Every finding on record at Mediguard America Inc

A recertification inspection survey was conducted on 05/31/2023. Licensed & Certified Home Health Services census was 46. Abbreviations/Acronyms: Adm/DON-Administrator/Director of Nursing Alt Adm-Alternate Administrator Office Mgr./PAS Sup-Office Manager/Personal Assistance Services Supervisor EP-Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019 HIV/AIDS-Human immunodeficiency virus/Acquired Immunodeficiency Syndrome

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for three of three years reviewed (2020, 2021 and 2022). The agency failed to include the COVID-19 pandemic/endemic in its risk assessment. The failure could place the agency’s patients’ health, safety, and care at risk if the agency was not prepared in emergency or disaster situations. FINDINGS INCLUDED: During the entrance conference on 05/31/2023 at 12:20 p.m. the Adm/DON self-identified as the Disaster Coordinator and identified the Office Mgr./PAS Sup as the Alternate Disaster Coordinator. The surveyor requested all agency EP records. Review of the agency’s EP binder did not reveal that the agency had maintained an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach, which included the COVID-19 pandemic/endemic for the years 2020, 2021 and 2022. The EP binder included “All Hazard Community/Agency Based Risk Assessment for Potential disasters” assessments dated 02/13/2020; 02/12/2021; 02/11/2022; and 02/08/2023. The risk assessments were signed by the alternate disaster coordinator (Office Mgr./PAS Sup) and did not include the COVID-19 pandemic/endemic. The assessments included, under “Type of Disaster,” an area to specify “Endemic or Pandemic.” The types of potential endemic/pandemics listed were influenza, HIV/AIDS, Ebola, Zika Virus, and Other.” Each listed potential disaster was scored as “1=low (risk).” The binder did not include an all-hazard risk assessment that included the COVID-19 pandemic for the years 2020, 2021 and 2022. During an interview with the Adm/DON and Office Mgr./PAS Sup on 06/09/2023 at 10:15 a.m. the surveyor discussed the findings that the agency’s risk assessments did not include the COVID-19 pandemic/endemic for the years 2020, 2021, and 2022. The surveyor asked why the agency did not maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment that included the COVID-19 pandemic/endemic for the years 2020, 2021 and 2022. The Office Mgr./PAS Sup stated that the risk assessment should have been updated. He also stated that the agency had policies and he thought that the polices were all that was needed. During an interview on 06/09/2023 at approximately 10:00 a.m., the Adm/DON and Office Mgr./PAS Sup stated that the agency’s processes were based on their policies. Review of agency policy titled, ““Emergency Preparedness and Response Plan” revised 04/01/18 read in part: “Purpose…II…To ensure the Agency develops, establishes, maintains, and implements emergency preparedness policies and procedures, based on the risk assessment, emergency plan, and communication plan, that will be reviewed and updated at least annually…Policy I. The Agency will have a written emergency preparedness and response plan that comprehensively describes its approach to a disaster that could affect the need for its services or ability to provide those services. The plan will be based on and include a documented all-hazard risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area…”

A recertification inspection survey was conducted on 05/31/2023. Licensed & Certified Home Health Services census was 46. Abbreviations/Acronyms: Adm/DON-Administrator/Director of Nursing Alt Adm-Alternate Administrator Office Mgr./PAS Sup-Office Manager/Personal Assistance Services Supervisor COVID-19- Novel Coronavirus Disease 2019 EHR- Electronic Health Record PT- Physical Therapist RN-Register Nurse LVN-Licensed Vocational Nurse hha-Home Health Aide FNP-Family Nurse Practitioner POC- Plan of Care SOC- Start of Care HHA- Home Health Agency QAPI-Quality Assessment Performance Improvement SN/SNV- Skilled Nursing/Skilled Nurse Visit UTI-Urinary Tract Infection

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the agency failed to integrate services, that were provided directly and under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in two (Patients # 2 and # 3) of two patient records reviewed who received a home visit and had a diagnosis of congestive heart failure (a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). The failure could affect the patients’ safety and treatment effectiveness if patient service needs were not identified and coordinated between all disciplines involved in the provision of services. Findings included: Clinical Record # 2: Record review of the clinical record for Patient # 2 revealed a POC with a SOC date of 04/15/2023. The POC contained a certification period of 04/15/2023 to 06/13/2023 dated and signed by RN B on 04/15/2023. The POC included a chronic systolic congestive heart failure and cardiomyopathy. The POC also contained orders for SN visits one time per week for ten weeks. Continued review of the POC revealed an order for SN to weigh patient every visit and report to physician weight gain of two pounds in one day or five pounds in one week. The record also contained a PT POC dated 