Genesis Home Health Services, Inc.

“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 review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP was reviewed at least every two years. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had reviewed their EP within the last two years. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the EP had not been reviewed within the last two years.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP addressed the type of services the HHA could provide in an emergency. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had reviewed their EP within the last two years including the type of services the HHA can provide during an emergency. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“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 review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the plan included cooperations and collaboration with local, tribal, regional, State, and Federal emergency officials. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had a process to ensure cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials to ensure an integrated response during a disaster or emergency. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“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 review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP was based on the HHA’s risk assessment for potential hazards. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had performed a risk assessment for the basis of the HHA’s EP plan. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to develop policies to inform state and local emergency officials about patients in need of evacuation from their homes at any time due to an emergency. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA had developed policies to notify state and local emergency officials of patients in need of evacuation during an emergency. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“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 review of the Home Health Agency’s (HHA) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP plan included notifying the state and local officials of any on-duty staff or patients that the HHA had been unable to contact during an emergency situation. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA included notification of the state and local officials of on-duty staff or patients the HHA had been unable to contact during an emergency. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP addressed the use of volunteers during an emergency situation and contained emergency staffing strategies. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA developed a plan related to the use of volunteers during an emergency situation and emergency staffing strategies. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to collaborate with Federal, State, and local officials to ensure their communication plan complies with Federal, State, and local requirements. This had the potential to affect all 11 patients served by the agency in case of an emergency situation. Findings include: Review of the HHA’s EP plan revealed no evidence the HHA collaborated with Federal, State, and local officials to ensure the communication plan complied with Federal, State, and local requirements. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to ensure the HHA’s communication plan included contact information for Federal, State, tribal, and regional emergency preparedness officials. This deficient practice had the potential to affect the 11 patients and staff in the event a disaster occurred. Findings include: Review of the agency’s emergency preparedness plan indicated the communication plan did not include contact information for Federal, State, tribal, and regional emergency preparedness officials. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to develop a procedure for providing information about the HHA’s occupancy, needs, and its’ ability to assist the authority having jurisdiction, the Incident Command Center, or designee during a disaster. This deficient practice had the potential to affect all 11 patients and staff in the event a disaster occurred. Findings include: Review of the agency’s emergency preparedness plan indicated the plan did not include procedures for providing information about the HHA’s occupancy, needs, and its ability to assist the authority having jurisdiction, the Incident Command Center, or designee during a disaster. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer confirmed the above findings.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on review of the Home Health Agency’s (HHA’s) emergency preparedness (EP) plan and interview, the HHA failed to ensure the EP contained a written training and testing program. This had the potential to affect the 11 patients currently receiving services from the HHA. Findings include: Review of the HHA’s EP plan revealed no evidence of a written training and testing program. During an interview on 04/01/25 at 10:30 AM, the Director of Clinical Services, the Chief Executive Officer and the Chief Clinical Officer 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 record review, interview, and policy review, the facility failed to ensure that patient Plans of Care (POCs) included patient specific measurable goals to assess if progress toward expected outcomes were being met for 3 of 3 sampled patients (Patient (P) 1, P2, P3) reviewed for care plan development. This deficient practice had the potential to affect all patients receiving services from the facility. Findings include: Review of the undated facility policy titled “Care Planning Process,” indicated “. . . A written individualized plan of care will be initiated . . . The patient-specific clinical plan of care includes . . . measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care . . .” The policy also indicated that care plans should contain “. . . reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient . . .” P1 Review of the Care Plans, indicated P1 had a Start of Care date of 02/19/25, with diagnoses which included congestive heart failure (CHF), and stage 4 chronic kidney disease. A Care Plan developed to meet P1’s gastrointestinal needs had a goal of Patients gastrointestinal system will remain within normal limits throughout cert period. A Care Plan developed to address P1’s medication management had a goal of Patient will demonstrate compliance with med regimen throughout the cert period. A Care Plan developed to address P1’s musculoskeletal needs had a goal of Patient will be free from falls throughout the cert period. A Care Plan developed to address P1’s integumentary needs had a goal of Patient will not have any new evidence of skin breakdown throughout cert period. P2 Review of the Care Plans, indicated P2 had a Start of Care date of 06/06/24 with diagnoses which included Parkinson’s disease, constipation, and benign prostatic hyperplasia without lower urinary tract symptoms. A Care Plan developed to meet P2’s neurological needs had goals of actively participate in decisions about care and daily activities and demonstrate safe, consistent, and nurturing physical environment. A Care Plan developed to address P2’s gastrointestinal needs had a goal of Patients gastrointestinal system will remain within normal limits throughout cert period. A Care Plan developed to address P2’s musculoskeletal needs had a goal of Patient will be free from falls throughout the cert period. A Care Plan developed to address P2’s medication management had a goal of Patient will demonstrate compliance with med regimen throughout the cert period. A Care Plan developed to address P2’s integumentary needs had a goal of Patient will not have any new evidence of skin breakdown by end of cert period. A Care Plan developed to address P2’s pain had a goal of Patient/caregiver will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures, behavior modification, to avoid factors that increase pain/use of pain scale to identify and determine comfort goal by _____. P3 Review of the Care Plans indicated P3 had a Start of Care date of 03/17/25 with diagnoses which included Mesothelioma of pleura and pulmonary mycobacterial infection. A Care Plan developed to address P3’s musculoskeletal needs had a goal of Patient will be free from falls throughout cert period. A Care Plan developed to address P3’s medication management had a goal of Patient will demonstrate compliance with med regimen throughout the cert period. A Care Plan developed to address P3’s respiratory needs had a goal of clear lungs by___, free of respiratory infection by___, and Sp02 will be within physician established parameters by____. A Care Plan developed to address P3’s pain had a goal of Patient/caregiver will verbalize/demonstrate measures to manage pain: medication management/alternative pain relief measures, behavior modification, to avoid factors that increase pain/use of pain scale to identify and determine comfort goal by _____. During an interview with the Chief Clinical Officer (CCO), the Director of Clinical Services, and the Chief Executive Officer (CEO), on 04/02/25 at 11:00 AM, the CCO stated that care plans are a weakness for the Agency and verbalized understanding that care plan goals are not measurable and in some instances the Care Plans for P1, P2, and P3 included the same goals for the three patients, taking away from them being patient specific. The Director of Clinical Services and the CEO verbalized agreement regarding the Care Plans currently in place for P1, P2, and P3.”