Dream Care LLC

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review, observation and interview, the Agency failed to follow accepted standards of practice, including the use of standard precautions to prevent the transmission of infections and communicable diseases for 1 (Patient #7) of 5 active patients whose records were reviewed for infection control in that: 1. LVN A failed to follow aseptic technique while performing a blood glucometer check and the administration of insulin. 2. LVN A failed to minimize potential exposure of infections and bloodborne borne pathogens to himself, Patient #6, and other family members in the home setting during the administration of insulin. These deficient practices could place active patients at risk of exposure and infection and inadequate care when infection control practices are not applied. The findings included: Record review of Patient #7’s electronic medical record included a “Home Health Certification and Plan of Care” (POC) signed and dated 12/18/24 that documented a start of care date of 09/11/24 and a certification period of 11/10/24 through 01/08/24. Furthermore, the POC documented a principal diagnosis of hypertensive chronic kidney disease with stage 1-4/unspecified chronic kidney (high blood pressure caused by damage kidney disease). The POC documented Insulin Glargine 100 unit/ML solution Pen-injector 30 units daily in afternoon subcutaneous (SQ) U DM ii on the list of medications. Additionally, the POC documented the following orders for disciplines and treatment: · SN frequency: every day for 60 days (QDx60) · SN to wash hands for 20 seconds using proper handwashing technique, disinfect equipment and don CDC recommended PPE. SN to perform Skilled head to toe assessment Q (every) visit using standard precautions. SN to use sterile supplies and aseptic technique when applicable including blood sugar checks and preparations and administration of Insulin Glargine 100 Unit/ML solution Pen-injection 30 units daily in afternoon subcutaneous. Prior to leaving home. SN to disinfect all equipment prior to placing in nursing bag, remove all PPE, dispose of all waste per OSHA guidelines, and wash hands for 20 seconds using proper handwashing technique. · SN to obtain blood sugar level via fingerstick PRN signs/symptoms of hyperglycemia/hypoglycemia, per request or if not checked prior to SN visit. · SN to prepare and administer Insulin Glargine 100 unit/ML Solution Pen-injector 30 units daily in afternoon subcutaneous as ordered During a home visit to Patient #7 on 02/19/25 at 02:20 p.m., an observation was made of LVN A performing blood sugar level via fingerstick and administration of Insulin Glargine. Upon arrival to the home visit, LVN A and Surveyor A were escorted to Patient #7’s kitchen table where Patient #7 was observed to be sitting in a clean home, well dressed, and sitting comfortably on a chair. After introductions were briefly made, LVNA set up his field on a disposable pad in the adjacent living room sofa (LVN A did not wash his hands for 20 seconds using aseptic technique per ordered on POC and Agency policies prior to performing blood sugar check via fingerstick or administration of Insulin). LVN A proceeded to sanitize his hands with an alcohol-based rub, donned gloves, and gathered supplies. He then moved over to the kitchen table where he set up a clean field using a disposable pad. LVN A placed his supplies on the field and quickly prepared his supplies, including inserting a lancet into a lancet device and testing strip into Patient #7’s glucometer. LVN A then swabbed Patient #7’s finger and using the lancet device, poked Patient #7’s finger. LVN A took the small sample of blood with the glucometer and swabbed the remaining blood with the alcohol pad. After the glucometer analyzed the blood sample and beeped producing the random glucose reading of 238 mg/dL, LVN A removed the used lancet from the lancet device and disposed of the lancet and the glucose testing strip in a red sharp’s container (LVN A failed to change gloves, sanitize, or wash hands prior to starting new procedure involving medication). LVN A proceeded to screw a new insulin needle onto the insulin pen and removed the cap. LVN A then walked back to his bag in the adjacent living room sofa, collected an alcohol pad, walked back to Patient #7, swabbed Patient #7’s right lower abdomen and administered Insulin Glargine 30 units subcutaneously to the right lower abdominal quadrant (LVN A walked away from Patient #7 to bag in adjacent living room with exposed/uncapped needle with Patient and 3 other family members in home to obtain more supplies for procedure). LVN A removed the needle and disposed of the needle in the sharp’s container. He then instructed the caregiver to keep the sharps container away from the child sitting next to Patient #7 on the kitchen table. LVN A finished by returning the insulin to Patient #7 to be stored. LVN A then proceeded to assess the patient’s vitals signs and performing an assessment of all body systems. LVN A collected and sanitized his supplies, collected, and disposed of the trash, doffed his gloves, and sanitized his hands with an alcohol-based rub prior to leaving the home (LVN A failed to wash hands for 20 seconds using proper handwashing technique per POC orders and Agency policies). In an interview on 02/19/25 at 02:30 p.m., LVN A stated he did not wash his hands because Patient #7 did not have an open wound and Patient #7 was in a temporary living situation with family members