Every finding on record at V N A Corporation

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/11/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 06/11/2025. The provider had 332 current patients.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated reviewed/revised “01/2018,” showed in part: - The case manager is responsible for accurate medication reconciliation. The case manager or designee (physical therapy assistant (PTA), licensed practical nurse (LPN), certified occupational therapy assistant (COTA) will perform medication reconciliation every visit; - All other disciplines will assess for changes on their visit and ensure the electronic medical record (EMR) is updated when the discrepancy is identified; - The EMR will consist of medications actually in the home and what the patient says he/she is taking (discrepancies from the written discharge instructions will be noted in a clinical note and called to the doctor); and - All other disciplines other than the case manager and/or nursing will observe and interview the patient for changes. If discrepancies are noted a medication reconciliation will be completed and the EMR is updated at the visit the discrepancy was identified. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; and - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters). Review of the provider's current medication profile, showed in part: - Fluoxetine (a medication given to treat depression) 20 mg (milligrams). Take one capsule two times a day; and - Potassium Chloride 20 milliequivalent extended release. Take one tablet two times daily. Observation on 06/10/2025 at 9:00 AM, with registered nurse (RN)-A, the following medication discrepancies were noted when a medication reconciliation was performed with the patient: - The patient was taking the fluoxetine once daily (it was ordered twice daily); and - The patient was taking the potassium chloride every other day (it was ordered two times daily). Per interview conducted with the patient during observation the patient stated that: - He/she had never taken the fluoxetine twice a day; - He/she had taken the potassium every other day “for a long time”; and - The first person that had come must have gotten that wrong. He/she was the one that had taken/written the medication list down. During an interview on 06/11/2025 at 10:30 AM the alternate administrator stated that the provider’s policy was to have a correct medication list.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care (POC) when the patients did not receive specific detailed pain assessment as ordered on the plan of care in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider's policy titled, "Plan of Care/Physician Orders Policy," dated reviewed/revised “2/2019”, showed in part, the direct service providers conform to the doctor’s orders as noted on the POC. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) and secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver); and - The patient lived at home with an adult child. Review of the POC dated 05/22/2025 to 07/20/2025 showed skilled nurse (SN) to assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects. Review of the SN visit note dated 05/28/2025 showed: - “Patient seen for PleurX drain procedure. Patient tolerated without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 05/30/2025 showed: - “Patient seen for PleurX draining. Drained today without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/03/2025 showed: - “Patient seen for PleurX drain procedure. Patient denies any pain with draining”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/06/2025 showed: - “Patient seen for PleurX draining. Patient tolerated draining without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Review of the SN visit note dated 06/10/2025 showed: - “Patient seen for PleurX drain procedure. Patient tolerated without complaints”; and - The SN failed to document a pain assessment as ordered in the POC. Observation on 06/10/2025 at 9:00 AM, showed registered nurse (RN)-A failed to complete a pain assessment that included pain level, frequency, location, quality, precipitating factors, and side effects as ordered on the POC. During an interview on 06/11/2025 at 10:30 AM, the alternate administrator stated that the POC should be followed.

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 policy review, record review, home visit observation, and interview, the home health provider failed to develop a complete/individualized plan of care (POC), in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect the care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care/Physicians Orders,” revised on 09/2019, showed in part: - A physician’s written plan of care is required for each patient receiving home health services; - The plan of care is developed by the patient’s physician in consultation with agency home health care service providers, and the patient/caregiver, and includes the following in part: * Medications, allergies, and treatments * Any safety measures to protect against injury * Any other appropriate item. (Example: laboratory procedures and any contraindications or precautions to be observed) - Within 24 (twenty-four) hours of the initial assessment visit by the care provider, the physician must be consulted to confirm the appropriateness of the initial plan of care or to approve additions or modifications to the original plan; - Agency (home health provider) professional staff promptly alerts the physician to any change that suggests a need to alter the plan of care; - The direct service providers conform to the doctor's orders as noted on the plan of care; and - Agency (home health provider) staff administers drugs and treatments only as ordered by the physician. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to home health services on 05/06/2025 with the primary diagnosis of interstitial cystitis (a chronic, painful bladder condition) without hematuria (blood in the urine); and - The patient resided at home alone. Review of the POC dated 05/06/2025 to 07/04/2025 showed: - An additional diagnosis of type 2 (two) diabetes mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood); - Skilled nurse (SN) to assess blood sugar monitoring and results and notify the medical doctor (MD) as indicated; - SN to perform skin care; and - The POC failed to include the frequency for how often the patient was to check blood sugar levels, blood sugar results that needed to be reported to the MD, and what specific skin care the SN was to provide. Observation on 06/10/2025, beginning at 3:40 PM showed, in part: - The patient reported that he/she did not check his/her blood sugar levels; - The physician did not require the patient to check blood sugars; and - The patient did not have any open wounds that required the SN to perform wound care on. During an interview on 06/11/2025 that began at 10:50 AM, the predesignated administrator stated that: - The patient’s physician was contacted for clarification of blood sugar monitoring and verification was received that the patient did not have to check blood sugar levels; - Blood sugars were monitored by the physician twice a year by obtaining labs; - The patient did not have any open wounds but was using barrier cream to his/her coccyx to prevent skin