Amakes Quality Home Care Inc.

“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: E-0006 Based on the agency’s Emergency Preparedness Plan and Program (EPP) review and staff interview, the agency failed to update the facility and community-based risk assessment using an all-hazards approach every 2 years. This failure had the potential to affect all 18 of the agency patients and all 13 of the agency staff. Census is 18. Findings are: A. Review of the Agency’s Emergency Preparedness Plan and Program dated 11/13/2018 revealed: 1. That the EPP contained a facility and community-based risk assessment using an all-hazards approach. 2. There was no documentation in the agency’s EPP that the agency’s facility and community-based risk assessment based on an all-hazards approach was reviewed or updated after 11/13/18. B. During an interview on 11/30/23 at 11:10 AM, The Administrator confirmed that a facility and community-based risk assessment based on an all-hazards approach, was not updated since 11/13/2018.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: E-0039 Base on the agency’s Emergency Preparedness Plan and Program (EPP) review and staff interview, the agency failed to conduct an additional exercise every 2 years. This failure had the potential to affect all 18 of the agency patients and all 13 agency staff. Census was 18. Findings are: A. Review of the agency’s EPP dated 11/13/2018, there was no documentation in the EPP that an additional exercise was completed in 2021, 2022, or 2023. B. During an interview on 11/30/23 at 11:10 AM, the Administrator confirmed that the agency failed to conduct an additional exercise of choice in 2021, 2022, or 2023.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency staff failed to measure wounds weekly, complete skilled nurse (SN) visits, perform catheter changes, and/or document the services provided as ordered on the patient’s plan of care for 4 of 8 clinical records reviewed (Patient 1, 2, 4, and 5). The census was 18. Findings are: A. Review of the agency policy and procedure titled, 64, Patient Care and Treatment, revised 1/2020 revealed: 1. A written plan of care (POC) is devised by an Registered Nurse (RN) after the initial assessment of the patient. 2. The POC is approved by the patient’s physician. 3. A physicians order is necessary for home health care services. B. Review of the agency policy and procedure titled, 44, Wound Care, revised 11/29/23, revealed: 1. A physician’s order is required for wound care. 2. Wound measurements are to be completed weekly. 3. The policy and procedure did not provide a step by step process for wound care and measurements of wounds when new, when healed, where to document, and when to notify the physician. C. Review of the agency policy and procedure titled, 57, Record Keeping, effective 6/11/03 revealed all entries into the clinical record must be made by the person providing services and must contain a statement of facts personally observed. D. Review of the agency policy and procedure titled, 35, Care, Changing, Irrigation, and Removal of Suprapubic Catheter, effective 2/3/03, revealed: 1. A physicians order is required. 2. May use normal saline or sterile water to irrigate the catheter per the POC and physician orders. 3. Documentation was to include procedure and patient tolerance, catheter size, and other pertinent findings. E. Review of Patient 1’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 9/22/23 through 11/20/23, included orders for Skilled Nurse (SN) 1-3 times per week for 10 weeks to provide wound care and assessments, and to measure wounds weekly. The POC also included orders to change the wound vac (a vacuum assisted device with foam or gauze dressing applied to a wound to assist in wound healing) to the midline abdominal surgical incision wound 3 times per week. 2. The Home Health Certification and Plan of Care (POC) for the certification period of 11/21/23 through 1/19/24 included orders for SN 1 time per week for 9 weeks to provide wound care and assessment, and to measure wounds weekly to the midline abdominal surgical incision. 