he was not comfortable with. LVN A stated Patient #7 did not usually have a child in the home and LVN A was not familiar with this child being in the home. LVN A stated he forgot alcohol wipes and he had to walk back to his bag to obtain more supplies. LVN A stated he did not want to “leave it there” (indicating prepared, uncapped, exposed, and on the table). LVN A stated he “should have prepared” better for the procedure prior to starting. LVN A stated walking with an exposed needle was a safety and infection control issue. In an interview on 02/19/25 at 02:35 p.m., Patient #7 stated his living situations was temporary because his sister lived in housing and that could potentially affect her. Patient #7 stated he was currently living with his sister and other family members and would be moving with his brother soon. Patient #7 stated he went to a day care center in the mornings. Patient #7 stated he was happy with the services provided by the Agency and had no complaints since his admission to the home health. Patient #7 stated he could not remember when that was, but it was after his wife had passed away because he could no longer administer his own insulin on a daily basis. Patient #7 stated staff called prior to the arrival to the home. In an interview on 02/20/25 at 11:55 a.m., the DON stated the staff was not supposed to recap needles and point needles away from body. The DON stated the incident was an infection control and safety issue. The DON stated the Agency used CDC and OSHA guidelines for infection control. The DON stated this was a potential exposure for risk infection and bloodborne pathogens. The DON stated it was her responsibility to in-service nurses and staff on infection control. In an interview on 02/20/25 at 12:15 a.m., the Adm, stated the Agency followed OSHA guidelines for infection control. The Adm stated the incident was not appropriate and did not follow infection control measures by Agency. The Adm stated the nurse should have washed his hands prior to and after the visit client per the orders on the plan care and Agency policies. The Adm stated LVN A should have gathered enough supplies prior to starting procedure so that he would not have exposed a needle to himself, the patient, and other family members in the home. The Adm stated the potential negative effects of this was a risk of infection for staff and other patients. The Adm stated it was her responsibility for ensuring Agency policies were followed related to infection control and safety. In a concurrent record review and follow up interview on 02/21/25 at 11:00 a.m., the DON stated she had only been employed with the Agency for approximately 2 weeks and was in the process of learning all Agency policies. The DON confirmed start of care for Patient #7 as 09/11/24 and certification period of 11/10/24 through 01/08/24. The DON stated LVN A was currently the nurse who primarily performed skilled nurse visits to Patient #7. The DON stated Patient #7 was in a temporary living situation and currently living with a sibling and other family members in the home. The DON stated the Agency and LVN A did not follow Agency policies regarding infection control and safety. The DON stated that according to the POC, LVN A should have followed aseptic technique and washed his hands for 20 seconds. The DON stated LVN A also failed to follow Agency policies regarding infection control and safety because of the exposed needle in the patient setting. The DON stated it was her responsibility to ensure Agency policies regarding infection control and safety policies were implemented. The DON stated not implementing infection control or safety policies could negatively affect patients because staff could injure patients or cause infection. In a simultaneous record review and interview on 02/21/25 at 12:30 a.m., the Alt Adm confirmed Patient #7’s start of care was 09/11/24 and certification period of 11/10/24 through 01/08/24. The Alt Adm stated it was not acceptable for LVN A to walk with an exposed needle per agency policy. The Alt Adm stated LVN A did not follow the infection control or safety precautions listed on Patient #7’s plan of care and, therefore, did not follow Agency policies. The Alt Adm stated Agency staff get in-serviced at least once a year on infection control and safety precautions by the director of nurses. The Alt Adm stated it was the DON’s responsibility to ensure these topics were addressed with staff because she “sets them up verbally and on paper”. Record review of Agency policy titled, “Infection Control/Exposure Plan”, with no revised date noted, quoted in part, “[Agency]” maintains policies and procedures for the service of patients with infections and/or contagious diseases and for infection control practices by personnel that conform to OSHA (Occupational Safety and Health Regulations) regulations and currently accepted standards of service. Agency personnel will protect the patients and themselves using universal promulgated by the CDC (Centers for Disease Control) …” Record review of Agency policy titled, “Universal Precautions”, with no revised date noted, quoted in part, “[Agency]” will require the following as part of its overall infection control program…It should be assumed that patient blood and all body fluids, whether visible or not, are potentially infectious… The following rules apply… (1) Wash hands: (a) Before and after direct patient contact, (b) After contact with bodily fluids or excretions, mucous membranes, non-intact skin or wound