Every finding on record at Winneshiek County Public Health Nursing Service

The recertification survey, conducted from 4/5/2022 through 4/11/2022 found the agency operating in substantial compliance with the requirements of the Appendix Z Establishment of Emergency Preparedness. The agency reported a census of 49 patients at the time of the survey.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 4/5/2022 through 4/11/2022, found the agency operating out of compliance with the following Conditions of Participation: 1) Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care (G570, G574, G580); and 2) Condition of Participation 42 CFR 484.100 Compliance with Federal, State and Local Law (G848) and 3) Condition of Participation 42 CFR 484.105 Organization and Administration of Services (G940) The survey also found the agency operating out of compliance with multiple standard level deficiencies. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 4/11/2022 and ending on 4/11/2024. The agency reported a census of 49 patients at the time of the survey.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, review of the agency's patient roster, agency policy review and agency staff interview, the agency failed to: 1) ensure patients were admitted with a reasonable expectation that the agency could meet the patient's medical, nursing and rehabilitation needs in his/her place of residence (See G570 information); 2) ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included on each patient's Plan of Care (see G574); and 3) to provide medications, treatments and services only as ordered by a physician (see G580). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 49 patients. Findings include: According to the agency policy, titled Admission and Discharge Policy and dated 4/12/2017, acceptance of patients who request services is based on a reasonable expectation the applicant's medical, nursing and personal care needs can be met safely through services provided in the home. During agency staff interview on 4/6/2022 at 10:40 AM, the Administrator/Clinical Manager reported the agency has one patient (Patient #4) who does not want the nurse to come to the patient's residence to perform Haldol injections so the nurse contacts the patient via telephone to set up an appointment to come to the home health office for injections once every month. The Administer/Clinical Manager reported, "The visit takes literally 5 minutes." The Administrator/Clinical Manager reported Patient #4 was the only patient currently coming to the office for skilled nursing services. During agency staff interview on 4/7/2022 at 8:10 AM, Staff D, RN, (current primary RN for Patient #4), reported only one patient came to office to receive skilled nursing services, identifying Patient #4. Staff D, RN, reported the patient stops at the pharmacy on the way to the office to pick up the Haldol and brings the medication to the office for the RN to inject. Review of the agency's patient roster revealed Patient #4 was included in the agency's current home health care census. Patient #4 had a start of care date of 11/20/2008. Clinical record review and associated agency staff interviews revealed the following: The Plans of Care, dated 11/12/2021 to 1/10/2022; 1/11/2022 to 3/11/2022 and 3/12/2022 to 5/10/2022, documented Patient #4's primary diagnosis as bipolar disorder. The Plans included the medication Haldol Decanoate 100 mg intramuscularly every 4 weeks. The above stated Plans of Care included physician orders for skilled nursing visits 1-2 times for 2 months to assess effects of medications on cognitive function; assess neurologic status; assess psychosocial needs/implications; assess reaction to stimuli; assess for aggressive/abusive behavior; assess mental/emotional status; assess use of coping mechanisms; assess temperature, pulse, respirations and blood pressure as needed; assess medication compliance and administer Haldol Decanoate intramuscularly every 4 weeks. The Plan of Care Summaries, dated 11/10/2021, 1/7/2022 and 3/10/2022, documented the patient came into the home health agency's office for the recertification comprehensive assessments. The update to the comprehensive assessments at the time of recertification were completed in the office instead of the patient's home. Accompanying drug regimen reviews were completed in the office instead of the patient's home. The Summaries documented Patient #4 goes around town to different establishments, plays cards watches sports and visits with others. Patient drives out of town at times for recreation. The Charting/Clinical Notes, dated 11/18/2021, 12/17/2021, 1/13/2022, 2/10/2022 and 3/10/2022, documented Patient #4 came to the office for visits. During the office visit, Staff D, RN, assessed the patient according to the home health Plan of Care and performed administration of the Haldol Decanoate intramuscularly in the office setting. All provision of skilled nursing services, including administration of injection, recertification comprehensive assessments, assessments as directed in the Plans of Care and drug regimen reviews occurred in the office setting instead of the patient's place of residence as required by regulation and the agency's own policy. The above stated findings were reviewed with the Administrator/Clinical Manager and Staff B, RN. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation and agency staff interview, the agency failed to ensure the Plan of Care included complete medication and treatment orders for accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 7 sampled patients (Patients #3 and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy, titled Clinical Record and 6/2010, the individualized plan of care must include medications, services and treatments, each with amount, frequency and duration specified. 