05/11/2023 and signed by Contractor PT A. The PT POC contained a PT visit frequency and duration of one time per week for five weeks. Further review of Patient # 2’s clinical record revealed a vital sign report log. The vital sign report log revealed the following: on SNV dated 05/23/2023 Patient # 2 weighed 185 pounds and on SNV dated 05/29/2023 he weighed 195 pounds (ten-pound weight gain in one week). There was no record the clinical record that indicated Patient # 2’s physician was notified. During an interview on 06/09/2023 at 11:00 a.m. with the Adm/DON, the surveyor discussed the findings and asked why the agency had not coordinated services/care (reported ten-pound weight gain) with the Patient # 2’s physician. The Adm/DON stated that the “nurse does it. They are very good about it. Sometimes the weight may be entered wrong.” Clinical Record # 3: Record review of Patient # 3’s clinical record revealed a POC with a SOC date of 03/17/2023. The POC contained a certification period of 03/17/2023 to 05/15/2023 signed by RN B on 03/17/2023. The POC included diagnoses of type 2 diabetes mellitus with other skin wound, chronic systolic congestive heart failure, and non-pressure chronic ulcer unspecified part of left lower leg with unspecified severity. The POC contained an order for SN visits two times per week for one week and one time per week for nine weeks. Further review of the POC revealed orders for SN to notify physician of blood pressure readings above 160/90 and heart rate less than 60. The POC also contained an order for SN to perform pressure ulcer care to left shin and apply “opti foam/antimicrobial silver (aides in healing).” Continued review of the POC revealed an order for SN to weigh patient every visit and report to physician weight gain of two pounds in one day or five pounds in one week. Further review of the record revealed physician orders: dated 04/10/2023; 04/13/2023, and 05/09/2023 and signed by the Adm/DON. The 04/10/2023 order read in part: “…Frequency change: Nursing [two times per week for three weeks and one time per week for three weeks] effective from 04/10/2023…” The 04/13/2023 order read in part: “…Home health [may] receive orders from Wound care specialist…” The 05/09/2023 order read in part: “…Increase SN visit to twice a week from 05/09/2023…” Continued review of the record revealed the following communication notes: A communication note dated 04/01/2023 for a “podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot, and ankle) and wound referral” and signed by the Adm/DON on 03/30/2023. A communication note signed by RN A and dated 04/12/2023 read in part: “…wound care provider, [Identifier 200] accepted [patient] for [evaluation] and treatment…” A communication note dated 04/14/2023 and signed by RN A that read in Part: “DON received a call from [FNP, Identifier 100] wound provider for [patient]. [Identifier 100] reported that wound to [right] posterior lower leg has calcium alginate which has become embedded in the wound…She asked DON to assess wound 04/17/2023 to ascertain whether surgical debridement is necessary. The remainder of the wounds are to be cleansed with NS, covered with gauze, then wrapped with rolled gauze and secured with tape. All [dressings] will be completed by home health [Monday and Wednesdays] [Identifier 100] will perform wound care on Fridays until further notice…[Identifier 100] also ordered that [patient receive nail care from podiatrist…” Review of SN visit notes for certification period 03/17/2023 to 05/16/2023 revealed the following: Review of SNV notes dated 03/23/2023 and 03/30/2023 and signed by LVN A revealed that wound care was performed to Patient # 3’s left shin. Review of SNV note dated 04/06/2023 signed by LVN A revealed that wound care was performed to Patient # 3’s left shin. The 04/06/2023 SNV note also revealed (on page 4 of 5) that Patient # 3 was hospitalized from [3/31 to 4/4] and wound care was ordered for right [lower leg]. The 04/06/2023 SNV note also read in part: “Multiple right leg alcers [ulcers (wounds)] cleanse with normal ceiling [saline] apply aqua cell silver daily [patient] said 3 times a week…” Review of SNV note dated 04/10/2023 signed by RN A revealed that wound care was provided to right and left lower legs cleansing with normal saline and applying calcium alginate with silver. Continued review of SNV notes revealed the following: SNV note dated 4/14/2023 signed by LVN A revealed a heart rate of 53; SNV notes dated 04/17/2023 signed by RN A revealed a blood pressure of 170/89, and SNV note dated 04/24/2023 signed by RN A revealed a blood pressure of 168/94. The record did not reveal that the agency notified the physician of blood pressure and heart rate readings that were within the range ordered to be reported to Patient # 3’s physician. Review of the following SNV notes revealed that Patient # 3 was not weighed at every visit as ordered: SNV notes 03/30/2023; 04/10/2023; 04/14/2023; 04/24/2023; 04/26/2023 and 05/09/2023. Further review of Patient # 3’s record did not reveal any assessment of the right lower leg wound by the Adm/DON on 04/17/2023. The record contained a SNV note dated 04/17/2023 signed by RN A. The record also did not contain any records that revealed the order for podiatry referral had been completed. Also, the clinical record