breakdown; and - Orders were received and the POC was updated to include the use of barrier cream for prevention of skin breakdown and blood sugar monitoring by the physician twice a year via Hgb A1C lab draws. RECORD/PATIENT#3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had A PleurX drainage catheter (a thin, flexible tube that's placed in your chest to drain fluid from your pleural space (fluid filled space that surrounds the lungs. This can make it easier for you to breathe.) In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 ml (milliliters)); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) The patient also had a secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver) and long-term current use of anticoagulants (blood thinning medication); and - The patient lived at home with an adult child. Review of the start of care assessment dated 05/22/2025 showed: - The patient had a pleurx drain; and - The patient was taking an anticoagulant medication. Review of the POC dated 05/22/2025 to 07/20/2025 showed: - A primary diagnosis of encounter for change or removal of drains (the patient had a pleurx drain); - An other pertinent diagnosis of long term current use of anticoagulants; and - The POC failed to be individualized with the management of/education for care of the pleurx drain or interventions to monitor for signs or symptoms of bleeding (such as excessive or abnormal bruising) or active bleeding due to the administration of anticoagulant therapy. Observation on 06/10/2025 at 9:00 AM, showed: - The patient had a pleurx drain; and - The patient was on an anticoagulant medication (apixaban). During an interview on 06/11/2025 at 10:30 AM the alternate administrator stated that: - Pleurx drain management, and education should have been on the POC; and - Education regarding the high-risk medication (apixaban) should have been on the POC.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure each patient received complete/accurate written instructions related to their medication schedule/instruction in, but not limited to, one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Medication Reconciliation” dated reviewed/revised “01/2018”, showed in part, “Reconciliation: The visiting staff observes meds in the home, written med list in the home and EMR (electronic medical record); all should match prior to leaving home.” RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to home health services on 05/22/2025 with a primary diagnosis of encounter for change or removal of drains; - The patient had a PleurX (brand) drainage catheter (a thin, flexible tube placed in the chest to drain fluid from the pleural space (fluid filled space that surrounds the lungs) to make it easier to breathe). In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 milliliters); - The patient also had diagnoses of malignant neoplasm of right choroid (a cancer that develops in the choroid, the vascular layer beneath the retina. It is the most common primary malignancy of the posterior segment of the eye in adults.) and secondary malignant neoplasm of the liver and intrahepatic bile duct (cancer that has spread from another part of the body to the liver and the bile ducts within the liver); and - The patient lived at home with an adult child. Observation on 06/10/2025 at 9:00 AM, showed the home health provider failed to ensure a written medication schedule was placed in the patient's home. Per interview conducted during observation, the patient stated that: - He/she did not have a written med list in their home; - He/she had some of their meds on their phone; and - The home health provider never left a list. During an interview on 06/11/2025 at 10:30 AM, the alternate administrator stated that the expectation was to leave a medication list in the home.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review Missouri regulations, policy review, employee file review, and interview, the home health provider failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire and failed to ensure all persons offered employment, registered with the Family Care Safety Registry (FCSR) prior to patient contact in one of four employee files reviewed (Employee #3). This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Registry, regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a Class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other states or has been found guilty of a crime, which if committed in Missouri would be a Class A or B felony violation of Chapter 565,566, or 569, or any violation of Subsection 3 of section 198.070 or section 568.020." Review of Section 192.2495.7, RSMo (effective August 28, 2018): "Any in-home services provider agency or home health agency shall be guilty of a Class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the Family Care Safety Registry or if such person: - (1) Has nay disqualifying factors listed in Subsection 6 of this section; - (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony under Chapter 195 or 579; - (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Section 568.045, 568.050, 568.175, 570.023, 570.025, 570.030, 570.040, as it existed prior to January 1,2017, 570.090, 570.145,570.223, 575.230, or 576.080; - (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of Section 577.010 or 577.012 and who is alleged and found by the court to be and aggravated or chronic offender under Section 577.023; - (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under Section 589.400; - (6) Is listed on the Department of Health and Senior Services Employee Disqualification List under Section 192.2490; - (7) Is listed on the Department of Mental Health Employee Disqualification Registry under Section 192.2490; and - (8) Has a finding on the Child Abuse and Neglect Registry under Sections 210.109 to 210.183." Review of the provider’s policy titled, “HR Onboarding Process,” dated reviewed/revised “7/15/20”, showed in part, the following pre-employment requirements must be met prior to beginning employment: - Missouri Family Care Safety Registry; and - EDL check. Employee #3: Review of the employee file showed: - Contract Speech Therapist (ST); - Date of hire: 03/02/2025; - Date of first patient contact: 03/02/2025; and - The file failed to contain an EDL check or evidence the employee was registered with the FCSR at the time of survey 06/11/2025. During an interview on 06/11/2025 at 9:10 AM, the alternate administrator stated that they (the provider) did not have an FCSR but they were submitting it. (The state agent (SA) was given a copy of the FCSR transaction 06/11/2025 at 9:27 AM). During an interview on 06/11/2025 at 9:18 AM the alternate administrator stated that this was all they sent him/her for an EDL and the SA was given a copy of a Confidential Background Screening Report, order #1859591122, which failed to contain evidence the employee was not on the Missouri EDL.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 07/07/2022. During the survey it was determined Visiting Nurse Association is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Visiting Nurse Association was completed on 07/07/2022. The agency had 401 total current patients, with 259 current patients at the parent agency in Kansas City, MO and 142 patients at the branch in Overland Park, Kansas.

