Every finding on record at Rogers Retirement Center, Inc

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 01/19/23, Rogers Home Health is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance conference was conducted on 01/17/23 at 10:30 AM with the Director of Nursing. An exit conference was conducted on 01/19/23 at 4:30 PM with administrative staff. The following deficiencies are based on the partial extended recertification survey completed 01/19/23. Rogers Home Health 368380, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 record review, policy review, observation and staff interview, the agency failed to complete a review of all medications the patient is currently using for two of three patients reviewed with home visits (Patient #1 and #2). This could affect all patients receiving services from the agency. The census was 51. Findings include: Review of the undated agency policy titled, “Medication Administration,” revealed the nurse shall routinely monitor all medications. A medication profile will be updated as indicated and reviewed at least every 60 days. 1. On 01/18/23 at 9:00 AM a home visit was made for Patient #1 with Staff A present. Review of the pre-filled medication card from the pharmacy, dated as filled 01/09/23, revealed Patient #1 had taken Lybaivi 15 milligrams (mg) (used to treat manic episodes), and Lipitor 10 mg (for high cholesterol) since 01/10/23. Per interview on 01/18/23 at 9:15 AM Patient #1 confirmed taking these medications. Review of the Medication Administration Record (MAR) at the group home where Patient #1 resided, and the medication profile did not reveal either of these medications. Additionally, it was noted that Patient #1 had not received the morning doses of Amlodipine (for high blood pressure), Escitalopram (antidepressant), Daily-Vite, Pantoprazole (for stomach ulcers), Lithium Carbonate (for mood disorders), Docusate Sodium (stool softener) and Lisinopril (helps the heart pump more efficiently) on 01/17/23. Review of the medical record for Patient #1 did not reveal any documentation of why the medications were not administered on 01/17/23. Per interview on 01/18/23 at 9:20 AM, Staff D confirmed the medications for Patient #1 had changed on 01/09/23. Per interview on 01/18/23 at 9:50 AM, Staff A stated the home health aides (HHA’s) assist the patient with taking the medications and was not aware of any changes in Patient #1’s medications. Per interview on 01/18/23 at 9:57 AM, Staff B stated the HHA’s mark the MAR when the patient took the medication. Staff B stated there was no registered nurse at the group home. 2. On 01/18/23 at 9:30 AM a home visit was made for Patient #2 with Staff A present. Review of the medication profile for Patient #2 revealed Sertraline HCL (antidepressant) 150 mg, take 1 ½ tablets per day. Review of the bottle in the home, filled on 12/27/22, revealed Sertraline HCL 100 mg, take 1 ½ tablets per day. Per interview on 01/18/23 at 10:08 AM, Staff A confirmed the medication in the patient's home did not match the patient's medication profile.

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: Based on record review, policy review and staff interview, the agency failed to ensure each patient receives the home health services that are written in the physician ordered plan of care for two of seven records reviewed (Patient #3 and #4). This could affect all patients receiving services from the agency. The census was 51. Findings include: Review of the undated agency policy titled, “Emergency Backup Plan/Missed Visits,” revealed the Doctor will be notified of any missed visits or schedule changes. 1. Review of the medical record for Patient #3 and the plan of care dated 11/23/22 revealed the home health aide (HHA) was to visit Monday through Friday. Review of the HHA visit sheets revealed two missed visits the weeks of 11/27/22, 12/04/22, 12/11/22, 12/18/22, 12/25/22, 01/01/23 and 01/08/23. There was no documentation the physician was notified of the missed visits. Per interview on 01/19/23 at 10:29 AM, Staff B confirmed the HHA should have gone Monday through Friday and confirmed the physician was not notified the missed visits. 2. Review of the medical record for Patient #4 and the plan of care dated 12/06/22 revealed the home health aide (HHA) was to visit Monday through Friday 3:00 PM-6:00 PM (three hours per visit). Review of the HHA visit sheets revealed visits Monday through Friday for only two hours per visit. There was no documentation in the patient's record that the physician was notified of the missed visits. Per interview on 01/19/23 at 12:00 PM, Staff B confirmed the HHA did not provide the hours as ordered in the plan of care and confirmed the physician was not notified the missed visits.