3. There was no documentation that wound measurements were completed the week of 9/24/23 through 9/30/23, 10/22/23 through 10/28/23, and 11/19/23 through 11/25/23. 4. There was only 1 SN visit completed the weeks of 11/5/23 through 11/11/23 and 11/12/23 through 11/19/23 (total of 2 missed visits each week). 5. There was no documentation in the clinical record to indicate the frequency of SN visits was decreased during the weeks of 11/5/23 through 11/11/23 and 11/12/23 through 11/19/23. F. Review of Patient 2’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 10/30/23 through 12/28/23 included orders for SN 3 times per week for 8 weeks, then 2 times per week for 1 week to complete wound care to left medial ankle and left sacral wound. The nurse was to measure wounds weekly. 2. A SN Visit Note dated 11/10/23. In the note the SN documented a new wound noted to the dorsal (top) left foot. There was no documentation the wound was measured when found. G. Review of Patient 4’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 8/9/23 through 10/7/23 included orders for SN 2 times per week for 1 week, then 3 times per week for 8 weeks to complete wound care assessment and weekly wound measurements to 3 wounds; wound 1- to the right lower extremity, medial, surgical, wound 2- a boil to the right upper thigh, wound 3- another boil to the right upper thigh. 2. The Home Health Certification and Plan of Care (POC) for the certification period of 10/8/23 through 12/6/23 included orders for SN 2 times per week for 1 week, then 3 times per week for 8 weeks to complete wound care assessment and weekly wound measurements to 4 wounds; wound 1- to the right lower extremity, medial, surgical, wound 2- a boil to the right upper thigh, anterior, wound 3- another boil to the right upper thigh, posterior, and wound 4- a boil proximal (near) to wound number 1. 3. SN Visit Notes revealed the week of 9/24/23 through 9/30/23 only wound 1 was measured, the week of 10/15/23 through 10/21/23 only wound 2 and 4 were measured, the week of 10/29/23 through 11/4/23 only wound 3 and 4 were measured, and the week of 11/12/23 through 11/18/23, wounds 1, 2, and 3 were measured. H. Review of Patient 5’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 9/2/23 through 10/31/23 included orders for SN to change the patient’s suprapubic catheter ( a tube inserted through the abdominal wall into the bladder to allow for the drainage of urine) monthly and as needed for obstruction. It does not include orders to flush the catheter for occlusion. The POC also included orders for home health aide (HHA) 2 times per week for 9 weeks beginning 9/3/23, to sponge bath patient. 2. The Home Health Certification and Plan of Care for the certification period of 11/1/23 through 12/30/23 included orders for HHA 2 times per week for 9 weeks to sponge bath patient. 3. SN Visit Notes dated 10/12/23 and 10/19/23, the SN documented the patient’s catheter was changed and flushed with 60 cubic centimeters (cc) of normal saline. There was no documentation in the notes to indicate the reason for the catheter changes on each date. 4. There was no documentation in the clinical record of the HHA services that were provided to the patient during the 10/3/23, 10/6/23, 11/15/23, and 11/17/23 HHA visits completed by the SN. I. During an interview on 11/30/23 at 9:50 AM, The SN who documented Patient 5’s catheter changes verbalized that the 10/12/23 catheter change was the routine monthly catheter change, and the catheter change completed on 10/19/23 was due to the catheter being occluded. The SN confirmed the documentation in the SN Notes for 10/12/23 and 10/19/23 did not include the assessment and observation to rationalize the second catheter change on 10/19/23. J. During an interview on 11/30/23 at 2:30 PM, the Administrator and the Director of Nursing confirmed the agency staff failed to follow the agency policy and procedures for measuring wounds weekly, completing skilled nurse (SN) visits, performing catheter changes, and/or documenting the services provided for Patient 1, 2, 4, and 5.”