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 policy review, record review, home visit observation, and interview, the agency failed to ensure an accurate and complete review of all medications was completed upon admission/ SOC (start of care) in three (Records/Patients #1, #2, and #4) of five full record reviewed. This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency’s policy titled, “Medication Management," (Number: 763-02-10), dated most recently revised: 06/2019 showed, in part: - All medications are reviewed on admission for potentially clinically significant medication issues that include: omission of medication, dosage errors, and non-adherence; - Medication reconciliation and medication instruction are also a required action for a complete medication management; - On admission the assessing clinician completes a medication reconciliation and medication review for potentially clinically significant medication issues that include: adverse or side effects, ineffective drug therapy, drug and food interactions, duplicative therapy, omissions of medications, dosage errors, and non-adherence; - The medication (bottles) in the home are compared with the medication list provided at discharge/discharge papers; - Any discrepancies (missing medications, dosage inconsistency) or any clinically significant medication issues are clarified with the HH (home health) physician and documented in the medical record no later than midnight of the next business day; - Do not add medications that are ordered but not in the home; and - The RN (registered nurse) will call and document notification to the physician on clinically significant issues. RECORD/PATIENT #1: Review of the clinical record showed the following medication discrepancies on admission/start of care (SOC): - The initial POC (plan of care), dated 06/26/2022 to 08/24/2022, showed the medication medroxyprogesterone 10mg (milligrams) 2 tablets daily to regulate cycle (menstrual); the referral discharge medication list dated 06/24/2022 failed to list the medroxyprogesterone; - The OASIS (Outcome Assessment Information Set- a standardized assessment), dated 06/26/2022, showed Item M2001 coded: 0-No-No issues found during review and medications reconciled without issue; and - A client coordination note date 06/26/2022 showed medication discrepancies: none. The clinical record failed to show documentation/physician order clarifying the medication discrepancy. Observation on 07/05/2022 at 1:55 PM, during the patient’s home visit showed the medroxyprogesterone on the home medication list. Per interview conducted during the observation the patient stated that he/she was taking medroxyprogesterone 10 mg, two tablets daily, as ordered. During an interview on 07/06/2022 at 2:50 PM, the CNO (chief nursing officer) stated that documentation and/or a clarification order would be expected since it was not on the discharge medication list and the patient was taking it. RECORD/PATIENT #2: Review of the clinical record showed the following medication discrepancies on admission/SOC: - The initial POC dated 05/18/2022 to 07/16/2022, showed Eliquis (used to treat and prevent blood clots) 5mg twice daily: The after visit summary medication list from the (named) hospital dated 05/17/2022 showed: Eliquis 5mg listed but failed to list a frequency; - The initial POC dated 05/18/2022 to 07/16/2022, showed lispro insulin u-100 (used to lower blood sugar) (units per cc) inject 25-30u (units) before meals: The after visit summary medication list from the (named) hospital dated 05/17/2022 showed the same (although these are the same order, they each need clarified due to dosage range); - The initial POC dated 05/18/2022 to 07/16/2022, showed Rosuvastatin 40mg (used to treat high cholesterol and triglyceride levels)1 daily: The after visit summary medication list from the (named) hospital dated 05/17/2022 showed Rosuvastatin 40mg listed but failed to list a frequency; - The after visit summary medication list from the (named) hospital dated 05/17/2022, showed senna/doc (a bowel softener) 8.6/50mg but it failed to be listed on the initial POC; - The OASIS dated 5/18/2022 showed Item M2001 coded: 0-No-No issues found during review and medications reconciled without issue; - A client coordination note date 05/18/2022 showed medication discrepancies: none, all medications in home; and - The clinical record failed to show documentation/physician order clarifying the medication discrepancies. During an interview on 07/06/2022 at 2:50 PM, the CNO stated that he/she would expect clarification with the physician documented regarding the medication discrepancies and physician orders written as needed. RECORD/PATIENT #4: Review of the clinical record showed the following medication discrepancies on admission/SOC: - The initial POC dated 05/10/2022 to 07/08/2022, showed culturelle (used to prevent the growth of harmful bacteria in the stomach and intestines) oral failed to be listed: The referral discharge medication list from the (named) hospital dated 05/06/2022 showed culturelle oral with no further directions; - The initial POC dated 05/10/2022 to 07/08/2022, showed biotin (a b vitamin supplement claimed to help hair growth) 10mg daily: The referral discharge medication list from the (named) hospital dated 05/06/2022 showed biotin 10mg but