Every finding on record at Nurse Resource Home Health, Inc

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure all staff members had attended annual training for emergency and disaster preparedness drills. This failure had the potential for the staffs to lack the knowledge to respond effectively during an emergency/disaster situation. Findings: During a concurrent interview and record review on 11/16/2022, at 10:00 am., with the Administrator (ADM) and Director of Patient Care Services designee (DPCSD), the Emergency Preparedness binder was requested to be reviewed. There was no documented evidence that all staff had emergency preparedness training/disaster drill for all staff members for the following dates and trainings/drills: 3/11/21- (Annual Earthquake Drill) 7/08/22 - (Fire drill) 8/05/22 - (Emergency Management-Heat Advisory) The DPCSD also stated not all staffs were able to be trained and that it was important so staffs would be aware on how to respond and what to do during a disaster. A review of the Hospice agency's policy titled, Emergency Disaster Preparedness Plan, year 2020, indicated staff education is provided for all employees to inform them of the agency’s disaster management plan.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #44186, Health Facilities Evaluator Nurse Surveyor ID #45887, Health Facilities Evaluator Nurse Unduplicated admissions: 39 Census: 35 Sample size: 7 Home Visits: 3

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct an initial assessment within 48 hours of the referral, for one of 7 sampled patients (Patient 5). This failure had the potential to delay treatment of the significant care needs identified during the assessment and could lead to affect the patient's health status and well-being. Findings: A review of Patient 5's clinical record indicated a start of care date (SOC) of 8/28/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and end stage renal disease (when the kidneys are no longer able to function normally). A review of Patient 5’s clinical record indicated a signed physician’s order for the HHA to admit the patient for skilled assessment, evaluation of all body systems, and to assess the patient’s safety at home. The referral order was dated 8/25/2022. On 11/16/2022, at 11:35 a.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), confirmed there was one day delay in performing the initial SOC assessment for Patient 5 and a physician order to delay the SOC had not been obtained prior to SOC. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” revised April 2021, indicated the initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician, or at the patient/family request with the approval of the physician.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to maintain an accurate, current medication profile for one of 7 patients (Patient 6). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 6's clinical record indicated a start of care date (SOC) of 8/15/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), malignant neoplasm of uterus (a disease in which cancer cells form in the tissues of the uterus [womb]), and malignant neoplasm of overlapping sites of rectum (the final section of the large intestine), anus and anal canal (a disease in which cancer cells develop in the rectum and anal canal [a tube at the end of your rectum]). A review of Patient 6's Plan of Care (POC) for the certification period of 10/14/2022 to 12/12/2022, included an order for Skilled nursing (SN) to visit once a week for nine weeks. The POC further indicated for the SN to instruct and reinstruct patient and/or patient caregiver on medications as to dosage, route, frequency, and adverse effects. On 11/15/2022, at 9:40 a.m., a joint home visit with Licensed Vocational Nurse (LVN 2) was conducted at Patient 6’s residence. During a review of Patient 6's current medication, it was noted a bottle of Oyster Shell Calcium 500 milligram (mg) 1 tablet by mouth twice a day as nutritional supplement. The medication profile provided by the agency did not have the medication listed. On 11/15/2022, at 10:30 a.m., during an interview with LVN 2 stated, "I was not aware the patient was on that medication." On 11/16/2022, at 11:35 a.m., during an interview with the Director of Patient Care Services Designee (DPCSD), stated visiting nurse should always ask the patient if there were new medications or changes to the current medications every visit, and update the medication profile in the patient’s electronic health records accordingly. A review of the agency’s policy and procedure titled “Medication Profile,” revised November 2018, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency staff failed to ensure the plan of care (POC) developed for one of 7 sampled patients (Patients 6) covered all pertinent diagnoses. For Patients 6, who has a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow), the staff did not document the care needed to monitor the catheter site. This deficient practice had the potential to put the patient at risk for complications like infection, bladder spasms, obstruction, or problems at the catheter site. Findings: A review of Patient 6's clinical record indicated a start of care date (SOC) of 8/15/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), malignant neoplasm of uterus (a disease in which cancer cells form in the tissues of the uterus [womb]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and encounter for attention to other artificial openings of urinary tract. On 11/15/2022, at 9:40 a.m., a joint home visit with Licensed Vocational Nurse (LVN 2) was conducted at Patient 6’s residence. During the visit it was observed Patient 6 had a suprapubic catheter on her lower abdomen connected to a urinary bag draining clear, yellow urine. A review of Patient 6's POC for the certification period of 10/14/2022 to 12/12/2022, included an order for Skilled nursing (SN) to visit once a week for nine weeks, to assess vital signs, perform skilled assessment and evaluation of all body systems. There was no documented evidence that instructions for suprapubic catheter assessment, care, and monitoring of site were included in the POC. A review of Patient 6’s Skilled Nurse (SN) Clinical Notes dated 10/06/2022, 10/14/2022, 10/21/2022, 10/28/2022 and 11/04/2022, indicated there was no documentation regarding suprapubic catheter care assessment, intervention and catheter site treatment provided. During an interview with the Director of Patient Care Services Designee (DPCSD) on 11/16/2022, at 11:35 a.m., she was not able to provide the documented evidence the agency developed POC regarding Patient 6’s suprapubic catheter site care and treatment. The DPCSD stated the agency nursing staff should have developed the POC addressing Patient 6’s suprapubic catheter management. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2019, indicated the clinical plan of care includes all pertinent diagnoses and interventions appropriate to each discipline, precautions, treatments, safety measures, and instructions.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure one of 7 sampled patients (Patient 6) received colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon) care as ordered by the physician. This deficient practice placed the patient at risk of infection that could lead to complications. Findings: A review of Patient 6's clinical record indicated a start of care date (SOC) of 8/15/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), malignant neoplasm of uterus (a disease in which cancer cells form in the tissues of the uterus [womb]), and malignant neoplasm of overlapping sites of rectum (the final section of the large intestine), anus and anal canal (a disease in which cancer cells develop in the rectum and anal canal [a tube at the end of your rectum]). A review of Patient 6's POC for the certification period 10/14/2022 to 12/12/2022, included an order for Skilled nursing (SN) visit once a week for nine weeks. The POC indicated for the SN to observe/re-assess colostomy site placement/functionality, and to perform regular colostomy care if needed, “SN to perform on SN visits, patient caregiver (PCG) on days with no SN visit”. One of the goals was the colostomy site will remain intact with no signs and symptoms (S/S) of infection throughout the certification period. On 11/15/2022, at 9:40 a.m., a joint home visit with Licensed Vocational Nurse (LVN 2) was conducted at Patient 6’s residence. Patient 6 was observed to have a colostomy on her left lower abdomen with a colostomy pouch attached. LVN 2 did not perform colostomy care nor asked the patient if she needed one. On 11/15/2022, at 10:30 a.m., during an interview with LVN 2, stated patient and/or PCG knew how to do colostomy care and does it daily. LVN 2 stated she should have offered to perform colostomy care to Patient 6 on her visit days as ordered. During an interview with the Director of Patient Care Services Designee (DPCSD), on 11/16/2022 at 11:35 a.m., stated the visiting nurse should perform colostomy care as ordered by the physician and document every treatment they provide in the clinical notes. DPCSD stated that if patient refused care, it should also be documented in the visit notes.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the Home Health Agency (HHA) failed to ensure there was an ongoing agency staff's communication with physician and other health care professionals involved in the development of the plan of care (POC) for one of seven sampled patients (Patient 1). This deficient practice has the potential in the delay to provide treatment and management of the identified patient care needs that could affect the health and safety of the patient. Findings: A review of Patient 1's Profile Information for certification period of 10/05/22 to 12/03/22, indicated a start of care (SOC) date of 10/05/22. Patient 1's primary diagnosis included Alzheimer’s disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, it also involves parts of the brain that control thought, memory, and language). A home visit was conducted on 11/15/22 at 11:15 a.m., with the Licensed Vocational Nurse 1 (LVN 1). During the visit, it was observed Patient 1 was sitting on her bed in her private room, alert and oriented but confused at times, not in any acute distress. LVN 1 performed hand hygiene and started his visit. During a concurrent interview, Patient 1 stated she wanted to change her diet from soft to mechanical diet as she does not want the consistency and taste of the food. A review of Patient 1’s plan of care dated 10/05/22 indicated an order for Speech Therapy (ST) evaluation and follow-up for safe swallowing and intelligible speech. LVN 1 stated that he did not know if Patient 1 had the ST evaluation. A review of Patient 1’s clinical record indicated the ST initial evaluation was conducted on 10/11/22. The evaluation indicated a referral for Speech Language Pathologist (SLP) to determine physiological aspects of swallowing for patient’s safety, intervention plan and management, however, there was no documented evidence the referral was communicated with the medical doctor. There was also no evidence Patient 1 was referred for dietary services to assess and change the diet. On 11/16/22 at 12:25 p.m., during an interview with the Director of Patient Care Services designee (DPCSD), DPCSD stated the recommendations from ST should have been communicated to the case manager to follow-up with the medical doctor. DPCSD stated that SLP evaluation was to be done outside their service, but the Case manager (CM) could still make arrangement for Patient 1 after an order from the medical doctor. At 12:35 p.m., during an interview with the CM stated she did not receive any communication notes from the speech therapist or the visiting nurse regarding the SLP recommendation. CM stated that if it was communicated to her, she could have made arrangement for SLP recommendation. A review of the HHA’s policy titled “Coordination of Services with other providers”, dated November 2018, indicated that other providers and all referrals to other service providers will be documented in the clinical records, the other service provider will be responsible to contact the physician (or other authorized licensed independent practitioner) for orders for its evaluation and treatment, the case manager or clinical supervisor will be responsible for the coordination between service providers and ongoing communication regarding specific patients will be the responsibility of the case manager or the appropriate clinician.