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 medical record review, staff interview, and policy review, the agency failed to ensure plan of care included the duration of visits to be made for two of seven records reviewed (Patient #1 and #6). This could affect all patients receiving services from the agency. The census was 51. Findings include: Review of the undated agency policy titled, “Comprehensive Assessment and OASIS Data Collection,” revealed all orders will include a frequency and duration for each discipline and included in the Plan of Care. 1. Review of Patient #1's plan of care for the certification period dated 12/03/22 through 01/31/23 lacked a frequency and duration of home health agency (HHA) visits, stating only that the HHA will provide/assist with personal care and assistance with activities of daily living. 2. Review of Patient #6's plan of care for the certification period dated 12/20/22 through 01/04/23 revealed orders for HHA services to be provided five days per week. There was no frequency of the visits listed on the plan of care. Per interview on 01/19/23 at 9:02 AM, Staff A confirmed the plans of care lacked frequency and duration of HHA visits.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on review of QSO memo 23-02-ALL Attachment G, review of the agency COVID-19 vaccine roster and vaccination records, staff interview, and review of facility policy, the agency failed to implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 for 16 of 42 staff (Staff E, F, G, H, I, J, K, L, M, N, O, P, Q, S, T, and U). This could affect all patients receiving services from the agency. The agency census was 51. Findings include: Review of QSO memo 23-02-ALL Attachment G, revised 04/05/22, revealed the home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The policies and procedures must include, at a minimum, the following components: A process for ensuring all staff (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control (CDC), due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; A process for ensuring that all staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; A process for tracking and securely documenting the COVID-19 vaccination status of all staff; A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC. Review of the undated agency policy titled, “COVID-19 Vaccination Policy, revealed all employees working either on-site or remotely are required to receive a full initial vaccine dosage with a SARS-CoV-2 vaccine (“COVID-19 vaccine”). In addition, all current employees must receive the booster within 30 days of becoming eligible. The policy further stated exemptions are available to any employee who (1) has a disability or qualifying medical condition that contraindicates the vaccination and/or booster or (2) objects to being vaccinated on the basis of sincerely held religious beliefs and practices. Review of the COVID-19 Employee Vaccine Roster, updated 01/19/23 at 3:00 PM, revealed 42 vaccinated staff, one religious exemption and 16 unvaccinated or exempted staff (Staff E, F, G, H, I, J, K, L, M, N, O, P, Q, S, and T), for a total of 60 staff. Staff U was not listed on the vaccine roster. The vaccinated rate of staff was 71.7%. The COVID-19 Employee Vaccine Roster lacked evidence of monitoring and tracking COVID-19 vaccine doses and any boosters received. Review of the COVID-19 vaccination records provided by the agency confirmed 16 staff with no evidence of COVID-19 vaccination or approved medical or religious exemptions. Per interview on 01/19/23 at 3:48 PM, Staff B confirmed these findings.

Substantial Allegation Survey Substantial Allegation OH00121876 An entrance conference was conducted with administrative staff on 05/10/21, and an exit conference was conducted with administrative staff on 05/11/21. The following deficiencies are based upon the substantial allegation OH00121876 completed on 05/11/21. Rogers Home Health 368380, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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: Based on medical record review and staff interview, the agency failed to provide home health services as ordered in the written plan of care for one of four patient medical records reviewed (Patient #1). This could affect all patients receiving services from the agency. Findings include: Review of Patient #1's medical record revealed orders to receive 20 hours of home health aide service per week for the certification period dated 02/20/21 through 04/20/21. There was no evidence home health aide services were provided the weeks of 03/28/21, 04/04/21, and 04/11/21. There was no documented evidence the physician was notified that services were not provided as ordered. Staff C was made aware of and confirmed this finding in an interview on 05/11/21 at 2:35 PM. This substantiates Substantial Allegation OH00121876.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure all orders were recorded on the plan of care for one of four patient medical records reviewed (Patient #1). This could affect all patients receiving services from the agency. Findings include: Review of Patient #1's medical record revealed the skilled nurse conducted telehealth visits on 04/08/21 and 04/15/21. There were no orders for telehealth visits. Staff C was made aware of and confirmed this findings in an interview on 05/11/21 at 1:54 PM.

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based the emergency preparedness survey completed on 01/04/21.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to develop a policy and procedure that addressed the use of employees in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This could potentially affect all patients receiving services from the agency. The census was 83 Findings include: Per interview on 12/09/2020 at 11:45 PM Staff D stated there was no policy and procedure for ensuring staffing to meet the needs of the patients when needed during an emergency, such as the COVID-19 outbreak. Staff D stated the patients had an emergency backup plan where family would take over the care if needed on a temporary basis.