dressings, (c) Before handling supplies or equipment for patient service whether or not gloves are used, (d) When moving from a contaminated body site to another site during service, (e) After contact with an inanimate surfaces and objects in the immediate patient area, (f) After removing patient service gloves, (g) Before handling medication or preparing food, (h) If hands are visibly dirty or soiled with blood or other body fluids, (i) After using the toilet… (2) Hand washing Techniques…(a) handwashing should take at least 20 seconds (b) wash hands with soap and water when visibly dirty or visibly, soiled with blood or other body fluids, after using the toilet or if exposure to potential spore-forming pathogens is strongly suspected or proven, (c) Use an alcohol-based rub as the preferred means for routine hand antisepsis in all other situations. If hands are not visibly soiled or if alcohol-based rub is not obtainable, wash hands with soap and water… (8) Sharps: To Prevent needle stick injuries, needles should NEVER be recapped, bent, broken, or manipulated by hand. Used sharps will be placed intact into puncture resistant containers, which may be provided by the Agency. The containers. When 2/3’s full, are to be returned to the Agency for proper disposal or disposed of in accordance with state or local regulations. When possible, use of needless systems will be utilized…” Record review of Agency policy titled, “Safety Management”, with no revised date noted, quoted in part, “[Agency] will plan for a safe environment, addressing physical safety in the work place and the patient’s environment… (3) All personnel, patients, and caregivers will receive applicable safety instruction including, but not limited to…(g) safe use of medical equipment, (i) use of gloves… (k) safe disposal of needles in a puncture-resistant container…(l) infection control, (m) proper hand washing, (n) universal precautions…” Review of OSHA 29 CFR 1910.1030, titled Bloodborne pathogens, accessed 02/27/25, quoted in part, “Occupational Exposure means reasonably anticipated skin, eye mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties… Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions…Regulated waste…contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials… (d)(1) General. Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials…(d)(2)(v) Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment…(d)(2)(vi) Employers shall ensure that employees wash hand and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials…. (2)(vii)(B) Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique… (d)3(ix) Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph(d)(3)(ix)(D); and when handling or touching contaminated items or surfaces…. (d)(4)(iii) Regulated waste… (d)(4)(iii)(A)(1) Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are… (d)(4)(iii)(A)(1)(i) Closable…(d)(4)(iii)(A)(1)(ii) Puncture resistant… (d)(4)(iii)(A)(1)(iii) Leakproof on sides and bottom; and… (d)(4)(iii)(A)(1)(iv) Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard.” Record review of Lippincott Advisor and Lippincott Procedures titled, “Sharps Disposal”, with a revised date 08/18/24, quoted in part, “Sharps are medical devices that have points or edges capable of puncturing or cutting the skin, such as needles, syringes, lancets, scalpels, broken glass, dental wires, and other devices…Injuries involving contaminated sharps are linked to transmission of various pathogens, including hepatitis B, hepatitis C, and human immunodeficiency virus. Proper handling and disposal of sharps can help prevent injury and transmission of pathogens to everyone in the health care environment…Perform hand hygiene…Handle all sharps carefully to avoid injury. Remember that gloves don’t provide protection from injury with a sharp object… Always keep sharps pointed away from yourself and others…Avoid recapping needles; if a safe needle device isn’t available and you must recap a needle, use a one-handed scoop recapping technique…” Record review of Lippincott Advisor and Lippincott Procedures titled, “Standard Precautions, home care”, with a revised date 08/18/24, quoted in part, The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection. Standard precautions are a group of infection prevention practices based on the idea that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may be infectious. CDC officials recommend that health care workers assume that all patients, regardless of their diagnosis, are potentially infected or colonized (carrying an organism but not showing signs or symptoms of infection) with an organism that the patient may transmit to others. Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens… Perform hand hygiene before and after patient care; before putting on and after removing gloves; before handling an invasive device; when moving from a contaminated body site to a clean body site; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (even if you wore gloves); and after contact with inanimate objects in the patient’s environment. If your hands aren’t visibly soiled, use an alcohol-based hand rub for routine hand hygiene. If they’re visibly soiled, wash them with soap and water and dry them with a paper towel… Change your gloves and perform hand hygiene if your gloves become damaged or heavily soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination. Avoid touching your face, body, and other surfaces and items not needed for direct patient care with your gloved hands to reduce the risk