“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 record review, policy and procedure review, ,the observation of provision of cares, and staff interview, 2 of 3 staff (Staff C and Staff E) observed during the provision of cares to 2 of 3 patients, (Patient 1 and Patient 3) respectively, failed to follow the agency’s policy and procedures for infection control, bag technique, handwashing, and/or standard precautions. The total sample size was 8. Census was 18. Findings are: A. Review of the agency’s policy and procedure titled, 75, Infection Control, revised 3/23, and the policy and procedure titled, 41, Handwashing, reviewed 2/2023, revealed, staff were to perform hand hygiene after each patient contact, after handling soiled material, after removing gloves, after contact with contaminated items, after contact with body secretions, and after contact with non-intact skin. B. Review of the agency’s policy and procedure titled, Bag Technique Procedure, reviewed 4/2018, revealed, staff were to sanitize hands prior to entering/re-entering the nursing supply bag. C. Review of the agency’s policy and procedure titled, 68, Standard Precautions, reviewed 1/2020, revealed: 1. Staff were to follow handwashing techniques as listed in the agency’s policy and procedure titled, 41, Handwashing. 2. Staff were to follow standard precautions when in contact with body secretions and non-intact skin. D. Review of the clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care for certification period 11/21/23 through 1/19/24 included orders for Skilled Nursing (SN), 1 time per week for 9 weeks for wound care. The midline abdominal wound was to be cleansed with wound cleanser or soap and water, dry with a sterile gauze, and cover with an ABD pad (a thick gauze pad to absorb wound drainage). 2. Patient 3’s Home Health Certification and Plan of Care for certification period 11/20/23 through 1/18/24 included orders for SN, 1 time per week for 9 weeks, to set up medication in medication cassettes and to assess vital signs. E. The observation and provision of cares to Patient 1 on 11/28/23 at 12:35 PM, revealed Staff C failed to: 1. Sanitize hands after removing the dirty dressing from the abdominal wound and removing 1 glove, and prior to re-entering the nursing supply bag with the ungloved hand. 2. Sanitize hands after cleaning the patient’s wound and removing gloves, and prior to entering the patient’s clean wound dressing supply bag to obtain an ABD pad. 3. Sanitize hands after completing patient cares and prior to leaving the patient’s home. F. The observation and provision of cares for Patient 3 on 11/29/23 at 10:05 AM, revealed Staff E failed to: 1. Sanitize hands after assessing patient’s vital signs and prior to re-entering the nursing supply bag. 2. Sanitize personal cell phone after use during the home visit and prior to placing in uniform pocket. 3. Sanitize hands after using personal cell phone. 4. Sanitize hands after completing patient cares and prior to leaving the patient’s home. G. During an interview on 11/29/23 at 2:20 PM, The Administrator and The Director of Nursing, confirmed that Staff C and Staff E did not follow the agency’s policies and procedures for infection control, bag technique, handwashing, and/or standard precautions during the provision of cares to Patient 1 and Patient 3 respectively.”

“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 record review and staff interview, the Administrator failed to ensure the pre-designated person acting in the absences of the Administrator, had access to all agency records during the Administrators absence from the agency. This failure had the potential to affect all 18 agency patients and all 13 agency staff. Review of the agency records revealed: A. Director of Nursing (DON) Job Description. The DON job description lists general function, distinguishing characteristics of the class, characteristic duties and responsibilities, supervision, job specifications, education, training, and experience needed. The job description does not include a description of Administrative role duties. B. A form titled, Organizational Structure. The form indicates the DON is designated to assume all responsibilities of the Administrator, in the absence of the Administrator. The form was signed by the agency Administrator and the agency DON on 6/5/23. C. A form titled, Administrator Responsibilities, signed by the Administrator with no date indicated, included 12 responsibilities of the Administrator including but not limited to: 1. Item number 2, organize and direct the agency’s ongoing functions. 2. Item number 8, ensure the completion, maintenance, and submission of reports, records, and requests as required by the Nebraska Health and Human Services Department (NEHHS) and/or the State of Nebraska. D. During an interview on 11/27/23 at 9:20 AM, The DON revealed the agency Administrator was out of town for the week during which the survey was being conducted. The DON confirmed [gender] was the person designated in writing to act in the absence of the Administrator. E. During an interview on 11/27/23 at 11:15 AM, The DON/Back-up Administrator reported that access to the agency’s personnel files were unavailable to Back-up Administrator’s access and State Surveyor review due to the files being locked in the Administrators office. F. During an interview on 11/30/23 at 2:00 PM, the Administrator confirmed personnel files were not accessible to the Back-up Administrator and State Surveyors during the Administrators absence from the agency from 11/27/23 through 11/28/23.”