Every finding on record at Ultimate Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/02/25. Standard level deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to ensure that the Emergency Preparedness plan was tested and /or activated as required. Findings include: 1. The Emergency Preparedness Plan was reviewed on 05/02/25. The Agency’s Emergency Preparedness Plan contained documentation that the Agency activated its Emergency Preparedness Plan for actual emergency event on 02/03/22 and on 12/12/24. The Plan lacked documentation that the Agency conducted Emergency Preparedness testing in 2023, as required. 2. During an interview with the Clinical Supervisor/Director of Nursing (DON) and Case Manager/Alternate DON on 05/01/25 at 1:30 PM, the Administrative Staff confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/02/25. Standard level deficiencies cited. Abbreviations: # = number AM = morning SOC = Start of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. . Findings include: 1. The Agency's Pt. admission folder was reviewed on 04/28/25. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. On 04/28/24, 04/30/25 and 5/01/25, home visits were conducted on the following Pts. Pt. #1. SOC Pt. #2. SOC 05/29/24 Pt. #3. SOC 07/23/20 During the home visits, the patient's admission folder was observed and lacked the name and contact information of the Administrator. 3. The clinical records of the following Pts. were reviewed from 04/3025 to 05/01/25. Pt. #1. SOC Pt. #2. SOC 05/29/24 Pt. #3. SOC 07/23/20 Pt. #4. SOC 09/09/24 Pt. #5. SOC 01/20/24 Pt. #6. SOC 02/06/23 Pt. #7. SOC 09/19/24 The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy review and Staff interview, it was determined that in 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7), clinical records reviewed, the Agency failed to ensure Pts. were assessed for the status of Influenza and Pneumonia vaccination per Agency policy. Findings include: 1. The following clinical records were reviewed from 04/29/25 to 05/01/25. The records contained a "Patient Vaccination Check- Off Form" that lacked documentation that the patients were completely assessed for the Influenza/ Pneumonia vaccine status. Pt. #1 SOC 06/10/23 Pt. #2 SOC 05/29/24 Pt. #3 SOC 07/23/20 Pt. #4 SOC 09/09/24 Pt. #5 SOC 01/20/24 Pt. #6 SOC 02/16/23 Pt. #7 SOC 08/02/22 2. The Agency policy on Influenza and Pneumonia Vaccination was reviewed on 05/01/25. The Agency policy required: “….Influenza….the home health agency shall document in the client/patient’s medical record that an annual vaccination against influenza was administered, arranged, refused, or medically contraindicated…. A form is used to document this information….Pneumococcal vaccine….the agency will document, using the attached form, whether the pneumococcal vaccine has been received. If the patient does not recall, the referring doctor will be consulted for the date of the vaccination….” 3. During interviews with the Clinical Supervisor/Director of Nursing, Case Manager/Alternate Director of Nursing and Office Manager on 05/01/25 from 12:45 PM to 2:15 PM, the Administrative Staff confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and Staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) discharged records reviewed, the Agency failed to ensure a discharge summary was sent to the Physician. Findings include: 1. Pt. #6 was admitted to Home Health Services on 02/16/23 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and With Stage 5 Chronic Kidney, Unspecified Diastolic (Congestive) Heart Failure, Dependence on Renal Dialysis. The clinical record was reviewed on 04/30/25. The clinical record contained a discharge assessment and a discharge summary dated 10/31/24. The record lacked documentation that the discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 08/02/22 with the diagnosis of Unspecified Dementia without Behavioral disturbance. The clinical record was reviewed on 04/30/25. The clinical record contained a discharge assessment and a discharge summary dated 08/20/24. The record lacked documentation that the discharge summary was sent to the Physician. 3. During an interview with the Clinical Supervisor/Director of Nursing (DON) and Case Manager/Alternate DON on 05/01/25 at 1:30 PM, the Administrative Staff confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency’s Emergency Plan and staff interview, it was determined the Agency failed to develop and maintain an emergency communication Plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Plan was reviewed on 2/15/22 at 3:25 PM. The plan’s communication plan lacked names and contact information for all staff members, entities providing services under arrangement, patient physicians, and volunteers. 2. During an interview with the Director of Nursing and RN Case Manager/Alternate Administrator on 2/16/22 beginning at 11:00 AM, it was confirmed the Agency did not have a complete communication plan, which included the required names and contact information.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care RN = Registered Nurse AM = Morning PM = Afternoon, Evening E = Employee

