All Homecaring Minnesota

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and document review the agency failed to ensure the emergency preparedness plan was reviewed and updated every 2 years. This had the potential to impact all patients receiving care from the agency. When interviewed on 11/7/23 at 3:04 p.m., the Administrator stated the Director of Nursing (DON) would know more about the emergency preparedness plan and wasn’t aware of the review. DON acknowledged the plan had not been updated within the past two years and there was work to be completed on the emergency preparedness plan. An agency policy titled Emergency Preparedness Plan, no date, directed staff to conduct an analysis to identify potential emergencies and the direct and indirect effects the emergencies may have on agency operations.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and document review the agency failed to develop a risk assessment that was based on an all-hazards approach. This had the potential to impact all patients who received care. The facility’s risk assessment was requested however was not received. When interviewed on 11/8/23 at 3:05 p.m. the Administrator and Director of Nursing (DON) verified there was not a current facility risk assessment completed and there was no all hazard-assessment. DON further stated the Emergency preparedness plan needed some work and had not been updated since 2018. An agency policy titled Emergency Preparedness Management Policy no date, directed staff to complete a risk assessment based on an all-hazards approach.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on interview and document review the agency failed to develop an emergency plan that included a process to collaborate with local, state, tribal and federal agencies. This had the potential to impact all patients who receive care from the agency. The agency’s emergency preparedness plan lacked evidence the plan included a process to collaborate with local, state, tribal an federal agencies. When interviewed on 11/7/23 at 3:04 p.m., the Director of Nursing (DON) and administrator verified the emergency plan lacked a process of when and how collaboration would take place other agencies. DON further acknowledged there was a lot of work to get the emergency plan up to date. An agency policy titled Emergency Preparedness Management Policy no date, directed staff to establish a structure to that identifies the agency’s relationship with community wide emergency management program.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on interview and document review the agency failed to develop policies and procedures based on the agency’s risk assessment. This had the potential to impact all patients receiving care at the agency. The agency’s emergency preparedness plan lacked policies and procedures based on the agency’s risk assessment. When interviewed on 11/7/23 at 3:05 p.m. the administrator and Director of Nursing verified the emergency preparedness plan lacked policies and procedures based on a facility risk assessment. An agency policy titled Emergency Preparedness Management no date, directed staff to establish guidelines for client care during periods of emergencies and processes for disaster readiness.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on interview and document review the agency failed to ensure their emergency preparedness plan included up to date contact information for all staff, entities, providers and volunteers. This has the potential to impact all patients receiving care from the agency. The agency’s emergency preparedness plan, undated, lacked indication up to date contact information for all staff, entities, providers and volunteers. When interviewed on 11/7/23 at 3:05 p.m. the administrator and Director of Nursing (DON) verified the facility’s emergency preparedness plan lacked updated contact information. DON further stated the emergency plan was lacking information and needed work. An agency policy titled Communication Plan for Emergency Preparedness no date, directed staff to develop and maintain a communication plan that complies with state, federal and local laws.”

“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 observation, interview, and document review the facility failed to communicate with the provider after consistent refusal of medication for 1 of 1 patient (P6) observed for medication set up. P6’s plan of care (POC) for certification period 9/25/23-1/23/23, indicated P6 had diagnoses of chronic kidney disease and heart disease. P6’s POC further indicated P6 required home services for weekly medication set up and assessment of medication compliance. P6’s POC included the order for potassium (electrolyte medication)10 milliequivalents (meq) 2 tablets daily. P6’s nursing note dated 10/30/23, indicated P6 had not been taking the ordered potassium due to experiencing hot flashes. P6 presumed the hot flashes were from the potassium. P6 was encouraged to take half the ordered a dose of potassium to see if P6 was able to tolerate, and if unable to tolerate reach out to provider before stopping completely. P6’s nursing note dated 11/6/23, indicated P6 had not been taking her ordered potassium due to experiencing hot flashes that P6 presumed the hot flashes were from the potassium. P6 was encouraged to try half the ordered dose of potassium to see if able to tolerate. If unable to, instructed P6 to discuss with kidney provider who ordered it and confirmed the follow up appointment was on 11/30/23. An observation on 11/6/23 at 2:15 p.m. registered nurse (RN)-A was observed to set up P6’s medications. RN-A noted P6 had not taken her prescribed potassium (electrolyte medication) for a second week