1. Patient #3 had a start of care date of 6/6/2017. Clinical record review revealed the following: a. The Plan of Care, dated 3/12/2022 to 5/10/2022, documented Patient #3 used Naphazoline-Glycerin Ophthalmic Solution 0.012-0.25%. The Plan of Care documented the patient should instill 1-2 drops "to affected eye(s) as needed". The medication orders lacked the physician approved reason for use of the "as needed" medication and lacked the frequency of use each day of the medication when taken on an as needed basis. b. The Plan of Care, dated 3/12/2022 to 5/10/2022, documented Patient #3 took Probiotic-10 chewable, an over-the-counter medication, "1 daily". The medication orders lacked the dosage in each chewable tablet. c. The physician's interim order, dated 2/8/2022, directed the registered nurse (RN) to insert a 16 French 10 cc indwelling urinary catheter with extension tubing connected to a leg bag and secure the bag with a strap to the patient's leg- change the urinary catheter monthly and as needed. The Plan of Care, dated 3/12/2022 to 5/10/2022, lacked any physician orders for the urinary catheter. Surveyor observation during a home visit while accompanied by Staff A, RN, on 4/6/2022 at 1:55 PM revealed Patient #3 had a 16 French indwelling urinary catheter attached to a leg bag. During agency staff interview during the home visit, Staff A, RN, reported changing the urinary catheter once monthly and the urinary drainage bag once every 2 weeks. 2. Patient #6 had a start of care date of 2/2/2022 and was discharged from agency services on 3/3/2022. Clinical record review revealed the following: The Plan of Care, dated 2/2/2022 to 4/2/2022, documented Patient #6 took Miralax (polyethylene glycol and docusate sodium) powder 1 tablespoon every morning. The medication orders lacked the dosage of medication in each tablespoon of powder. The above stated findings were reviewed with the Administrator/Clinical Manager and Staff B, Registered Nurse. The agency provided no further documentation prior to the end of the survey.

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 clinical record review, home visit observation and agency staff interview, the agency failed to provide treatments only as only as ordered by the physician for 1 of 1 sampled patients (Patient #3). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Patient #3 had a start of care date of 6/6/2017. Clinical record review revealed the following: The physician's interim order, dated 2/8/2022, directed the registered nurse (RN) to insert a 16 French 10 cc indwelling urinary catheter with extension tubing connected to a leg bag and secure the bag with a strap to the patient's leg- change the urinary catheter monthly and as needed. The clinical record lacked documentation indicating the RN changed the patient's urinary catheter between 2/8/2022 and 3/12/2022. The Plan of Care, dated 3/12/2022 to 5/10/2022, lacked any physician orders indicating the patient continued use of the indwelling urinary catheter, including a lack of size of catheter or frequency for catheter changes. The skilled nurse visit note, dated 3/18/2022, documented the RN removed and replaced Patient #3's urinary catheter with a 16 French catheter. The clinical record lacked any physician interim orders directing the RN to change the patient's catheter. Surveyor observation during a home visit while accompanied by Staff A, RN, on 4/6/2022 at 1:55 PM revealed Patient #3 had a 16 French indwelling urinary catheter attached to a leg bag. During agency staff interview during the home visit, Staff A, RN, reported changing the urinary catheter once monthly and the urinary drainage bag once every 2 weeks. The above stated findings were reviewed with the Administrator/Clinical Manager and Staff B, RN. The agency provided no additional information prior to the end of the survey.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on agency policy review, review of the agency's vaccination tracking forms, personnel file review and agency staff interview, the agency policy lacked a procedure for staff requesting approval for non medical exemptions according to title VII and the EEOC, (Equal Employment Opportunity Commission). The agency failed to ensure exempted employees including contracted employees follow the contingency plan set forth in the agency policy for 1 of 2 sampled agency exempted employees (Staff C). The agency employed 12 staff directly, 32 staff by arrangement and 7 nursing students at the time of the survey. The agency reported 12 fully vaccinated staff, 30 fully vaccinated contracted staff, 2 unvaccinated and 7 fully vaccinated nursing students, 0 religious exemptions, 0 with granted non-medical exemptions and 0 granted exemptions for medical reasons or temporary delay of the vaccination. Failure to develop policies addressing contingency plans for unvaccinated employees and/or provide each nonvaccinated employee with accurate, consistent contingency plans placed agency patients and other agency employees at an increased risk of exposure/transmission of the COVID-19 virus. According to the agency policy titled Winneshiek County Public Health’s Mandatory Vaccination Policy dated 2/09/2022, the purpose of the policy; to reduce the presence and severity of COVID-19 cases in the workplace, in communities, and in the nation as a whole. All employees covered by this policy are required to be fully vaccinated as a term and condition of employment at Winneshiek County Public Health. Unvaccinated employees must wear a NIOSH approved N95 or equivalent or higher level face covering over the nose and mouth when indoors, in the office and when occupying a vehicle with another person for work purposes. Unvaccinated staff will be tested weekly for Covid-19. Review of the agency's COVID-19 tracking forms revealed the agency failed to review the non- medical exemption for two contracted employees. The tracking forms revealed all other directly hired staff and those hired by arrangement were fully vaccinated. During a home visit observation on 4/5/22 at 3:30 PM with Staff C, PTA, physical therapy assistant the surveyor observed Staff C wearing a surgical mask. During an interview on 4/6/2022 at 9:15 AM, the Administrator/Clinical Manager reported that all staff had been fully vaccinated. During an interview on 4/7/22 at 12:04 PM, the Administrator/Clinical Manger provided a document titled Vaccine Exemption Approval dated 4/7/2022 for Staff C. During an interview on 4/7/22 at 12:34 PM Staff C reported the contracted agency supervisor provided education to use a surgical mask and perform hand hygiene using hand sanitizer when performing direct patient care. The Home Health Care Agency failed to provide COVID-19 mitigation education to contracted agency staff.

