Westarm Homecare

“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 a review of the facility emergency preparedness plan and interview with agency administrator the agency failed to develop and implement emergency preparedness policies and procedures that address 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. Findings included: Review of Emergency Preparedness Plan on 6/18/24 at approximately 11:00am revealed no evidence that the agency included policies and procedures that address 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. Interview with Administrator on 6/18/24 at approximately 2:30pm confirmed findings.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on a review of the facility emergency preparedness plan, personnel files (PF), and interview with agency administrator the agency failed to conduct initial training in emergency preparedness policies and procedures new staff for one (1) of five (5) PF reviewed (PF#1) and failed to provide emergency preparedness training annually, per agency policy, for three (2) of five (5) PF review (PF#1, PF#4 & PF#5). Findings included: Review of Emergency Preparedness Plan on 6/18/24 at approximately 11:00am revealed...”Training: 1. The training includes: Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing service under arrangement and volunteer staff if applicable. 2. Training is provided annually and demonstrates staff knowledge of emergency procedures...4. Al training will be documented in the personnel record of staff, individuals under arrangement, and volunteers, if applicable...” Review of PF on 6/18/24 at approximately 1:30pm revealed: PF#1, date of hire (DOH) 9/29/22, PF failed to include evidence of emergency preparedness training upon hire and for 2024. PF#4, DOH 2/16/23, PF failed to include evidence of emergency preparedness training for 2024. PF#5, DOH 6/5/23, PF failed to include evidence of emergency preparedness training for 2024. Interview with Administrator on 6/18/24 at approximately 2:30pm confirmed findings. Repeat deficiency, previously cited: 6/20/2018”

“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: Based on a review of the facility emergency preparedness plan and interview with agency administrator, the agency failed to conduct exercises to test the emergency plan at least annually for three (3) of four (4) years reviewed. (2021, 2022, 2023) Findings included: Review of Emergency Preparedness Plan on 6/18/24 at approximately 11:00am revealed...”Testing: 1. The agency tests the emergency management plan at least annually, in response either to an actual emergency or in a planned exercise. 2. The agency participates in a full-scale exercise that is community-based or individual, facility-based if a community-based exercise is not accessible...4. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical, and support staff. Documentation will be used to identify deficiencies and opportunities for improvement based on all monitoring activities and observations during the exercise or actual emergency. The documentation will identify the effectiveness of the preparedness, mitigation, response, and recovery activities of the emergency operations plan...” Review of documented testing/drills on 6/18/24 at approximately 11:20am revealed one (1) table-top drill documented for 2024. No documentation available to demonstrate testing by method or full-scale exercise, actual emergency, or table-top drills of the Emergency Preparedness Plan for 2012, 2022, or 2023. Interview with Administrator on 6/18/24 at approximately 2:30pm confirmed findings.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on review of Clinical Records (CR) and interview with agency administrator, the agency failed to provide all services as ordered for five (5) of ten (10) CR reviewed (CR#2, CR#4, CR#7, CR#8, & CR#9). Findings included: Review of CR#2 on 6/20/24 at approximately 10:00am revealed start of care (SOC) 11/13/23, dates reviewed 11/13/23-11/29/23. CR included referral for Physical Therapy (PT) and Occupational Therapy (OT). No evidence that OT evaluated patient for services. No documentation of patient refusal of OT services. Review of CR#4 on 6/21/24 at approximately 9:10am revealed SOC 6/7/24, dates reviewed 6/7/24-6/21/24. CR included referral for PT for lymphedema management and evaluation for new leg wraps. CR revealed skilled nurse assessment on 6/7/24 and no additional visits. Pt evaluation conducted 12 days later. Documentation reflected therapist not available due to vacation. Review of CR#7 on 6/21/24 at approximately 1:40am revealed SOC 4/29/24, dates reviewed 4/29/24-6/21/24. Plan of Care (POC) included PT frequency of 2 times a week for 4 weeks effective 5/5.1 Pt visit conducted week of 5/26/24 followed by no additional visits or discharge. Patient remained on services with no discipline visits from 5/29/24-date of review, 6/21/24. Review of CR#8 on 6/21/24 at approximately 2:00pm revealed SOC 6/3/24, dates reviewed 6/3/24-6/21/24. CR included order on POC for OT evaluation week of 6/3/24. OT evaluation completed 8 days later, week of 6/9/24. Note in CR documented “OT no available.” Review of CR#9 on 6/25/24 at approximately 9:40am revealed SOC 5/2324, dates reviewed 5/23/24-6/21/24. POC included skilled nurse (SN) frequency of 2 times a week for 3 weeks effective 6/2/24. One SN visit conducted weeks of 6/2/24, 6/9/24, and 6/16/24. POC included Pt frequency of 1 time a week for 2 weeks effective 5/26/24. No PT visit conducted week of 6/2/24. Interview with agency President, Vice President, and Administrator on 6/25/24 at approximately 2:30pm confirmed findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on review of Clinical Records (CR), home visit observations (HV), and interview with agency administrator, the agency failed to complete a review of all medications the patient is currently using for five (5) of ten (10) CR reviewed (CR#1, CR#2, CR#6, CR#8, & CR#9). Findings included: Review of CR#1 on 6/20/24 at approximately 9:30am revealed, start of care (SOC) 4/23/24 date reviewed 4/23/24-5/21/24. Plan of care (POC)/medication list failed to include or address the following medications that were ordered to be taken upon referral/hospital discharge: Albuterol 90 mcg/actuation inhaler-2 puffs every 4 hours as needed, Breo Ellita 100-25 mcg/dose inhalation- 1 puff daily, clobetasol 0.05% ointment, OptiChamber Diamond VHC Spcr device-use as directed. Review of CR#2 on 6/20/24 at approximately 10:00am revealed, SOC 11/13/23, date reviewed 11/13/23-11/29/23. Referral/hospital discharge included medication list to be taken post discharge. No medications included in POC or medication list. Review of CR#6 on 6/21/24 at approximately 1:15pm revealed, SOC 5/13/24, date reviewed5/13/24--6/21/24. POC/medication list failed to include or address the following medications that were ordered to be taken upon referral/hospital discharge: Nitroglycerin 0.4mg sublingual every 5 minutes as needed, may repeat every 5 minutes x3. Review of CR#8 on 6/21/24 at approximately 2:00pm revealed, SOC 6/3/24, date reviewed 6/3/24-6/21/24. POC/medication list failed to include or address the following medications that were ordered to be taken upon referral/hospital discharge: Cyclobenzaprine HCL oral tablet 10 mg- give 0.25 tablet by mouth every 12 hours as needed for muscle spasm. Review of CR#9 on 6/25/24 at approximately 9:40am revealed, SOC6/6/24, date reviewed 6/6/24-6/21/24.During HV#3 conducted 6/20/24 at approximately 2:00pm patient reported taking Arimidex. POC/medication list failed to include or address this medication. Interview with agency President, Vice President, and Administrator on 6/25/24 at approximately 2:30pm confirmed findings.”