failed to list a frequency; - The initial POC dated 05/10/2022 to 07/08/2022, showed Centrum Silver (a multivitamin) 1 daily: The referral discharge medication list from the (named) hospital dated 05/06/2022, showed Centrum Silver but failed to list a frequency; - The initial POC dated 05/10/2022 to 07/08/2022, showed estrogens (conj) (conjugated) (hormone replacement used to treat hot flashes) 0.625mg 1 tab daily: The referral discharge medication list from the (named) hospital dated 05/06/2022 showed estrogens (conj) 0.625mg nightly take for 21 days then do not take for 7 days; - The initial POC dated 05/10/2022 to 07/08/2022, failed to show furosemide (used to treat fluid retention) listed: The referral discharge medication list from the (named) hospital dated 05/06/2022 showed furosemide 40mg twice daily; - The initial POC dated 05/10/2022 to 07/08/2022, failed to show tresiba (long acting insulin used to decrease blood sugar): The referral discharge medication list from the (named) hospital dated 05/06/2022 showed tresiba Sub Q (subcutaneous- under the skin in the subcutaneous tissue) with no dosage or frequency directions; - The initial POC dated 05/10/2022 to 07/08/2022, failed to show A-G pro hair growing: The referral discharge medication list from the (named) hospital dated 05/06/2022 showed A-G pro hair growing daily; - The initial POC dated 05/10/2022 to 07/08/2022, showed Diclofenac 75mg (non-steroidal anti-inflammatory used to treat arthritis pain) 1 daily: The referral discharge medication list from the (named) hospital dated 05/06/2022 failed to show diclofenac; - The OASIS dated 5/10/2022 showed Item M2001 coded: 1-Yes- issues found during review, item M2003 medication follow up coded:. Yes, medications reconciled without issue; - A client coordination note dated 05/01/2022 showed: * Patient refuses to take Lasix and insulin as ordered; * Will not take diuretic (Lasix/furosemide); * Does not want to run to the bathroom all the time; * Cannot afford his/her insulin (tresiba). Patient does not plan to resume insulin; and * Medication discrepancies: patient not taking Lasix or insulin. The clinical record failed to show documentation/physician order clarifying the medication discrepancies other than the communication note (unsigned by the physician) discussing the Lasix/furosemide and the insulin/tresiba. Observation on 07/06/2022 at 1:30PM, during the patient’s home visit, showed the home medication list matched the initial POC med list. Per interview conducted during the observation, the patient stated that he/she is taking the culturelle (that was noted on the discharge medication list). During an interview on 07/07/2022 at 9:40 AM, the CNO stated that it (medication discrepancies) is inconsistent.

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 policy review, record review, home visit observation, and interview the agency failed to ensure the plan of care (POC) included all of the required elements in, but not limited to, two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect the care of all patients served by the agency. RECORD/PATIENT #2: Review of the POC (plan of care) dated 5/18/2022 to 7/16/2022 showed: - The patient’s diagnoses included disruption of external operation (surgical) wound (dehiscence of operation wound- a partial or total separation of a previously approximated (tissue edges are close together), infection following a procedure- deep incisional surgical site, type II diabetes (a chronic condition that affects the way the body processes blood sugar) with diabetic peripheral angiopath (a blood vessel disease cause by high blood sugars, unspecified atherosclerosis (deposition of plaques) of the native arteries of left leg, and long term (current) use of insulin; - Orders for disciplines and treatments included, but not limited to, skilled nurse for instruction/reinforcement of diabetic care to include: diet, skin care, administration of insulin, blood glucose testing & diabetic foot care. Instruct patient to monitor blood sugars and report three consecutive readings of blood sugars less than 70 or greater than 240; and - Medications included, but not limited to, insulin lispro (u-100) 100units/ml (milliliter), subcutaneous (method of administering medication under the skin into the subcutaneous tissue) pen per instructions before meals inject 25-30 units before meals (medication to decrease blood sugar). The POC failed to show: - A frequency for the blood sugar to be monitored; and - A specific order or explanation of the dosage range for the lispro insulin. During an interview on 07/06/2022 at 2:50 PM, the CNO (chief nursing officer) stated that: - It (the POC) seems to be patient driven; - I don’t find anything (order clarifying dosage of lispro insulin); - He/she would expect an order with the frequency the blood sugar is to be monitored; and - He/she would expect either a specific order or an explanation of the dosage range for the lispro insulin. Findings included: Review of the agency’s policy titled, “Plan of Care/Physician Order Policy,” dated 03/02/2001, showed, but not limited to, the following: - A physician’s written plan of care is required for each patient receiving home health services; - The plan of care is developed by the patient’s physician in consultation with agency home health service providers, and