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide written instructions to patient and caregiver to ensure patients and families understand what services to expect from the HHA, the purpose of each service and when to expect the services and updated as the current plan of care changes (POC- information identified based upon the patient identified needs and development of appropriate interventions) for one of 7 sampled patients (Patients 6). This failure has the potential to result in the lack of coordination of the plan of care with the patient, caregivers, and other clinicians involved in the patient care and treatment. Findings: A home visit to Patient 6's residence was conducted on 11/15/2022 at 9:40 a.m., with Licensed Vocational Nurse 2 (LVN 2). A review of Patient 6's home health agency's folder, indicated there was no written instructions to patient and caregiver in the folder that included the POC for the current certification period. During an interview with LVN 2, on 11/15/2022 at 10:00 a.m., she confirmed there was no current copy of the plan of care available in the home for Patient 6. LVN 2 stated an updated plan of care should have been provided to Patient 6. A review of Patient 6's clinical record indicated a new plan of care with a certification period 10/14/2022 through 12/12/2022, indicated it was approved by the physician on 10/19/2022. During an interview with the Director of Patient Care Services Designee (DPCSD), on 11/16/2022, at 11:35 a.m., stated the visiting nurse should have provided a copy of the new plan of care to Patient 6. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2019, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The organization shall provide the patient and caregiver with a copy of the written instructions.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) nursing staff failed to assess the patient's pain level (intensity) as ordered in the plan of care, for two of 7 sampled patients (Patient 5 and 6). This deficient practice had the potential to result in the patients' discomfort due to unrelieved pain that could affect their quality of life and well-being. Findings: a. A review of Patient 5's clinical record indicated a start of care date (SOC) of 8/28/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and end stage renal disease (when the kidneys are no longer able to function normally). A review of Patient 5's Home Health Certification and Plan of Care (POC) for the certification period 8/28/2022 to 10/26/2022, included an order for Skilled nursing (SN) to visit twice a week for two weeks, then once a week for seven weeks. The POC further indicated for the SN to perform vital signs check and record on every visit, and to check patient pain levels using pain scale 0 to10 (zero being no pain, and 10 being the worst possible pain) and report to physician (MD) if pain is greater than 7/10. A review of Patient 5’s Skilled Nurse (SN) Clinical Notes dated 9/03/2022, 9/10/2022, 9/17/2022, 9/24/2022 and 10/08/2022, under the section “Pain”, it indicated the box “No Negative Findings” were checked off but the “Intensity” was blanked. There was no documented evidence patient’s pain level was assessed and recorded using the pain rating scale. b. A review of Patient 6's clinical record indicated a start of care date (SOC) of 8/15/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), malignant neoplasm of uterus (a disease in which cancer cells form in the tissues of the uterus [womb]), and malignant neoplasm of overlapping sites of rectum (the final section of the large intestine), anus and anal canal (a disease in which cancer cells develop in the rectum and anal canal [a tube at the end of your rectum]). On 11/15/2022, at 9:40 a.m., a joint home visit with Licensed Vocational Nurse (LVN 2) was conducted at Patient 6’s residence. Patient 6 was observed awake, alert, and ambulatory using a cane. Patient 6 stated she had on and off pain in her right leg and takes pain medication as needed. A review of Patient 6's Home Health Certification and Plan of Care (POC) for the certification period of 10/14/2022 to 12/12/2022, included an order for Skilled nursing (SN) to visit once a week for nine weeks. The POC further indicated for the SN to perform vital signs check and record on every visit, and to check patient pain levels using pain scale 0 to10 and report to physician (MD) if pain is greater than 7/10. A review of Patient 6’s Skilled Nurse (SN) Clinical Notes dated 10/14/2022, 10/21/2022, 10/28/2022 and 11/04/2022, under the section “Pain”, it indicated the box “No Negative Findings” were checked off but the “Intensity” was blanked. There was no documented evidence patient’s pain level was assessed and recorded using the pain rating scale. During a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), on 11/16/2022, at 11:35 a.m., the DPCSD acknowledged the finding and stated that the visiting nurse should assessed patient’s pain level using the pain scale 0 to 10 in accordance with the physician’s order in the plan of care. A review of the agency’s policy and procedure titled “Pain Assessment,” revised November 2018, indicated that when the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: Pain intensity using a rating scale (on a scale of 0-10: 0 = no pain, 10 = unbearable pain). Pain intensity should include current pain, worst pain, and the least pain using the scale. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2019, indicated the purpose of the policy is to provide clinical direction to clinicians providing direct patient care. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA (Home Health Agency) failed to include emergency contact information on Intake form/face sheet for one of seven sampled patients (Patient 1). This failure has the potential to result in missing and inaccurate information causing delay of services, and coordination with the patient's physician and patient's representatives in order to implement the continuity of patient care. Findings: A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 10/05/22, with a certification period of 10/05/22 to 12/03/22. Patient 1's primary diagnosis of Alzheimer’s disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, it also involves parts of the brain that control thought, memory, and language). A review of Patient 1’s clinical record dated 10/05/22 indicated no emergency contact on Face sheet/Intake information and comprehensive assessment. On 11/16/22 at 11:30 a.m., during an interview with the Director of Patient Care Services Designee (DPCSD) stated “SN (Skilled Nurse) should ensure that intake form and face sheet include the patient’s emergency contact information”. The agency was unable to provide a policy and procedure related to patient’s emergency contact information to include in intake process.