Caretenders

“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 review of the Emergency Preparedness Plan (E.P.P.) documents, it was determined the facility failed to review and/or incorporate a community-based risk assessment, developed by local/regional emergency preparedness officials. Review of the Emergency Preparedness Program (E.P.P.) on 09/24/24 between 8:00 a.m. and 11:30 a.m. with Staff A (Facility Administrator) revealed the facility-based risk assessments were presented with three topics included: Ice/snowstorm, Emerging Infectious Disease, and Hurricane. The community-based risk assessment review is to address local/regional emergency disaster threats and concerns that need to be taken into account to provide for continuity of care from the current business location. It is unclear if the community-based risk assessment would alter the highest risk categories or alter the facilities plan without the actual review. Interview on 9/24/24 with Staff A confirmed the above findings and was unaware of the community-based risk assessment requirements.”

“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 review of the Emergency Preparedness Plan (E.P.P.) documents, it was determined the facility failed to ensure a process to communicate or collaborate with local, tribal, regional, State, and Federal emergency preparedness officials or efforts to maintain an integrated response during an emergency situation. Review of the E.P.P. on 9/24/24 between 8:00 a.m. and 11:30 a.m. with Staff A (Facility Administrator) revealed that the facility failed to have a process to engage in collaborative planning for an integrated response to a widespread emergency situation. The facility had contact information for the Fire and Police departments in the local town the business was located but failed to have any additional emergency/non-emergency contact information for more than 30 towns/cities that healthcare services are being provided. Interview on 9/24/24 with Staff A confirmed the above findings and available documentation.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on interview and review of the Emergency Preparedness Plan (E.P.P.), it was determined that the facility failed to ensure that agreements with other health care services were arranged to ensure continuity of care for clients during a disaster/emergency event. Review of the Emergency Preparedness Plan (E.P.P.) on 9/24/24 between 8:00 a.m. and 11:30 a.m. with Staff A (Facility Administrator) revealed the facility failed to have policies or agreements to outline transfers of the clients for continuity of care, such as a hospitals, nursing homes, or like service providers, as well as policies to follow-up with staff and clients during a disaster/emergency event beyond the facilities control or when the facility is not able to provide necessary care under their control. Interview on 9/24/24 with Staff A confirmed the above findings and available E.P.P. documentation.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and review of the Emergency Preparedness Plan (E.P.P.) documents, it was determined that the facility failed to ensure training and testing requirements were met with practical applications of the facilities policies. The facilities Emergency Preparedness/Operations Plan, Policy # 9.001, pages 4 and 5 state: B. Preparation for Emergencies and Disasters: 9. The agency shall test their emergency operations plan annually. The agency must do one of the following: a. Participate in a full-scale exercise that is community-based, whenever accessible, or an individual facility-based if not accessible. b. Participate in a natural or man-made emergency that requires activation of the emergency plan. c. Mock disaster drill or tabletop exercise, but this method is only allowed every other year. 10. The plan shall test each exercise drill as follows: a. The procedures used to sort patients needing assistance to evacuate. b. The process the agency will use to assist patients in obtaining supplies and medications to sustain them through an emergency. c. The procedures used to notify the agency Staff and the office of emergency preparedness in the parishes/counties in which the agency provides care. d. Documentation of the actual or drill critique will be kept on file in the agency. (Refer to the Disaster Review form) e. The Executive Director shall critique the actual event or exercise by using a multidisciplinary team to include clerical and support staff. Any modification or opportunities for improvement will be listed. Review of the Emergency Preparedness Program (E.P.P.) on 9/24/24 between 8:00 a.m. and 11:30 a.m. with Staff A (Facility Administrator) revealed the facility failed to ensure a community-based disaster drill was attempted, communicated with emergency officials, communicated with other healthcare and/or like facilities to participate. The facility had 28 listed staff employed and had conducted the following tabletop drill/exercises: 4/5/24- snowfall/power outage (3 participating signatures); 10/13/23- severe weather/hurricane (8 participating signatures); 12/16/22- snowstorm/power loss (1 participating signature); 2/25/22- snow fall/sleet (1 participating signature); 2/2/21- snowstorm (no signatures). The tabletop disaster drill documents failed to include any documentation of policy changes, After Action Reports (AAR) or actual comprehensive testing. Interview on 9/24/24 with Staff A confirmed the available E.P.P. training documentation.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to timely encode and electronically transmit Outcome and Assessment Information Set (OASIS) assessments to the Centers for Medicare and Medicaid Services (CMS) for 51 of 1648 records between 9/21/23 to 9/20/2024. Review on 9/24/24 of the CMS “HHA [Home Health Agency] Error Summary by Agency” report for 9/21/23 to 9/20/24 revealed under the error “-3330 Records Submitted Late: The submission date is more than 30 days after M0090 on this new record” was noted to have 51 records of 1648 assessments submitted late. Interview on 9/24/24 at approximately 8:30 a.m. with Staff A (Administrator) confirmed the above findings.”