in a row. P6’s potassium medication was left in the P6’s pill box. P6 confirmed she had not wanted to take it as she believed it to cause hot flashes. RN-A then asked P6 to try taking just one of the potassium pills a day to see if symptoms come back. RN-A also reminded P6 to let her provider know she hadn’t been taking the medication for a few weeks at her next visit. When interviewed on 11/6/23 at 2:15 p.m., RN-A stated P6 was prescribed the potassium a few weeks ago. P6 thought it was causing some nausea and hot flashes and therefore had not been taking the potassium. RN-A stated she asked P6 to try to take at least one of the potassium tablets for a week to re-introduce it slowly but noted P6 had not tried that either. RN-A stated P6’s kidney provider starts and stops potassium at times due to labs that fluctuate due to P6’s kidney disease. RN-A further stated if P6 still wasn’t taking the potassium, RN-A would notify P6’s provider next week. When interviewed on 11/8/23, at 3:07 p.m., the Director of Nursing (DON) stated staff were expected to notify providers of any refusals of services or treatments, including missed or refusal of medications. Provider notification was important to communicate any changes as well to ensure there were no other orders or monitoring needed due to the refusal. An agency policy titled Coordination of Client Services no date, directed staff to provide the provider with an ongoing assessment of the client and identify the client’s response to services provided.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure the initial assessment was completed within 48 hours for 2 of 2 patient (P7, P10) reviewed for physical therapy services. P7’s plan of care (POC) for certification period 10/5/23-12/3/23, indicated P7 had diagnoses of lung disease and high blood pressure and received physical therapy (PT) and occupational therapy (OT) from the agency. P7’s POC indicated the start of care (SOC) was 10/5/23. P7’s provider order dated 9/28/23, indicated P7 was ordered in home PT and OT services on 9/28/23. P7’s medical record lacked evidence P7’s provider had been notified of a delayed SOC. When interviewed on 11/7/23 at 2:45 p.m., PT-A stated P7 had been opened up to therapy on 10/5/23. PT-A did not recall why P7 had a delayed start and if there was a reason, there would be an order in P7’s medical record. P10’s plan of care (POC) for recertification period 8/24/23- 10/22/23, indicated P10 had diagnoses of low back pain and depression. P10’s Oasis assessment for SOC for certification period 8/24/23- 10/22/23, indicated the assessment was completed by physical therapist (PT)-A on 9/16/23. A follow up interview on 11/9/23, at 9:39 a.m. PT-A stated if a patient had only therapy needs, PT-A would be the patients case manager. PT-A acknowledged P10’s SOC assessment was completed late. PT-A had been providing care for P10 but had not realized P10 had PCA services only and required the SOC assessment. When interviewed on 11/8/23 at 3:07 p.m., the Director of Nursing (DON) expected patients to be seen within 48 hours of their orders. If there was a reason for start of care to be delayed, the provider had to be updated. DON was not sure where the breakdown was around P10, and stated PT-A should have completed the assessment the first visit. Furthermore, the DON acknowledged an initial comprehensive assessment was important to ensure the patient received services or treatments needed. An agency policy titled Client Admission Process no date, directed when therapy service was the only skilled need, the initial assessment may be completed by the appropriate therapist within 48 hours of referral unless documentation indicates otherwise.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure the individualized plan of care (POC) included durable medical equipment (DME) for 2 of 4 patients (P5, P7) observed during a home visit. Furthermore, the facility failed to ensure current pertinent surgical diagnoses and activity restrictions were included in the POC for 1 of 4 patients (P5) observed in a home visit. P5’s POC for certification period 10/20/23- 12/18/23, indicated P5 had diagnoses of depression and diabetes, however lacked a surgical diagnoses of a left ankle bone fusion and hardware procedure that occurred during the previous certification period of 8/21/23- 10/18/23. P5’s POC listed P5 used a glucometer and test strips (DME used for blood sugar testing). Furthermore, the POC indicated P5 had had activity restrictions and did not require a walker or wheelchair. When observed on 11/6/23 at 11:18 a.m., P5 had a home visit from occupational therapist (OT)-A. OT-A stated P5 had the surgical cast removed a few days ago in clinic and now was able to place partial weight on the left foot, but only with the walker. During OT’s visit, P5 had used the walker to ambulate to the bathroom. P5’s bathroom was observed to have a shower bench. OT also worked with P5 on self-propelling in the wheelchair and transferring from the chair to the toilet. When interviewed on 11/7/23 at 11:24 a.m., registered nurse (RN)-A stated physical and occupational therapy has started during 8/21/23-10/19/23 recertification survey due to a left ankle procedure. RN-A verified R5’s POC had not been updated with the activity restrictions, DME used, or surgical diagnoses. RN-A further stated the therapy plan would have addressed the restrictions but did not think about activity restrictions as being provider orders. P7’s POC for certification period 10/5/23-12/3/23, indicated P7 had diagnoses of chronic obstructive pulmonary disease (lung disease) and vascular disease. P7’s POC further indicated P5’s DME included a bath bench, cane and walker but