did not reveal that Patient # 3’s physician had been notified that the referral had not been completed. Continued record review of the clinical record for Patient # 3 revealed a POC with a SOC date of 03/17/2023. The POC contained a certification period of 05/16/2023 to 07/14/2023 dated and signed by RN A on 05/15/2023. The POC included diagnoses of type 2 diabetes mellitus with other skin wound, chronic systolic congestive heart failure, and non-pressure chronic ulcer unspecified part of left lower leg with unspecified severity. The POC also contained orders for SN visits one time per week for one week and two times per week for eight weeks. The POC also included an order for SN to perform pressure ulcer wound care to left lower leg, times three areas, apply silver alginate. The POC did not include wound care orders for right leg wounds that were first documented on SN visit note dated 04/06/2023. During a home visit conducted with RN A on 06/02/2023 at approximately 12:00 p.m., the surveyor observed that Patient # 3 had wound dressings to both lower legs from below the knees to ankle area. The dressings were soiled with large amounts of dried drainage. Above and below the drainage areas the kerlix type dressing was stained brown. When RN A cut the dressings to remove them the dressings were dried and stuck to the open wound areas on both legs. Patient # 3’s toenails and fingernails were long/protruding, curving and had thick black/brownish substance under the nails. During an interview (at home visit) with RN A the surveyor asked how often Patient # 3 received wound care. RN A stated, “Three times a week.” During an interview (at home visit) with Patient # 3 the surveyor asked how often the nurses came to visit. He stated that [RN A] “comes on Monday, another nurse comes on Wednesday. I don’t know what happened, she didn’t come Wednesday. I was waiting on her. Another nurse was supposed to come from out of town today, but this nurse came.” There were no records in the clinical record that indicated the agency had notified Patient # 3’s physician of the missed visit (on 05/31/2023). During an interview on 06/09/2023 at 11:00 a.m. with the Adm/DON, the surveyor discussed the findings and asked why the agency had not integrated/coordinated services/care with Patient # 3’s physician as follows: Blood pressure and heart rate not reported to physician as ordered; No weights were completed every visit as ordered; no follow-up with wound assessment by DON on 04/17/2023; wound care orders for right leg not included in the POC, and podiatry referral not completed/physician not notified the podiatry visit not completed. The Adm/DON stated that the “nurse does it [send communication to physicians]. They are very good about it. Sometimes the weight may be entered wrong.” She also stated that sometimes Patient # 3 “is not home” when the nurses went to visit and when podiatrist went to visit. During an interview on 06/09/2023 at 11:59, the surveyor asked how not integrating/coordinating services/care for Patient # 3 could adversely affect him. The Adm/DON stated that Patient # 3 could get an infection and It “can affect the wound healing process.” During an interview at approximately 10:00 a.m. on 06/09/2023, the Adm/DON and Office Mgr./PAS Sup stated that the agency’s processes were based on agency policies. Review of agency policy titled, “Monitoring Patient Care/Coordination of Care PC.10” revised 05/0/119 read in part: “Purpose[:] To ensure coordination of patient/client care and treatment. Policy[:] I. The Agency will monitor, evaluate and report the patient’s/client’s physician regarding the patient’s/client’s progress towards achieving goals established on the plan of care…Procedure[:] I. The Agency will: A. Ensure communication with all physicians involved in the plan of care. B. Integrate orders from all physicians involved in the plan of care to ensure the coordination of all services and interventions provided to the patient/client. C. Integrate services, whether services are provided directly or under arrangement, to ensure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines. D. Coordinate care delivery to meet the patient’s/client’s needs, and involve the patient/client…in the coordination activities…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, observations, and interviews, the agency failed to provide a current written visit schedule in three (Patients # 1, # 2 and # 3) of three patients who received a home visit. The HHA failed to provide the patients and caregiver with a copy of the written visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The failure could place the patient’s health and safety at risk if the patient and caregiver did not understand what services to expect from the HHA, the purpose of each service and when to expect the services. FINDINGS INCLUDED: Review of the agency's sample "Medicare" admission packet on 05/31/2023 revealed that the sample packet contained a blank form titled, “Nine Week Planner,” for visit schedules. Clinical Record # 1: Record review of the clinical record for Patient # 1 revealed a POC with a SOC date of 12/26/2022. The POC contained a certification period of 04/25/2023 to 06/23/2023 dated and signed by RN B on 04/20/2023. The POC also contained orders for SN visits one time per