the patient/caregiver, and includes the following: * Types of service, supplies and equipment required; * Functional limitations; * Specific procedures and modalities for therapy; * Activities permitted; * Medications, allergies and treatments; and * Any other appropriate item (example: observation of any contra-indications or precautions). Review of the agency’s policy titled, “Pain Management,” dated 02/2019, showed the following: - Pain interventions/care plan; - Individualized interventions based on the assessment process including: * Education provided to individuals and/or family; * Pharmacological and non-pharmacological interventions; * Instruct in pain med administration, action and side effects; and * Instruct in premedication for procedures/activities. RECORD/PATIENT #3: Review of the hospital discharge summary, dated 06/23/2022 at 11:37 AM, showed the following; - Teach patient how to adjust rigid collar (used to stop almost all movement in the neck in any direction), cleanse/change pads, and change every three days; - Percocet (used to relieve moderate to severe pain) 5/325 milligrams (mg), two tablets every four hours as needed for pain seven out of ten (rating pain on a scale with zero representing no pain and 10 representing the worst pain) and taper off as discussed; - Check blood pressure prior to taking prescribed blood pressure medications, if systolic blood pressure (the first number when taking blood pressure that measures the pressure in the arteries when the heart beats) is less than 100 you should hold your dose until later in the day, then recheck your blood pressure. Recommend doing this while taking Percocet ad Zanaflex (treats muscle spasms) for pain control, as both can cause hypotension (low blood pressure), especially in conjunction with antihypertensive; - Do not submerge incision for six weeks, no diving for one week, no lifting greater than ten pounds for one month, no sports/activities, no strenuous activity, and no swimming for six weeks, shower only, and walk three times a day; - Wound/dressing care: Do not submerge incision, keep wound clean and dry and okay to shower tomorrow; and - Notify primary care physician of signs and symptoms of chest pain, increased redness, increased tenderness/pain, moderate/large bleeding, numbness, pus-like discharge, red line from wound, shortness of breath, and temperature greater than 101 degrees. Review of the comprehensive assessment dated 06/25/2022 at 11:55 AM, and completed on 06/26/2022 at 11:25 PM, showed the following: - Diagnosis included, but not limited to, encounter for other orthopedic aftercare, migraine, other spondylosis (age related degeneration of the vertebrae and discs) of the lumbar regions (lower back), hypertension, encounter for fitting and adjustment of urinary device, retention of urine, and type 2 diabetes mellitus (chronic disease affecting blood glucose regulations) without complications; - Pain to shoulders and medications and rest and sleep relieve pain; - Indwelling catheter; and - Rigid collar in place. Review of the plan of care (POC), dated 06/25/2022 through 08/23/2022, failed to include the following: - The rigid collar; - Hold blood pressure medication until later in the day if systolic blood pressure below100 and then recheck your blood pressure, especially while taking Percocet and Zanaflex which can cause hypotension; - Individualized pain interventions; - Interventions to taper off Percocet; - Specific incision aftercare instruction; - Specific signs and symptoms to report to the physician; and - Changing the Foley catheter and how often; and - Education on identifying, preventing and reporting urinary tract infections. Observation on 07/06/2022 at 8:00 AM, during the patient’s home visit, showed the following: - The patient had a ridged collar around his/her neck; - The patient said he/she had the wrong padding for under the neck collar but now had the right pad, his/her spouse washes the pad when he/she takes a shower, and he/she had a waterproof collar for showers; - He/she is experiencing burning while urinating since the urologist removed the Foley catheter on 06/27/2022 (the plan of care was not updated); - The patient had shoulder pain for the past three days and was taking Tylenol (no order for Tylenol), ice to the shoulders was not working and the doctor said heat might work (there was no orders for ice to the shoulder); and - He/she takes blood pressure every morning to see if he/she should hold the blood pressure medication. During an interview on 07/06/2022 at 8:00 AM, the occupational therapist stated that: - The patient was to wear his/her collar at all times except last Friday the patient had a shower and the nurse changed the pads; - He/she was not sure about a cold pack and did not know how effective that would be with the collar; and - The patient had Foley catheter pain and it was removed. During interview on 07/06/20022 at 10:50 AM, the clinical manager stated that there system was home care home based (home health care management software), the staff can choose care pathways, and did not feel the plan of care is individualized. During an interview on 07/07/2022 at 9:00 AM, the chief nursing officer stated that he/she expected any treatment, education, and instructions regarding the patient’s care to be addressed on the plan of care.