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on surveyor observation, clinical record review, agency staff interview and review of Iowa pharmaceutical laws, the agency failed to follow state pharmaceutical laws by storing patient medication in the agency office and dispensing patient medications on a weekly basis from the stored medications for 2 of 2 patients sampled (Patients #8 and #9). The agency reported storing the medications in the office for 2 patients at the time of the survey. Findings include: Chapter 657 of the Iowa Administrative Code outlines professional laws and standards of practice for pharmaceutical products. This law, except for health care facilities as defined in the law (i.e. long term care facilities, hospitals, etc.), prohibits the storage of routine medications requiring a prescription for dispensing when a pharmacist is not present or employed by the entity. Chapter 155A.4 prohibits dispensing routine prescription medications by licensed personnel of a home health or hospice agency, except to obtain, possess and transport emergency medications. During agency staff interview on 4/7/2022 at 8:10 AM, Staff D, Registered Nurse (RN), reported the agency stored 2 patients medications in the home health agency office, identifying the two patients as seen by Staff A, RN, and Staff B, RN. During agency staff interview on 4/7/2022 at 8:15 AM, Staff A, RN, reported she was the primary RN for Patient #8. Staff A, RN, reported she kept Patient #8's medications in the home health office as the patient's home was "very messy- things would get lost in there." She reported the patient "was a high suicide risk" so the nurse kept the medications in the office, set up the medications in a weekly planner and transported the medications to the patient's home on a weekly basis. Staff A, RN, reported the medications for Patient #9 were also stored in the office and dispensed in the same manner; however, Staff B, RN, was Patient #9's primary nurse so Staff A, RN, was unsure of the reason. Surveyor observation on 4/7/2022 at 8:20 AM, revealed the following: Staff A, RN, lead the surveyor into the treatment room. Staff A, RN, opened an unlocked metal filing cabinet, withdrew an individual key, inserted the key into a locked metal filing cabinet located next to the unlocked cabinet and unlocked the cabinet doors. The surveyor observed two shelves inside of the metal filing cabinet had plastic grocery bags filled with bottles of medications and the upper shelf had an unlocked black plastic file container. 1. Staff A, RN, removed all the items from the first shelf and presented the items to the surveyor for review. The plastic bags and the plastic file contained prescription and over-the-counter medications. The prescription bottles were marked with pharmacy labels identifying the medications as dispensed to Patient #8. The bag also contained an empty weekly medication planner. The medications being stored at the home health agency were: Quetiapine- antipsychotic, Senna S- natural laxative, Roprinirole- Parkinson's medication, Pravastatin- cholesterol, medication, Vitamin D3, Losartin- antidiabetic medication, Colace- stool softener, Levothyroxine- treats hypothyroidism, Escitalipram- antidepressant, Montelukast- asthma medication, Loratadine- allergy medication Lithium- bipolar disorder, Folic Acid, Omeprazole- acid reducer, Amitriptyline- antidepressant, Metformin-antidiabetic, Prazosin- antihypertensive, Fiber tablets, Lamotrigine- anticonvulsant, Ambien- sedative, Topiramate-anticonvulsant. None of the above medications are emergency medications. 2. Staff A, RN, removed all the items from the second shelf and presented the items to the surveyor for review. The plastic bag contained prescription and over-the-counter medications. The prescription bottles were marked with pharmacy labels identifying the medications as dispensed to Patient #9. The medications being stored at the home health agency were: Venlafaxine- antidepressant, Centrum Silver Multivitamin, Oxcarbazepine- anticonvulsant, Bupropion- antidepressant, Simvastatin- cholesterol medication, Furosemide- diuretic, Loratadine- antiallergy, Abilify- antipsychotic, Generic Stool Softener/Laxative, Levothyroxine- treats hypothyroidism. None of the above medications are emergency medications. During agency staff interview on 4/7/2022 at 11:00 AM, Staff B, RN, reported she is the primary registered nurse for Patient #9. She kept the patient's medications at the office due to the patient's depression diagnosis. Clinical record review revealed the following: 3. Patient #8 had a start of care date of 8/20/2012. The Plans of Care, dated 9/2/2021 to 10/31/2021; 11/1/2021 to 12/30/2021; 12/31/2021 to 2/28/2022 and 3/1/2022 to 4/29/2022, documented the patient received skilled nursing and homemaking services. The Plans documented the patient's diagnoses as schizoaffective disorder, insomnia, diabetes and chronic post-traumatic stress disorder. The Plans indicated the RN planned to store the patient's medications at the home health office due to Patient #8's previous history of poor medication adherence as well as self harm ideation. 