of transmitting infectious organisms…Wear gloves if you may or will come into contact with blood, specimens, tissue, body fluids, secretions, excretions, mucous membranes, broken skin, or contaminated surfaces or objects… Handle used needles and other sharps carefully. Don’t bend, clip, recap, or otherwise manipulate them. Activate any safety mechanisms, such as a retraction feature on a syringe or lancet and a hinged or sliding shield on a needle, immediately after use… Discard the sharps immediately after use into a puncture-resistant sharps disposal container. Never force a sharp into a container or put your fingers into the container. Never place used sharps in regular household trash, recycling bins, or plastic biohazard bags… The agency did not dispute the survey findings and did not provide this surveyor with any additional requested documents upon exit.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to enforce a written policy that detailed its care practice for an initial assessment for 1 (Patient #2) of 5 active patients whose records were reviewed in that, there was no documented evidence that the Agency conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral or ordered start of care date. This failure has the potential to prevent staff from determining the immediate care and support needs of patients and prevented the initiation of required services in a timely manner. The findings included: Record review of Agency policies titled, “Admission”, with no revised date, quoted in part, “[Agency] is committed to providing timely, well-coordinated, comprehensive, competent, quality, and supportive care by utilizing its multi-disciplinary team to meet the identified needs of the referred patient. The agency admits a patient to care on referral who meets the Medicare home health care benefit eligibility criteria and only if ordered by the patient’s referring physician…The admission process will be initiated within 24-28 hours of the referral date unless specific admission date is ordered…(2) All referrals to home health care will be taken by a referral intake person or qualified alternate and responded within 24 hours and either opened for serviced or referred to a more appropriate agency within 48 hours unless otherwise agreed upon by patient and patient’s physician…” Record review of Agency policies titled, “Skilled Nursing Services”, with no revised date, quoted in part, “[Agency] provides skilled nursing services by a RN or LPN under the direction of a RN within the scope of their practice in a licensed home health agency…(1) Completion of a first home visit within 48 hours of referral, unless otherwise specified by the physician or requested by the patient (with permission by the physician) to determine the immediate care and support needs of the patient…” Record review of Agency active “Patient Survey Census” dated 02/14/25 provided to surveyor upon entrance documented Patient #2 Start of Care (SOC) date as 01/13/25 and a current certification period of 01/13/25 through 03/13/25. Record review of Patient #2’s electronic medical record (EMR) included a “Patient Profile” that documented a SOC date 01/13/25 and a referral date 01/10/25. Further review of Patient #2’s EMR included a plan of care (POC), not signed, or dated, that documented a SOC date 01/13/25, a certification period 01/13/25 through 03/13/25, a primary diagnosis hypertensive chronic kidney disease with stage 1-4/unspecified chronic kidney (long standing kidney condition), and skilled nurse frequency ordered 4 weeks for 1 week (4w1), 3 weeks for 7 weeks (3w7), and 2 weeks for 1 week (2w1). Record review of Patient #2’s EMR included an OASIS E-1 (Outcome and Assessment Information Set) Start of Care signed and dated 01/13/25 that documented a SOC date 01/13/25, referral date 01/10/25 and a certification period 01/13/25 through 03/13/25. Further review of Patient #2’s record failed to include documentation of completion of the first home visit within 48 hours of referral or the request by physician or patient (with permission by the physician) to delay the first home visit. In a simultaneous record review and interview on 02/21/25 at 11:00 a.m., the DON stated she had only been employed with the Agency for approximately 2 weeks and was not familiar with all patients and was in the process of learning all Agency policies including Admission and Nursing policies. The DON stated Patient #2 was admitted prior to her employment and was not familiar with the patient’s admission. The DON confirmed Patient #2’s SOC date 01/13/25 and referral date 01/10/25. The DON stated Patient #2 was not admitted within 48 hours. The DON stated the Agency had to admit a client within 48 hours of referral per Medicare guidelines or obtain a physician order to start on a different date. The DON stated there was no documentation or physician order by previous DON in Patient #2 EMR that documented reason why there was a delay in start of care. In a concurrent record review and interview on 02/21/25 at 12:30 p.m., the Alt Adm stated confirmed Patient #2’s SOC date 01/13/25 and documented referral date 01/13/25. The Alt Adm stated the Agency had 48 hours from referral to complete the patient’s admission. The Alt Adm stated she could not recall what was the reason for delay in SOC. The Alt Adm stated there was no documentation that documented why there was a delay in admission and why it was not completed within 48 hours. The Alt Adm stated Patient #2 could have potential negative effects of this delay because she had wound care that needed to be taken care of and the nurse needed to assess the patient to find out who was taking care of the patient during that time. The Alt Adm stated there was a potential risk for infection during that time if the nurse did not see the patient in a timely manner. The Alt Adm stated the nurse was responsible for seeing this patient within the 48 hours and she failed to follow agency policy. The Alt Adm stated she was responsible for ensuring the nurses followed agency policy.