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure informed consents contained the disciplines that will provide care and the frequency of visits. This was found in 5 of 7 clinical records reviewed. (Pts. #2, 4, 5, 6, and 7). Findings Include: 1. The following clinical records were reviewed beginning 2/14/22 at 12:50 PM to 2/15/22 at 2:30 PM: Pt. #2 SOC: 2/3/21 Pt. #4 SOC: 1/25//22 Pt. #5 SOC: 6/23/18 Pt. #6 SOC: 9/24/21 Pt. #7 SOC: 3/17/21 The records lacked documentation the above Pts. consented to the disciplines that will provide care and the frequency of visits at the SOC. 2. During an interview with the Director of Nursing and the RN Case Manager/Alternate Director of Nursing on 2/16/22 beginning at 11:00 AM, it was confirmed that the above records lacked documentation the Pts. consented to the disciplines that would be providing care and the frequency of visits at the SOC.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review, and staff interview, it was determined the Agency failed to assess Patients' Influenza and/or Pneumococcal pneumonia vaccination status as required by the Agency policy. This was found in 5 of 7 (Pts. #1, 7, 2, 3 and 4) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/24/22. Principal Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 2/14/22 at 2:00 PM. The record contained a form titled “Influenza and Pneumococcal Vaccination Check-Off Form.” The form lacked documentation of the Pt.’s Influenza and Pneumococcal vaccination status. 2. Pt. #7. SOC 3/17/21. Principal Diagnosis: Urinary Tract Infection, Unspecified. The clinical record was reviewed on 2/14/22 at 2:45 PM. The record contained a form titled “Influenza and Pneumococcal Vaccination Check-Off Form.” The form lacked documentation of the Pt.’s Influenza and Pneumococcal vaccination status. 3. Pt. #2. SOC 2/3/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/14/22 at 12:50 PM. The record lacked documentation the Pt. was screened at the SOC for the status of the Influenza and Pneumococcal Pneumonia vaccine. 4. Pt. #3. SOC 3/5/21. Primary Diagnosis: Breakdown (Mechanical) of Internal Fixation Device of Vertebrae, Subsequent Incounter. The clinical record was reviewed on 12/15/22 at 9:35 AM. The record lacked documentation if the Pt. had been vaccinated with the Influenza and/or pneumococcal vaccine, or wished to receive these vaccinations. 5. Pt. #4. SOC 1/25/22. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/15/22 at 12:30 PM. The record lacked documentation the Pt. was screened at the SOC for the status of the Influenza and Pneumococcal Pneumonia vaccine. 6. The Agency policy titled “Influenza and Pneumococcal Vaccination Policy” was reviewed on 2/16/22 at 9:30 AM. The policy required: “…The Agency shall arrange for administration of a pneumococcal vaccination…to each Client/Patient who is 65 or over who has not received this immunization prior to or upon service initiation, unless the Client/Patient refuses the offer for vaccination or the vaccination is medically contraindicated…the Home Health Agency shall document in the Client/Patient’s medical record that an annual vaccination against Influenza was administered, arranged, refused, or medically contraindicated or that the Client/Patient is not a member of a vaccination priority population…” 7. During an interview with the Director of Nursing and the RN Case Manager/Alternate Director of Nursing, the Director of Nursing stated the RN should screen Pts. upon admission for the status of the Influenza and Pneumococcal Pneumonia vaccine. If the Pt. requests the Influenza vaccine during flu season (October 1 through March 31), or the Pneumococcal vaccine, the Pt. is referred to their Primary Physician or Pharmacy for administration of these vaccines. The Patient’s vaccination status or refusal of vaccination should be documented in the Patient’s clinical record.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: A. Based on observation and staff interview, it was determined the Agency failed to ensure a pre-designated Alternate Administrator was in place during the Administrator’s absence. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. Upon entrance to the Agency on 2/14/22 at 9:10 AM, the Administrator was not present. 2. On 2/14/22 at 9:40 AM, the RN Case Manager/Alternate Director of Nursing stated the Administrator would return on 2/15/22. Surveyor requested the Agency present documentation that the Agency’s governing body and Administrator had pre-designated someone to act as Alternate Administrator in the Administrator’s absence. 3. During an interview with the RN Case Manager/Alternate Director of Nursing and E #6 on 2/14/22 at 9:50 AM, E #6 stated there was no documentation that the Agency’s governing body and Administrator had pre-designated someone to act as Alternate Administrator in the Administrator’s absence. 4. During an interview with the Director of Nursing and the RN Case Manager/Alternate Director of Nursing on 2/16/22 beginning at 11:00 AM, the above findings were confirmed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview, the Agency failed to ensure documentation of forms were complete and accurate. This was found in 4 of 7 (Pt. #1, 3, 5 and 7) clinical records reviewed. Findings include: 1. The following records were reviewed from 2/14/22 at 2:00 PM to 2/15/22 at 10:45 AM: Pt. #1 SOC: 1/24/22 Pt. #3 SOC: 3/5/21 Pt. #5 SOC: 6/23/18 Pt. #7 SOC: 3/17/21 The records contained signed forms titled, "Beneficiary Elected Transfer" which lacked documentation of the previous agency's name. 2. During an interview with the Director of Nursing and RN Case Manager/Alternate Director of Nursing on 2/16/22 beginning at 11:00 AM, it was stated the above-mentioned Pts. did not transfer from another agency. and this form should only be completed if the Pt. was transferred from another agency. During the same interview, the above findings were confirmed.