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 policy review, clinical record review, and interview, the agency failed to ensure staff obtained a physician order for treatment and services which affected two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 06/26/2022 with, but not limited to, diagnoses of aftercare following joint replacement surgery and presence of left artificial knee joint. Review of the POC (plan of care) dated 06/26/2022 to 08/24/2022 showed: - Physical therapist to provide instruction regarding pain control including pharmacological (with the use of medicines) and non-pharmacological methods (if using cold or heat-specify); and - The POC failed to specify orders for the use of cold. Observation on 07/05/2022 at 1:55 PM, during the patient’s home visit observation showed: - The PT questioned the patient if he/she was still icing their knee; and - The patient stated that they were still icing their knee. During an interview with the CNO (chief nursing officer) 07/06/2022 at 2:50 PM he/she stated that: - If the patient is using heat or ice the clinician is supposed to delete out the word specify and input the specific orders on the POC; and - He/she would expect the orders for the cold or heat to be complete, including frequency and duration. Findings included: Review of the agency’s policy titled, “Patient Care and Documentation Standards Policy,” dated September 2019, showed, but not limited to, the following: - Physician orders must be followed every visit; - Visiting staff should have access to the current plan of care and/or pertinent supplemental orders and refer to them during the visit; - Call the physician to get orders to add a treatment; and - Follow the phone call with a supplemental order to be sent to the physician for signature. Review of the agency’s policy titled, “Plan of Care/Physician Order Policy,” dated 03/02/2001, showed, but not limited to, agency staff administer treatments only ordered by physicians. RECORD/PATIENT #3: Review of the plan of care (POC), dated 06/25/2022 through 08/23/2022, showed, in part: - The patient was admitted to home health services on 06/25/2022; - Diagnoses included encounter for other orthopedic aftercare; - Skilled nurse for observation/assessment of pain, effectiveness of pain management regimen and skilled teaching related to pain management to monitor signs/symptoms of pain including type, frequency, and location and relief measures (there was no relief measures listed); and - Physical therapist to instruct in pain control to include use of modalities as prescribed by the physician (there was no modalities for pain control listed). Review of the physical therapy’s visit note, dated 07/01/2022 at 10:53 AM, showed instructed patient/caregiver in cold/heat application for 15 to 20 minutes three to four times a day. There was no documentation to show where the patient was to apply cold/heat. There was no physician orders to apply cold/heat. During interview on 07/06/20022 at 10:50 AM, the clinical manager stated that heat and ice are non-pharmacological interventions and if the patient is using the modality outside of treatment there would not be much control and would not be part of the treatment plan. - Therapy does not have modalities (any physical agent applied to produce therapeutic changes to biological tissues); - Physician orders was not needed since they are not providing the modality; and - He/she left instruction on the use of ice.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in, but not limited to, three (Records/Patients #1, #3, and #6) of six records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 06/26/2022 with, but not limited to, diagnoses of aftercare following joint replacement surgery and presence of left artificial knee joint. Review of the POC (plan of care) dated 06/26/2022 to 08/24/2022 showed a frequency/duration of visits: OT (occupational therapy) 1 time only. Further review of the clinical record showed a client coordination report dated 06/27/2022 that showed: - Missed visit notification; and - Declined OT. The clinical record failed to show a signed physician order to discontinue the OT visit due to patient declined services from that discipline. Observation on 07/05/2022 at 1:55 PM during the patient’s home visit showed a home visit calendar with solely PT (physical therapy) listed. Per interview conducted during observation: - The patient stated that he/she didn’t need OT this time; and - The PT (physical therapist) stated that the patient was doing much better this time than the previous episode. During an interview on 07/06/2022 at 2:50 PM, the CNO (chief nursing officer) stated that he/she would expect an order to discontinue the OT visit due to patient declined service of that discipline. Findings included: Review of the agency’s policy titled, “Patient Care and Documentation Standards Policy,” dated September 2019, showed, but not limited to, the following: - Visit at the frequency ordered and perform only those interventions identified on the plan of care and the supplemental orders; - Physician orders must be followed every visit; - Visiting staff should have access to the current plan of care and/or pertinent supplemental orders and refer to them during the visit; - Call the physician to report the following and document the call in the clinical record: *Reason visits not made at the frequency ordered; * Patient not following plan of care; * Change in patient condition; and - A supplemental order needed for discharge from discipline or agency, notification to physician and documentation of that notification is required. Review of the agency’s policy titled, “Pain Management,” dated 02/2019, showed the following: - Pain interventions/care plan; and - Individualized interventions based on the assessment process including when to notify the physician if pain goals not met. Record/Patient #3: Review of the start of care, dated 06/25/2022 at 11:55 AM, and completed on 06/26/2022 at 11:25 PM, showed pain in shoulders daily, but not constantly and rated his pain a four (zero representing no pain and 10 representing the worst pain), and acceptable level of pain was a two. The patient had one surgical wound and no other skin issues. Foley catheter in place for urine retention, some discomfort with catheter, catheter repositioned, and no further complications. Review of the plan of care (POC), dated 06/25/2022 through 08/23/2022, showed the following: - Skilled nurse for observation/assessment of pain, effectiveness