lacked indication oxygen was also required. When observed on 11/7/23 at 2:00 p.m., P7 had a home visit from physical therapist (PT)-A. During the visit, P7 told PT-A she had used her oxygen the prior night however did not need it currently. When interviewed on 11/7/23 at 2:45 p.m. PT-A stated she had opened P7’s services as there was no order for skilled nursing visits. PT-A verified P7’s oxygen had not been included on the POC and believed nurses would also be reviewing the POC to review medications, but it was missed. When interviewed on 11/8/23 at 3:07 p.m., the director of nursing (DON) expected POC’s to be accurate and include activity restrictions, accurately reflect all diagnoses, and include any necessary DME. Furthermore, an accurate POC was important to ensure all caregivers understood health status, plan and goals of the patient. An agency policy title Plan of Care, no date, directed staff to complete the POC in full and was required to include all pertinent diagnoses, surgical procedures, activity restrictions, and medical supplies and equipment that is needed.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure all patient care orders were included as part of the patient’s plan of care (POC) for 1 of 1 patients (P8) reviewed for wound care. P8’s POC for certification period 10/13/23-12/11/23, indicated P8’s start of care was 10/13/23. P8 required nursing services weekly for observation and assessment of wound healing status, wound measurements and wound care as needed. P8’s POC lacked orders or instruction of how to care for P8’s wounds. P8’s transitional care unit (TCU) discharge orders dated 10/10/23 listed the following orders: -ensure sleeve was on left arm at all times for wound monitoring. -foam dressing to left buttock skin tear change daily. -foam dressing to left hand, forearm scratches. Cleanse and dry area with dressing changes. -encourage not to pick wounds/scabs -sure prep () to right heel twice daily until resolved, initiate daily wound care if area opens up P8’s nurse’s start of care note dated10/13/23, indicated P8 had a pressure wound on the right heel, a diabetic wound on the right 2nd toe, a pressure wound on the right lower calf, a pressure wound on the buttocks, and traumatic wounds on both upper extremities. Nurse’s start of care assessment lacked evidence P8’s wounds were measured. P8’s resumption of care (ROC) nurse’s note dated 10/29/23, indicated P8 had a short hospital stay for cellulitis in the left arm. The ROC note further indicated P8’s left arm wound care was provided per hospital discharge orders. P8’s medical record lacked indication P8’s hospital wound care instructions were documented or added to P8’s POC. P8’s hospital discharge orders were requested however were not received. P8’s medical record lacked indication of a verbal change order was received from P8’s vascular provider for wound cares. When interviewed on 11/8/23 at 11:08 a.m., registered nurse (RN)-B stated at admission from a hospital or TCU, the discharge orders would be followed and added to the POC until there was a change in what the provider wanted. RN-B acknowledged R8’s POC did not include any wound care from the SOC or ROC. RN-B stated there was some confusion of what was needed for P8’s wounds after returning from the hospital until 11/1/23, when P8 saw her vascular provider and wound care was clarified. RN-B stated once the order was received a copy of the orders would be placed in P8’s medical record and a verbal order note was needed to show the new order. RN-B wasn’t sure if P8 had the current wound orders were reflected in her medical record. When interviewed on 11/8/23 at 3:07 p.m., the Director of Nursing (DON) stated staff were expected to update the POC when any new orders were received. DON further acknowledged obtaining orders from the hospital or TCU was sometimes difficult but needed to be completed. DON expected P8’s wound care orders to be reflected on the POC or as verbal orders in the medical record. When interviewed on 11/9/23 at 9:00 p.m., RN-C verified P8’s hospital orders had not been sent to the agency when discharged. RN-C further stated P8 had an after-visit summary to review in home but had not obtained a copy and had not reached out to the hospital for a copy, so orders had not been reflected in P8’s POC or medical record. An agency policy titled physicians orders not date, directed staff to ensure all orders were maintained in the patient’s chart. Furthermore, if a written order was received form the patient’s provider, the nurse will write and date the order and the day informed of the change as well as the date the change was made.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure the plan of care (POC) was revised within a 60 day period for 1 of 4 patients (P5) observed for in home visits. Upon entrance on 11/6/23 at 10:30 a.m., P5’s current POC was requested however was not received. P5’s POC for recertification period 8/21/23-10/19/23, indicated P5 had diagnoses of depression, diabetes, and pain. P5 received nurse, physical therapy, and occupational therapy from the agency. When interviewed on 11/7/23 at 11:24 a.m. registered nurse (RN)-A stated a revised POC had to be generated with every recertification. RN-A had completed P5’s recertification assessment on 10/18/23, however had not signed it and verified P5 did not have an updated care plan until 11/6/23. When interviewed on 11/8/23 at 3:07 p.m. the Director of Nursing (DON) verified P5’s POC was not revised within the 60 days and expected staff to complete, sign and develop POC’s timely. An agency policy titled Plan of Care no date, directed staff to revise and update POC’s as necessary but at least every 60 days.”