“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 review of Clinical Records (CR), home visit observations (HV), and interview with agency administrator, the agency failed to ensure the Plan of Care (POC) included supplies, and equipment required for two (2) of ten (10) CR reviewed (CR#4 & CR#9), patient-specific interventions, education and measurable outcomes and goals for three (3) of ten (10) CR reviewed (CR#4, CR#5, & CR#9) Findings included: Review of CR#4 on 6/21/24 at approximately 9:10am revealed start of care (SOC) 6/7/24, dates reviewed 6/7/24-6/21/24. POC included diagnosis of Diabetes Mellitus II, parameters for blood sugar readings, and medication list included insulin. POC failed to include diabetic supplies or interventions to check blood glucose. Patient referred for Physican therapy (PT) and receiving PT services as of date of review., POC failed to include interventions and goals for PT. Review of CR#5 on 6/21/24 at approximately 10:30am revealed SOC 5/29/24, dates reviewed 5/29/24-6/21/24. CR revealed patient receiving skilled nursing (SN), PT, occupational therapy (OT), and speech therapy (ST) services. No interventions or goal developed in POC for SN or ST. Wound documented upon SOC to patient sacrum/coccyx, no wound care interventions/orders documented. Review of CR#9 on 6/25/24 at approximately 9:40am revealed SOC 5/2324, dates reviewed 5/23/24-6/21/24. HV#3 conducted 6/20/24 at approximately 2:00pm revealed patient referred to home health services post vehicle accident resulting in wound to left lower leg. Patient and nurse confirm upon start of care wound care was a wet to dry dressing per plan of care. Patient has Vaseline gauze in home and reports those to be old supplies from previous wound care. Wound care conducted at visit as followed: cleansed with soap and water, applied Santyl, covered with ABD, wrapped with Kerlix, secured with Coban-per nurse and patient this is performed daily. POC failed to include updated wound orders for current wound care performed or previous wound care that included use of Vaseline gauze. Interview with agency President, Vice President, and Administrator on 6/25/24 at approximately 2:30pm confirmed findings. Repeat deficiency, previously cited: 6/2/21.”