of pain management regimen and skill teaching related to pain management. Skilled nurse to intervene with increased pain level to minimize complication; - Skilled nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled nurse to report significant changes in status to physician for early intervention; - Skilled nurse for instructions/reinforcement of care of indwelling catheter; - Skilled nurse to perform observation/assessment of genitourinary status and intervene to minimize complications of disease process; - Physical and occupational therapy to instruct on pain control including pharmacologic and non-pharmacologic methods; and - Licensed professional to report vital signs falling outside the following established parameters: Fasting blood sugars 70 to 240 and pain greater than five. Review of the physical therapy (PT) evaluation, dated 06/26/2022 at 8:40 AM, showed the patient had pain at the cervical and thoracic area of the spine, and rated the pain as sharp and a seven. The patient’s coccyx reddened (no further assessment). The documentation failed to show physician notification of the pain and reddened coccyx. Review of the occupational therapy (OT) evaluation note, dated 06/27/2022 at 7:55 AM, showed the patient rated his/her pain a seven of spine and pelvis, and the pain was burning and sharp. The pain in the pelvis was located in genitourinary and posterior buttocks. The patient has an external catheter. The patient is also reporting pain in sacral coccyx area and redness noted (no further assessment). Review of an OT client coordination note, dated 06/27/2022, showed hopes the catheter removed at today’s urology visit. Pain: “Playstation support” (patient reports pain) across shoulders and cervical spine seven out of ten, patient reports some coccyx pain and rated eight out of ten, and during the evaluation catheter pain nine out of ten. The plan of care evaluation summary will be faxed the physician. The documentation failed to show physician notification of the pain and areas of pain. Review of the skilled nurse note, dated 06/28/2022 at 11:26 AM, showed the slight redness at the patient’s coccyx with no broken skin (no further assessment). Pain regimen adequately managed with current regimen. The Foley catheter removed and there was no further genitourinary issues (the plan of care not updated). The documentation failed to show physician notification of the reddened coccyx. Review of a registered nurse client coordination note, dated 06/28/2022, showed slight redness at coccyx with no broken skin (no further assessment). Pain regimen adequately managed with current regimen. The documentation failed to show physician notification of the reddened coccyx. Review of the PT note, dated 06/29/2022 at 2:02 PM, showed the patient coccyx was reddened (there was no further assessment). The documentation failed to show physician notification of the reddened coccyx. Observation on 07/06/2022 at 8:00 AM, during the patient’s home visit, showed the following: - His/her coccyx has a reddened are on the crack of the butt and the urologist thought it was from him/her laying on something while in the hospital; - He/she has been treating it aggressively “drawing salves” with tucks, hydrocortisone cream, or A&D ointment and the area is almost healed; - He/she is he burns when he urinates since the urologist removed the Foley catheter on 06/27/2022; and - The patient had shoulder pain for the past three days and was taking Tylenol (no order for Tylenol), ice to the shoulders was not working and the doctor said heat might work (there was no orders for ice to the shoulder). During an interview on 07/06/2022 at 8:00 AM, the occupational therapist stated that: - He/she did report the reddened coccyx to the nurse and the coccyx is no longer red (OT did not assess the coccyx during the visit); - The patient’s pain parameters are orders nursing receives from the physician and are on the plan of care; - If a patient has a change in the patient’s condition he/she notifies the physician and coordination team; and - Last week the patient had Foley catheter pain and the Foley catheter removed. Record/Patient #6: Review of the plan of care dated, 04/08/2022 through 06/06/2022, showed the start of care date 04/08/2022. The skilled nurse to visit one week for five weeks, and one visit every other week for four weeks. Review of a physician order, dated 04/21/2022 (one week after the start of care), showed skilled nurse discontinued per the patient’s request and physical therapy to continue. The physician order was not sent to the physician for signature, verbal order not obtained, and the physician’s signature left blank. During an interview on 07/07/2022, the chief nursing officer stated that no information found to show the physician notified of skilled nursing discharge while visits still ordered.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation and interview, the agency failed to ensure that the accepted standards of practice were used during wound care in one (Record/Patient #4) out of three home visits observed. This deficient practice has the potential to adversely affect the safety from infection of all the agency’s patients receiving wound care. Findings included: Review of the agency’s policy titled “Infection Control Policy," (Policy Number: 11-01), most recently reviewed/revised date of 02/2019 showed: - The agency will maintain a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases; - Infection control procedures consist of personal hygiene, including hand hygiene, special procedure technique, including aseptic technique and safeguards to prevent drug contamination; - The use of personal protective devices; and - Cleaning and disinfecting and sterilizing equipment and supplies. Review of the agency’s policy titled, “Hand Washing, Number: 763-03-12,” dated most recently reviewed/revised 09/2020 showed: - Hand hygiene will be performed to prevent cross contamination between patients and personnel; - Hand hygiene is the single most important factor to prevent spread of communicable infection; - Personnel providing care/service in the home setting will cleanse their hands with soap and water or use an alcohol-based rub before and after gloves are used; and - The use of gloves does not eliminate the need for hand hygiene nor does the use of hand hygiene eliminate the need for gloves. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency 05/10/2022 with, in part, diagnoses of venous insufficiency (chronic, peripheral) (improper functioning of the vein valves in the leg not allowing blood to flow back to your heart), non-pressure chronic ulcer (open sore) of the left lower leg with fat exposed, cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb (left leg), and type II diabetes (a chronic condition that affects the way the body processes blood sugar). Review of the physician order dated 06/01/2022 showed: - Cleanse the left lower extremity wound with saline or wound cleanser, pat dry, apply prisma (a collagen based dressing) and cover with a foam dressing; and - Change three times weekly by the HH (home health) nurse. Observation on 07/06/2022 starting at 1:30 PM during the patient’s home visit the RN (registered nurse) was observed completing the left lower extremity wound care. The RN failed to maintain infection control standards when he/she: - Removed the old dressing with gloved hands and continued to pick up a spiral notebook and document wound measurements with contaminated gloves; and - Failed to sanitize his/her hands after removing the contaminated and before applying the new pair of gloves to complete the dressing change. Per interview conducted during observation, RN stated that: - I may have forgotten that step; and - I remember sanitizing my hands at the beginning and at the very end when I was done after taking my gloves off. During an interview on 07/06/2022 at 2:50 PM the CNO (chief nursing officer) stated that he/she would expect the clinician to sanitize their hands in between changing gloves.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure skilled professional services were delivered according to the home health agency’s policies and procedures in one (Record/Patient #4) of five full record reviews. This deficient practice has the potential to adversely affect all patients on service with the agency. Findings included: Review of the agency’s policy titled “Wound Care Management,” dated most recently reviewed/revised: 02/2019 showed: - Purpose: To define a standardized skin assessment, pressure ulcer and prevention and management of acute and chronic wound and ostomy care for (titled agency) patients; and - Responsibilities: Case Manager- Documentation includes weekly measurements. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to the agency 05/10/2022 with, in part, diagnoses of venous insufficiency (chronic, peripheral) (improper functioning of the vein valves in the leg not allowing blood to flow back to your heart), non-pressure chronic ulcer (open sore) of the left lower leg with fat exposed, cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb (left leg), and type II diabetes (a chronic condition that affects the way the body processes blood sugar); and - The agency failed to document weekly wound measurements in the clinical record the week of 06/20/2022. During an interview on 07/07/2022 at 9:40 AM the CNO (chief nursing officer) stated that: - The agency’s policy was to perform/document wound measurements on a weekly basis; - He/she would audit the clinical record for the missing documentation; and - No further documentation was found by survey exit.

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 policy review, record review, and interview, the agency failed to provide services that were ordered by the physician as indicated in the plan of care in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to adversely affect all patients receiving care from the agency. Findings included: Review of the agency’s policy titled, “Plan of Care/Physician Orders Policy," (Policy Number: 03-02), dated most recently reviewed/revised: 09/2019 showed, in part: - A physician’s written plan of care is required for each patient receiving home health services; - The plan of care is developed by the patient’s physician in consultation with agency home health care providers, and the patient/caregiver; - The plan of care includes frequency of visits and duration; - Physician orders for additions, changes or deletions to the plan of care may be accepted by nurses, therapists, medical social workers, dieticians, respiratory therapists, and management staff; - The direct service providers conform to the doctor’s orders as noted on the plan of care; and - All communication with the patient’s physician will be recorded in the medical record. RECORD/PATIENT #4: Review of the plan of care dated 05/10/2022 to 07/08/2022, showed frequency/duration of visits as SN (skilled nurse) 2wk3 (two times week one, two and three), 1wk2 (one time week four and five), 1 every 2wk 4 (no visit due week six, one visit week seven, no visit week eight and one visit week nine), + 2 prn (as needed). Review of a physician order dated 06/20/2022 showed: - Change frequency per patient request; - Patient able to change dressing independently; and - SN effective 06/19/2022 (week 7), 1wk2 (one time week seven and eight), 2wk1 (two times week nine), +2prn. Further review of the clinical record SN visit notes showed SN frequency of visits made: - 2 times week 4 (one time a week was ordered); - 3 times week 5 (one time a week was ordered); and - 2 times week 6 (no visit ordered this week). The clinical record failed to show any further physician orders for changes in the plan of care regarding the SN frequency of visits. During an interview on 07/07/2022 at 9:40 AM, the CNO (Chief nursing officer) stated that: - He/she would expect the clinicians to follow the frequency on the plan of care; and - He/she would review the chart for additional information. On 07/07/2022 at 10:40 AM, after reviewing the clinical record, the CNO stated that he/she had found a physician visit note about increasing the SN visits but was unable to locate a signed physician order to update the plan of care.

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: Based on interview, the agency failed to ensure 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 when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Based on interview, the agency failed to ensure 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 when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: The agency failed to provide documentation from the governing body regarding the appointment of the pre-designated, qualified person to act in the absence of the administrator. During an interview on 07/07/2022 at 10:45 AM, the chief executive officer stated that he/she was unable to find, in writing, the approval for the chief nursing officer as the alternate administrator. He/she placed the issue on the July 2022 council meeting agenda.