week for nine weeks and hha visits for one time per week for nine weeks. During a home visit conducted on 06/02/2023 at approximately 9:00 a.m., the surveyor observed, and reviewed Patient # 1's home admission folder. The folder did not include a current visit schedule that included frequency of visits for SN and hha visits. The folder included a visit calendar (nine-week planner) that was not consistent with the patient's most current plan of care (certification period 04/25/2023 to 06/23/2023). The visit schedule dates were for June, July, and August (dates did not match 2023 calendar). The visit schedule listed SN visits but hha visits were not listed. The surveyor conducted the home visit with hha A. Clinical Record # 2: Record review of the clinical record for Patient # 2 revealed a POC with a SOC date of 04/15/2023. The POC contained a certification period of 04/15/2023 to 06/13/2023 dated and signed by RN B on 04/15/2023. The POC also contained orders for SN visits one time per week for ten weeks. The record also contained a PT POC dated 05/11/2023 and signed by Contractor PT A. The PT POC contained a PT visit frequency and duration of one time per week for five weeks. During a home visit conducted on 06/01/2023 at approximately 2:30 p.m., the surveyor observed, and reviewed Patient # 2's home admission folder. The folder did not include a current visit schedule that included frequency of visits for SN and PT. The folder included a visit calendar (nine-week planner) that was blank (not completed with a schedule of visits and frequency of visits) for the current certification period of 04/15/2023 to 06/13/2023. The surveyor conducted the home visit with Contractor PT A. Clinical Record # 3: Record review of the clinical record for Patient # 3 revealed a POC with a SOC date of 03/17/2023. The POC contained a certification period of 05/16/2023 to 07/14/2023 dated and signed by RN A on 05/15/2023. The POC also contained orders for SN visits one time per week for one week and two times per week for eight weeks. During a home visit conducted on 06/02/2023 at approximately 12:00 p.m., the surveyor observed, and reviewed Patient # 3's home admission folder. The folder did not include a current visit schedule that included frequency of visits by SN. The folder included a visit calendar (nine-week planner) that was not consistent with the patient's most current plan of care, for the certification period of 05/16/2023 to 07/14/2023. The visit schedule listed SN visit for every Tuesday. The visit schedule was not dated, did not include a visit frequency, and did not show visits for two times weekly. The surveyor conducted the home visit with RN A. During an interview with the Adm/DON on 06/09/2023 at 11:00 a.m., the surveyor discussed the visit schedules for Patients # 1, # 2, and # 3. The surveyor asked why the agency had not provided a written visit schedule that was consistent with the patient's most current plan of care with frequency of visits to Patients # 1, # 2 and # 3. The Adm/DON replied, “They (the nurses) are supposed to do it.” During an interview on 06/09/2023 at approximately 10:00 a.m., the Adm/DON and Office Mgr./PAS Sup stated that the agency’s processes were based on agency policies. Review of agency policy titled, “Implementing Care and Treatment PC.9” revised 12/01/18 read in part: “Purpose[:] To ensure patient/client care and treatment are provided as identified in the care plan…Procedure…VI. Written information to the patient/Client. 1. Visit schedule, including frequency of visits by Agency personnel and personnel acting on behalf of the Agency…” Review of agency policy, titled, “Patient/Client Rights and Responsibilities Rights of the Elderly RI.2” revised 01/13/18 read in part: “…Procedure…VI. The patient/client has a right to…D. Participate in, be informed about…with respect to…4. The disciplines that will furnish the care; 5. The frequency of visits…8. Any changes in the care to be furnished…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency‐wide program for the surveillance, identification, prevention, control, and investigation of infectious and/or communicable diseases that was an integral part of the HHA's QAPI program, in that: the agency failed to include a method for identifying infectious and communicable disease problems and a plan for the appropriate actions that were expected to result in improvement and disease prevention for (UTI’s and potential COVID-19 infections) in three (2020, 2021, and 2022) of three years reviewed. The failure could place agency clients at an increased risk of the spread of infectious and communicable diseases. The failure could also cause the agency to not identify trends in infections and therefore prevent the agency from developing action plans to prevent the trending infections. Findings included: During the entrance conference on 05/31/2023 at 12:20 p.m., the surveyor requested the agency’s infection control records. Review of the agency’s infection control binder revealed that it contained patient infection reports. The reports were primarily of UTI’s. The binder did not reveal that it contained surveillance data or reports of the occurrence of the UTI’s or any surveillance for COVID-19 infections/potential infections. The binder also did not include implementation of