4. Patient #9 had a start of care date of 10/7/2019. The Plans of Care, dated 9/26/2021 to 11/24/2021; 11/25/2021 to 1/23/2022; 1/24/2022 to 3/24/2022 and 3/25/2022 to 5/239/2022, documented the patient received skilled nursing and home health aide services. The Plans documented the patient's diagnoses as major depressive disorder, anxiety, osteoarthritis, fibromyalgia, hypothyroidism and obesity. The Plans indicated the RN planned to store the patient's medications at the home health office due to Patient #9's previous history of poor medication adherence as well as self harm ideation. The above stated findings were reviewed with the Administrator/Clinical Manager and Staff B, RN. The agency provided no additional information prior to the end of the survey.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on clinical record review, surveyor observation and agency staff interview, the governing body failed to: 1) maintain oversight of the day to day operation of the agency while the agency was operating out of compliance with multiple Conditions of Participation (G942); and 2) ensure the Administrator appointed a qualified, pre-designated person, authorized in writing by the Administrator and governing body, to act in the absence of the Administrator (G954). The systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and protected the rights of the agency's 49 patients.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of the agency's governing body meeting minutes, the agency failed to involve the governing body in the overall management and operation of the organization resulting in the governing body not being aware the agency was operating out of compliance with multiple condition level regulations. The agency reported a census of 49 patients at the time of the survey. Failure to include the governing body in the overall management and operation of the agency, placed agency patients at risk for inadequate and unsafe care. Findings include: Review of the agency's governing body meeting minutes from 1/2020 through 12/2021 demonstrated monthly meetings held by the Board of Health (identified by the agency as the governing body). The monthly meeting minutes did not reflect discussion of the home health agency's daily operations, focusing mostly on public health issues. The meeting minutes, dated 1/8/2020; 2/12/2020; 3/11/2020; 4/8/2020; 5/13/2020; 5/29/2020; 6/10/2020; 7/8/2020; 8/5/2020; 9/9/2020; 10/14/2020; 11/11/2020; 12/9/2020; 1/13/2021; 2/10;2021; 3/10/2021; 4/14/2021; 5/12/2021; 6/9/2021; 8/11/2021; 9/15/2021; 10/13/2021; 11/10/2021; and 12/12/2021, addressed the census/caseload numbers of the home health with no discussion about the day to day operation. The 8/11/2021 and 9/15/2021 meeting minutes discussed the retirement of the Assistant Administrator (and backup for the Administrator in the Administrators absence). The meetings thereafter did not discuss who would be temporarily appointed to cover the duties of the Assistant Administrator. The Board of Health did not appoint someone to act in the absence of the Administrator. (See G954 for additional information) The agency was operating out of compliance with the Conditions of Participation and state administrative code by admitting and maintaining patients with no reasonable expectation of providing services in the patients' homes, resulting in the patient receiving services in the office instead (See G570 for additional information), and the agency was storing and dispensing patient medications on the premises of the home health agency against state pharmaceutical administrative code (See G848 for additional information).

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 and policy review the agency failed to authorize in writing by the administrator and the governing body a qualified pre-designated person who assumes the same responsibilities and obligations as the administrator. During an interview on 4/6/22 at 2:48 AM the Administrator/Clinical Manager reported that she has not authorized anyone to assume the responsibilities as the administrator in her absence. She said that since the last assistant administrator left no one has been authorized to assume responsibilities of the administrator. Review of the policy titled Administrative Structure dated 1/2015 revealed the agency administrator will designate, in writing, the appropriate qualified person to perform delegated responsibilities in the absence of the administrator.