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Based on record review and interview, the facility failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by:

1) the hospital failed to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained. This deficient practice was evidenced by no documentation of performance improvement activities and no tracking or trending of identified problems. (See Finding A-0283)

2) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions. (See Findings A-0286)

3) the hospital failed to ensure a person qualified by education, experience and competency in infection control practices was designated as the infection control officer in the hospital. The deficient practice is evidenced by failure to have evidence of education and prior experience for the current infection control officer.(See Findings A-0748).

4) the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment (See Finding in A-0749).


5) the Infection Control Officer failed to document infection surveillance, prevention and control activities. This deficient practice is evidenced by failing to show any evidence of ongoing activities of tracking and trending infections, handwashing surveillance, and environmental rounds (See Findings in A-0773).

6) failing to have working call lights in the patient rooms or bathrooms for 6 out of 6 currently occupied patients' rooms (room b, c, e, f, j, n) The community shower room also failed to have a working call system. (see findings in A-0144).

Based on observations and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by the hospital failing to ensure patients received care in a safe setting. The deficient practice was evidenced by:


1) failing to have working call lights in the patient rooms or bathrooms for 6 out of 6 currently occupied patients' rooms (room b, c, e, f, j, n) The community shower room also failed to have a working call system (see findings in A-0144).

This deficient practice resulted in an immediate jeopardy situation for Patient #1, #2, #3, #4, #5, and #6. The patients did not have a working call system to notify staff of an emergency medical problem.


S5CFO was notified of the Immediate Jeopardy on 11/08/2021 at 10:30 a.m.

The Immediate Jeopardy was removed on 11/09/2021 at 2:32 p.m. when the facility had the call system repaired and in workable order.
The corrective actions included repair of the wireless and wire call system by a clinical service contractor and training of the staff on the call system.

This deficient practice had the potential for more than minimal harm for 6 out of 6 patients (#1, #2, #3, #4, #5, #6) currently admitted to the hospital.

2) Failing to ensure staff had keys to open patients doors if they became locked during an emergency for 4 (room a,b,c,f) of 14 ( rooms a, b, c, d, e, f, g, h, I, j, k, l, m, n) patient's rooms (see findings in A-0144).

Based on records review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

1) the hospital failing to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained. This deficient practice was evidenced by no documentation of performance improvement activities and no tracking or trending of identified problems (See Findings A-0283).

2) the hospital failing to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions (See Findings A-0286).

3) the hospital failing to ensure that the hospital conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could not provide documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project (See Findings A-0297).

4) the hospital's governing body failing to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to implement a quality assurance program for the hospital (See Findings A-0309).

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1. failing to ensure a person qualified by education, experience and competency in infection control practices was designated as the infection control officer in the hospital. The deficient practice is evidenced by failure to have evidence of education and prior experience for the current infection control officer (see findings in A-0748)

2. failing to maintain a sanitary environment (see findings in A-0749)

3. failing to document infection surveillance, prevention and control activities. This deficient practice is evidenced by failing to show any evidence of ongoing activities of tracking and trending infections, handwashing surveillance, and environmental rounds. (see findings in A-0773)

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologist performing telemedicine (radiology) services, was credentialed and privileged, by the governing body for 2 out 2 (S12MD and S13MD) radiologists' credentialing files reviewed for credentialing. Findings:

Review of Patient #6's medical record revealed an x-ray of the patient's left hand. With further review, the x-ray was reviewed by S12MD on 11/02/2021

Review of Patient #28's medical record revealed a radiology report read by S13MD.

An interview was conducted with S1Adm on 11/09/2021 at 10:00 a.m. She reported the S21HR did not have credentialing files for S12MD or S13MD.

Based on record review and interview, the hospital failed to ensure the services performed under contract were provided in a safe and effective manner. This deficient practice was evidenced by providing no documented evidence that all services provided by contract had been evaluated for safety and efficiency.
Findings:

Review of the QAPI plan provided to the surveyor by S3MR as the current QAPI plan revealed no documentation the contracted services had been evaluated for safety and efficiency.

An interview was conducted with S1Adm on 11/09/2021 at 11 a.m. She reported the contracted services are supposed to be evaluated in the QAPI program.

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:30 a.m. She reported she was the consultant for Quality Assurance program and she started working with the facility in January 2021. She went on to report the individual that was assigned to collect the data for the QAPI plan was no longer at the facility and she is unable to locate any of the QAPI information other than the initial plan.

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Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice is evidenced by:

1) failing to have working call lights in the patient rooms or bathrooms for 6 out of 6 currently occupied patients' rooms (room b, c, e, f, j, and n) The community shower room also failed to have a working call system; and

2) Failing to ensure staff had keys to open patients' doors if they became locked during an emergency for 4 (rooms a, b, c, f) of 14 (a, b, c, d, e, f, g, h, i, j, k, l, m, n )patient's rooms.

Findings:
1) Failing to have working call lights in patients' rooms and the community shower room

In an observation on 11/08/2021 at 9:00 a.m., all call lights above doors to patient's room were illuminated with the exception of room b and room d. The call lights in occupied patient's rooms did not notify anyone at the nurses' station or make an audible noise. The bathroom call lights were nonfunctional in the patient rooms and the community shower room did not have a functioning call system either.

An observation was conducted on 11/08/2021 at 9:30 a.m. of Patient #4 lying in bed. The patient's metal bell was located across the room by the patient's TV. When questioned Patient #4 if he could use the call system or reach his bell to call a nurse, he reported he could not reach the bell and he cannot walk.