appropriate preventive procedures, review any data collected to evaluate for trends or patterns. Further review of the binder did not reveal that any completed summaries of reviews, trend composites, recommendations, investigations, or related performance improvement activities, had been maintained by the agency for the UTI’s. Continued review of the binder did not reveal that the agency had reviewed and revised all aspects of the infection control program annually for the years 2020, 2021 and 2022, per agency policy. During an interview on 06/01/2023 at 1:29 p.m. the surveyor requested surveillance reports/data for COVID-19 from 09/18/2020 to 06/01/2023. The Adm/DON stated that no agency staff had COVID-19 during that time. She also stated that the agency’s client’s infections were documented in their EHR (except for the infections that were in the hard copy infection control binder). Review of the EHR did not reveal any COVID-19 infection surveillance of the agency’s clients. During an interview on 06/02/2023 at 1:42 p.m. the surveyor asked if the agency could print a surveillance report for client infections from 09/18/2020 to 06/01/2023. The Adm/DON stated that the agency could not print a surveillance report. The Office Mgr./PAS Sup printed an infection surveillance report, after discussion with the surveyor. The Adm/DON stated, “I didn’t know it could be done.” Review of the surveillance reports dated from 05/06/2021 to 05/26/2023 revealed that there were 15 total occurrences of UTI’s, one tooth infection and 1 respiratory infection. The reports did not reveal any implementation of appropriate preventive procedures, review any data collected to evaluate for trends or patterns; did not reveal that any completed summaries of reviews, trend composites, recommendations, investigations, or related performance improvement activities, had been maintained by the agency, for the UTI’s. During an interview on 06/09/2023 at 10:00 a.m. with the Adm/DON and Office Mgr./PAS Sup, the surveyor asked what the agency’s processes were for its infection control program. The Adm/DON and Office Mgr./PAS Sup stated that the agency’s processes were based on their policies. The surveyor asked who was responsible for implementing the agency’s processes/policies. The Adm/DON state that she was responsible. She replied, “We follow the policy and procedure.” The surveyor discussed that the agency’s infection control records did not reveal surveillance data or reports of the occurrence of the UTI’s or any surveillance for COVID-19 infections; did not include implementation of appropriate preventive procedures, review any data collected to evaluate for trends or patterns; did not reveal that any completed summaries of reviews, trend composites, recommendations, investigations, or related performance improvement activities, had been maintained by the agency, for the UTI’s, and did not reveal that the agency had reviewed and revised all aspects of the infection control program annually for the years 2020, 2021 and 2022, per the agency’s policy. The surveyor asked if the agency reviewed and revised its infection control program annually. The Adm/DON replied, “We will.” The surveyor asked why the agency had not reviewed and revised its infection control program annually. The Adm/ DON stated that the agency’s consultant reviewed the agency’s QAPI program. Review of the agency’s QAPI records did not reveal that it contained any surveillance data of the occurrence of the UTI’s or any surveillance for potential COVID-19 infections; did not include implementation of appropriate preventive procedures, review any data collected to evaluate for trends or patterns; did not reveal that any completed summaries of reviews, trend composites, recommendations, investigations, or related performance improvement activities, had been maintained by the agency for the UTI’s, and did not reveal that the agency had reviewed and revised all aspects of the infection control program annually for the years 2020, 2021 and 2022. Review of agency policy titled, “Infection Control IC.2” revised 070120 read in part: “…Policy…II. The Infection Control Program will include…C. A system that coordinates: 1. Surveillance for the occurrence of an infection…3. Implementing appropriate preventive procedures…5.Review of the data collected to evaluate for trends, patterns, etc…Procedure…I….C. Summaries of reviews, trend composites, recommendations, investigations and communicable diseases, and related performance improvement activities, completed…will be maintained by the agency…VI. Review[:] All aspects of the program will be reviewed and revised annually, and as needed…” Review of the American Medical Association Journal website, https://journalofethics.ama-assn.org/article/surveillance-infectious-diseases-information-action/2006-04, on 06/14/2023 revealed the following: “...Surveillance is defined as the “ongoing, systematic collection, analysis, and interpretation of outcome-specific data for use in the planning, implementation, and evaluation of public health practice…” Review of the Britannica Dictionary website, https://www.britannica.com/dictionary/surveillance, on 06/14/2023 revealed the following definition for surveillance: …the act of carefully watching… something especially in order to prevent or detect…”