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the physician reviewed and signed the total plan of care every 30 days as required by the Agency policy for 1 (Patient #6) of 5 active patients whose records were reviewed. This failure demonstrated a lack of quality of care, could place the Agency’s clients at risk of receiving inadequate care and at risk of negative client outcomes. The findings included: Record review of the Agency’s active “Patient Survey Census” dated 02/14/25 revealed Patient #6 was an active patient with a start of care date of 02/29/24 and a current certification period of 12/25/24 through 02/22/25. Record review of Patient #6’s electronic clinical record included a “Home Health Certification and Plan of Care” (POC) that documented a start of care of 02/29/24, a certification period of 10/26/24 through 12/24/24 and a primary diagnosis of essential hypertension (high blood pressure). Furthermore, Patient #6’s POC revealed the following orders: · Skilled nurse (SN) frequency: 1 time a week for 9 weeks (1w9) effective 10/27/24. · SN to perform complete physical assessment each visit with emphasis on hypertension (high blood pressure), gastrostomy (hole in abdomen through which a tube is inserted directly into the stomach for the purpose of bringing nutrition or medication directly into the stomach) care, Alzheimer’s disease (brain disorder that destroys memory and thinking skills) with dementia, caregiver burnout, fall prevention interventions, interventions to monitor and mitigate pain, interventions to prevent pressure ulcers, depression interventions, infection control and risks, and medication compliance. · SN to assess (for) vital signs, SpO2 (oxygen saturation), edema, and gastrostomy complications Q (each) visit. · SN to pre-fill pill box Q week per medication profile · SN to perform medication review Q visit and perform medication reconciliation Q week and PRN (as needed) change in medication regiment. · SN to instruct on gastrostomy care to include but not limited to proper placement of gastrostomy tube, proper positioning, during feedings, signs/symptoms of aspiration pneumonia, and when to report to SN/physician Record review of Patient #6’s electronic clinical record included a “Home Health Certification and POC” that failed to include a physician signature 30 days after the start of the certification period for 10/26/24 through 12/24/24 as required by the agency policy. In a concurrent record review and interview on 02/21/25 at 11:00 a.m., the DON stated she had only been employed with the Agency for approximately 2 weeks and was in the process of learning all Agency policies. The DON confirmed the start of care date for Patient #6 as 02/29/24 and a certification period of 10/26/24 through 12/24/24. The DON stated Patient #6 did not have a signed POC for certification period 10/26/24 through 12/24/24 in his electronic medical record and stated she was not sure why it was not signed. The DON stated she needed to obtain more information from the Alt Adm and left the room. Upon her return she provided a signed and dated copy of the POC. In a simultaneous record review and interview on 02/21/25 at 11:15 a.m., the DON stated the copy of the provided copy of the POC dated 02/20/25 was not signed within the 30 days per agency policy. The DON stated this could have a negative effect to patients if orders were not signed by physicians in a timely manner because staff were going to patients’ homes without orders. In an interview and simultaneous record review on 02/21/25 at 12:30 a.m., the Alt Adm confirmed the start of care date of 02/29/24 and certification period as 10/26/24 through 12/24/24 for Patient #6. The Alt Adm stated she did not know the Agency policy on timeframe to have POC signed. The Alt Adm stated the POC was not signed within the certification period. The Alt Adm stated this could negatively affect Patient #6 because the physician could have added orders or could have not agreed with orders on the POC, and the Agency would not have known. The Alt Adm stated she was responsible for ensuring the POC was signed. The Alt Adm stated she scheduled weekly pick up and drop off the POC to the physician’s office and Patient #6’s POC physician insisted the POC was either not available to be signed or not ready with signature to be picked up. The Alt Adm stated the physician’s office returned the POC signed only after QA called the physician’s office with a more determined tone. Record review of the Agency policies titled, “Physician Plan of Care Orders” with no revised date noted, quoted in part, “[Agency] certification and Plan of Treatment [CMS 485] is an individualized plan of care and treatment based on the comprehensive assessment of the patient by the RN Case Manager and signed by the patient’s physician…(1) The plan of care shall be developed within five days of the comprehensive assessment, with input from other disciplines if applicable, and signed and dated by the physician within 30 working days…””