviewed. Findings include: 1. Pt. #3. SOC 5/12/21. Diagnoses: Essential (Primary) Hypertension and Recurrent Personal History of Pneumonia. The clinical record was reviewed on 7/7/21 at 1:30 PM. The record contained weekly SN visit notes dated from 5/12/21 to 6/28/21. The Agency lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing care and/or service from 5/12/21 to 6/28/21, as required by the Agency. 2. Pt. #4. SOC 5/25/21. Primary Diagnosis: Varicose Veins of Bilateral Lower Extremities with Other Complications. The clinical record was reviewed on 7/7/21 at 2:00 PM. The record contained the SOC comprehensive assessment form dated 5/25/21, SN visit notes dated 6/1/21 and 6/4/21; and the weekly SN visit notes from 6/8/21 to 6/29/21. The Agency lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing care and/or service as indicated above. 3. Pt. #5. SOC 4/20/21. Diagnoses: Lumbar Region Radiculopathy and Unspecified Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 7/7/21 at 2:45 PM. The record contained weekly SN visit notes from 5/11/21 to 6/23/21. The Agency lacked documentation the SN screened the Pt. for COVID-19 symptoms, prior to providing care and/or service from 5/11/21 to 6/23/21. 4. Pt. #6. SOC 9/12/20. Diagnoses: Paroxysmal Atrial Fibrillation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 Unspecified Chronic Kidney Failure. The closed clinical record was reviewed on 7/7/21 at 9:20 AM. The record contained: Weekly SN visit notes from 9/12/20 to 10/6/20, inpatient transfer form completed by the SN and dated 10/12/20, resumption of care comprehensive assessment form completed by the SN and dated 10/23/20, SN visit notes dated 10/27/20, 11/3/20; recertification comprehensive assessment form completed by the SN and dated 11/6/20, PT evaluation dated 9/16/20, and PT visit notes 1 to 2 times a week from 9/20/20 to 11/7/20. The Agency lacked documentation the SN and PT screened the Pt. for COVID-19 symptoms before providing care and/or service, as indicated above.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Infection Prevention Plan binder and staff interview, it was determined the Agency failed to ensure staff receive infection control/prevention education relative to COVID-19. This has the potential to impact all Pts. and staff within the Agency. Findings include: 1. The Agency's Infection Prevention Plan binder was reviewed on 7/7/21 at 12:00 PM. The binder contained "Inservice Attendance" logs with the topics: "Policy and Procedure Process for COVID-19 Pandemic; Education of Proper Use, Disposal of PPE's and steps on proper in and out of PPE's; Proper Hand Washing and Nursing Bagging Technique and Return Demonstration, Steps to put on and off PPE's, Policy & Procedure and Process of Treatment for COVID-19 Pandemic; Board of Director Members and Quality Assessment and Performance Improvement (QAPI) Members Meeting Regarding Approval of Policy and Procedure, Process of COVID-19 Pandemic." All of the "Inservice Attendance" logs were left blank. The logs lacked a date, the presenter, names and titles of staff present. As of 7/7/21, the Agency lacked documentation indicating staff received COVID-19 education. 2. During an interview with the DON on 7/8/21 at 11:45 AM, the DON confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the transfer summary. This was found in 1 of 2 (Pt. #6) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/12/20. Diagnoses: Paroxysmal Atrial Fibrillation, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 to 4 Unspecified Chronic Kidney Failure. The closed clinical record was reviewed on 7/7/21 at 9:20 AM. The record contained documentation the Pt. had received SN and PT services during the certification period of 9/12/20 to 11/10/20. The record contained an inpatient transfer form dated 11/11/20. As of 7/7/21, the record lacked documentation a copy of the inpatient transfer was sent to the inpatient facility that received Pt. #6 and/or the Physician. 2. During an interview with the DON on 7/7/21 at 1:20 PM, the DON stated after Pt. #6 was admitted for inpatient care on 11/11/20, the Agency did not provide any further services. 3. During an interview with the DON on 7/8/21 at 1:20 PM, the DON confirmed the above findings.