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH00110863 and OH00117346 COVID-19 FOCUSED INFECTION CONTROL SURVEY The following deficiencies are based on the COVID 19 Focused Infection Control Survey and Substantial Allegation Survey completed on 01/04/21.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure patients received contact information and hours of operation of state toll free home health telephone hot line or that its purpose was to receive complaints or questions about local Home Health Agencies. This affected all patients receiving services from this agency. The census was 83. Findings include: Review of the Welcome packet provided to each patient at start of care revealed no contact information and hours of operation of the state toll free home health telephone hot line or that its purpose was to receive complaints or questions about local Home Health Agencies. Per interview on 12/23/2020 at 10:35 AM Staff D confirmed the state toll free home health telephone hot line and hours of operation were not in the Welcome packet.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and staff interview the agency failed to document the existence and resolution of two of three complaints reviewed. This could affect all patients receiving services from the agency. The census was 83. Findings include: Per interview on 12/09/2020 at 1:17 PM Staff D stated there were no documented complaints or incidents for 2020. 1. Review of the medical record for Patient #1 revealed a communication note dated 03/03/2020 by Staff D from stating Patient #1 complained Staff F stole toilet paper. Further review revealed Staff F was asked to come in and write a statement. There was no evidence of a statement by Staff F or any other investigation done and no resolution was documented. 2. Review of a Communication Note dated 10/27/2020 revealed a complaint of theft from the family of Patient #3. On 12/09/2020 at 12:25 PM Staff D confirmed there was no documented evidence of this complaint or resolution available.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure services were provided as written in the physician ordered plan of care for one of three records reviewed (Patient #3). This could affect all patients receiving services from the agency. The census was 83. Findings include: Review of Patient #3's medical record revealed the patient was admitted to the agency on 04/27/2020 with diagnoses including unspecified cerebral infaraction and essential hypertension. Review of the physician ordered plan of care for the certification period dated 04/27/2020 through 06/25/2020 revealed orders for home health aide services Monday, Wednesday, Friday, three hours per day. The patient lived with other caregivers in the home and was up with a walker and/or wheelchair. The patient had left sided weakness with movement and assisted ambulation. The patient was also alert, but forgetful. The author spoke with the patient's daughter who was looking to add more hours and would speak with the patient's case manager. Review of the aide plan of care revealed the home health aide (HHA) would go Monday-Friday 9:00 AM-12:00 PM and 5:00 PM-7:00 PM. The patient had poor vision and wore glasses, was confused and forgetful at times and then alert and oriented and had a stroke with left sided weakness and walked with a cane or walker. Review of a communication from the patient's case manager revealed home health aide hours were increased to 34.5 hours per week starting 05/01/2020. There was no evidence the physician ever ordered the increase in hours. There was no evidence any home health aide services were provided between 04/27/2020 and 05/01/2020. Review of the home health aide time sheets revealed the following: Week of 05/02/2020 - 9.5 hours were provided Week of 05/09/2020 - 33 hours were provided Week of 05/17/2020 - 6 hours were provided Week of 05/23/2020 - 25 hours were provided Week of 05/30/2020 - 35 hours were provided Week of 06/06/2020 - 35 hours were provided Week of 06/13/2020 - 35 hours were provided Week of 06/20/2020 - 15 hours were provided Week of 06/27/2020 - 6 hours were provided Week of 07/04/2020 - no documentation of any hours provided Week of 07/11/2020 - 2 hours were provided Week of 07/18/2020 - no documentation of any hours provided Week of 07/25/2020 - no documentation of any hours provided Week of 08/01/2020 - 3 hours were provided Week of 08/08/2020 - 35 hours were provided Week of 08/15/2020 - 35 hours were provided Week of 08/22/2020 - 35 hours were provided Week of 08/29/2020 - 35 hours were provided Week of 09/05/2020 - 35 hours were provided Week of 09/12/2020 - 35 hours were provided Week of 09/19/2020 - 35 hours were provided Week of 09/26/2020 - 35 hours were provided Week of 10/03/2020 - 35 hours were provided Week of 10/01/2020 - 35 hours were provided Week of 10/17/2020 - 35 hours were provided Week of 10/24/2020 - no documentation of any hours provided There was no evidence the physician was notified of any missed visits and there were no additional signed physician's ordered plan of care beyond the one dated 04/27/2020 through 06/25/2020. Per interview on 12/29/2020 at 4:00 PM Staff D confirmed there were no other physician orders. Per interview on 01/04/21 at 5:00 PM Staff E confirmed the aide visit/time sheets did not match the physician signed orders. This substantiates Substantial Allegation OH00117346.

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: Based on record review and staff interview, the agency failed to provide infection control education regarding transmission of infectious diseases and specifically mitigating transmission of COVID-19 to staff, patients, and caregivers. This could potentually affect all patients receiving services from the agency. The census was 83. Findings include: Per interview on 12/09/2020 at 1:30 PM Staff D stated there was no specific education for patients and family members regarding transmission of infectious diseases and specifically mitigating transmission of COVID-19.

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the home health aides (HHA) maintained satisfactory performance on a competency evaluation for five of five HHA personnel files reviewed (Staff A, B, C, F and G). The census was 83. Findings include: Review of the personnel files for Staff A, B, C, F and G revealed no documentation these five HHA's had successfully completed a competency evaluation program. Staff E was made aware of the findings in an interview on 01/04/21 at 5:15 PM.

24 consecutive months paid service CFR(s): 484.80(a)(2) A home health aide or nurse aide is not considered to have completed a program, as specified in paragraph (a)(1) of this section, if, since the individual's most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in §409.40 of this chapter were for compensation. If there has been a 24-month lapse in furnishing services for compensation, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure home health aides completed another program if they did not provide services as a home health aide for 24 consecutive months prior to working as a home health aide for one of three home health aide personnel files reviewed (Staff C). The census was 83. Findings include: Review of Staff C's personnel file revealed Staff C worked as a home health aide (HHA) from 03/2015 to 04/2017. Staff C then worked at a gas station from 2017 to 2019. Staff C was hired as an aide on 05/22/2020, which was more than 24 consecutive months since Staff C had worked as a HHA. There was no evidence Staff C completed another training program prior to providing services. On 01/04/21 at 5:15 PM, Staff E was made aware of this finding in an interview.