“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 interview and record review, it was determined that the facility failed to follow the written plan of care for the frequency of visits and notify the physician of missed visit (Patient Identifier #8); and failed to ensure that a Patient’s Home Health Certification and Plan of Care had been signed by the physician for 2 of 17 patient’s reviewed for physician’s orders (Patient Identifier #11). Patient #8 Review on 9/24/24 of Patient #8’s Home Health Certification and Plan of Care form for the certification period of 9/1/24 to 10/30/24 revealed the physical therapy (PT) orders were effective 9/3/24 for 1 time a week for 1 week, then 2 times a week for 3 weeks (starting on week 2). The order was signed by the physician on 9/18/24. Review on 9/24/24 of Patient #8’s Client Calendar Report revealed the patient had PT visits on 9/6/24 (week one); on 9/12/24 (week two), and then on 9/19/23 (week three). There was no additional visit for week 2 as per the physician order, and no documentation of a missed visit. Interview on 9/24/24 with Staff B (Business Office Manager) confirmed the above. Patient #11 Review on 9/25/24 of Patient #11’s Home Health Certification and Plan of Care form for the certification period of 5/3/24 to 7/1/24 revealed the physician had not signed the form. Interview on 9/25/24 at 11: a.m. with Staff B confirmed the above.”

“Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This Element is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to ensure that the patient and/or the patient’s legal representative were provided the Admission Consent Form (which includes the Consent for Care, Consent to the Use and Disclosure of Health Information/Release of Information, Patient’s Rights and Responsibilities and Privacy Acts) during the initial evaluation visit, in advance of furnishing care to the patient for 1 of 17 Patients reviewed (Patient Identifier #13). Review on 9/25/24 of Patient #13’s Home Health Certification and Plan of Care revealed that Patient #13 start of care was on 7/1/24. Further review revealed that Patient #13 was receiving skilled nursing at least weekly. Review on 9/25/24 of Patient #13’s consent forms revealed Patient #13 had an admission consent signed by facility staff on 7/1/24 but was not signed by Patient #13 or their representative. Further review of the consent forms revealed another Admission Consent form was signed by the facility and Patient #13’s representative on 8/16/24 (47 days after the Start of Care). Interview on 9/25/24 at 11:25 a.m. with Staff B (Business Office Manager) confirmed the above.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on interview and record review, it was determined that the facility failed to ensure that the patient and/or the patient’s legal representative were provided the Admission Consent Form, which includes the Patient’s Rights and Responsibilities during the initial evaluation visit and in advance of furnishing care to the patient for 1 of 17 patients reviewed (Patient Identifier #13). Review on 9/25/24 of Patient #13’s Home Health Certification and Plan of Care revealed that Patient #13 start of care was on 7/1/24. Further review revealed that Patient #13 was receiving skilled nursing at least weekly. Review on 9/25/24 of Patient #13’s consent forms revealed Patient #13 had an Admission Consent form that was signed by the facility and Patient #13’s representative on 8/16/24 (47 days after the Start of Care). Interview on 9/25/24 at 11:25 a.m. with Staff B (Business Office Manager) confirmed the above.”

“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 record review, it was determined that the facility failed to ensure that all patient care orders were recorded in the plan of care for 1 of 17 patient charts reviewed (Patient Identifier #15). Review on 9/25/24 of Patient #15’s Home Health Certification and Plan of Care form with a Start of Care on 9/21/24 revealed under Frequency/Duration of Visits that physical therapy was ordered one time a week for one week. Review on 9/25/24 of Patient #15’s physician’s orders revealed no additional orders for physical therapy. Review on 9/25/24 of Patient #15’s Client Calendar Report revealed that Resident #15 received therapy visits on 9/21/24, 9/22/24 and 9/23/24; two more days than what was ordered. Interview on 9/25/24 at 2:28 p.m. with Staff A (Administrator) confirmed the additional visits were completed without a physician’s order.”