An interview was conducted with S1Adm on 11/08/2021 at 9:00 a.m. S1Adm reported she had put in a request to the maintenance for the electrical and call bell issue to be repaired. She further reported issues had been ongoing for a year and the call bells would intermittently work and when there was a weather event the call lights would stop working. S1Adm reported she had purchased metal bells to be placed by the patient's bedside.

An interview was conducted with S2DON on 11/08/2021 at 9:17 a.m. She reported no emergency call features had been working since she has been employed. She further reported she started working at the facility about a month and a half ago.

An interview was conducted with Patient #3 on 11/08/2021 at 9:35 a.m. Patient #3 reported his call bell did not work. When questioned if he ever rang his bell and did not get a response, he stated about 1,500 times. The surveyor and Patient #3 rang the bell six times and nobody came to check on the patient. The surveyor crossed the hall and entered patient room b and rang the bell in that patient's room six-to eight times and no one responded the surveyor in room b.



2) Failing to ensure staff had keys to open locked patients doors

In an observation on 11/08/2021 at 11:05 a.m., 4 of 14 patients' rooms had a lock on the inside of the door. Further observation revealed to open the door from the outside, it required a key.

In an interview on 11:10 a.m., S2DON said she did not have the key to open patient's rooms if they were locked from the inside.

In an interview on 11:14 a.m. with S15RN, said she did not have the key to open patient's rooms during an emergency if they were locked.

In an interview on 11:16 a.m., S1Adm said she did not have the key to open patient's rooms if they were locked. When asked what would she do if a patient had locked their door and then required emergency assistance, she said she would call Company c (locksmith) to come open the door.

Based on record review and staff interviews, the hospital failed to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities and no tracking or trending of the identified problems. Findings:

Review of the hospital's QAPI records revealed no documented evidence of information on identifying the hospital's high risk, high-volume, or problem prone areas or actions to improve those areas.

Review of the policy titled, Quality Improvement Plan, revealed in part, the quality management/performance improvement program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care and organization functions. Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether or not problems are suspected or not.

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:30 a.m. She reported she was the consultant for Quality Assurance program and she started working with the facility in January 2021. She went on to report the individual that was assigned to collect the data for the QAPI plan was no longer at the facility and she is unable to locate any of the QAPI information other than the initial plan.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions.

Findings:

Review of the QAPI information provided to the surveyor, revealed no information related to tracking and trending medication errors or adverse events.

An interview was conducted with the S2DON on 11/09/2021 at 10:00 a.m. She reported she only had one incident report related to a nurse hurting herself on the medicine cart and no documentation of medication errors. She did not have any other incident reports; she had only been at the facility for a month and a half. S2DON went on to report she did not know if the other DON had incident reports, she has not seen any other incident reports.

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:30 a.m. She reported she was the consultant for Quality Assurance program and she started working with the facility in January 2021. She went on to report the individual that was assigned to collect the data for the QAPI plan was no longer at the facility and she is unable to locate any of the QAPI information other than the initial plan.

Based on record review and staff interview, the hospital failed to ensure that the hospital conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could not provide documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project. Findings

Review of the hospital's QAPI records revealed no documented evidence of a performance improvement project in the past or an ongoing performance improvement project.

An interview was conducted with S3MR/QAPI on 11/09/2021 at 11:30 a.m. She reported she was the consultant for Quality Assurance program and she started working with the facility in January 2021. She went on to report the individual that was assigned to collect the data for the QAPI plan was no longer at the facility and she is unable to locate any of the QAPI information other than the initial plan.

Based on record review and interview, the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to implement a quality assurance program for the hospital.
Findings:

Review of the Quality Assurance program given to the survey revealed an initial plan for the hospital QAPI program, but no data, outcomes or evaluation of the data was provided to the surveyor.

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:30 a.m. She reported she was the consultant for Quality Assurance program and she started working with the facility in January 2021. She went on to report the individual that was assigned to collect the data for the QAPI plan was no longer at the facility and she is unable to locate any of the QAPI information other than the initial plan.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff. The deficient practice was evidence by the hospital failing ensure documentation of any competences for 7 out of 7(S4LPN, S8CNA, S15RN, S16RN, S17RN, S18LPN, S19CNA) personnel records reviewed for competencies. Findings:

Review of the following personnel records revealed no evidence of documentation of competencies; S4LPN, S8CNA, S15RN, S16RN, S17RN, S18LPN, and S19CNA.

An interview was conducted with S21HR on 11/10/2021 at 2:00 p.m. She reported the competencies should had been in the nurses and CNA's personnel record.

Numerous requests were made from S1Adm and S2DON on 11/10/2021 for the nurses' and CNAs' competencies and no documentation was provided.

Based on record review and interview, the Director of Nursing failed to ensure the nurses adhered to the policies and procedures of the hospital. This deficiency is evidenced by missing Daily Nursing Documentation form in three (#25, #26, and #29) of three (#25, #26, and #29) records reviewed for missing nursing notes.
Findings:

Review of hospital policy titled, "Charting Procedure" revealed in part, "The nursing flow sheet is a daily assessment of the patient status documented on each 12-hour shift."

Patient #25
Review of the medical record of Patient #25 revealed missing Daily Nursing Documentation on 09/14/2021, 09/15/2021, and 09/16/2021 for the 7 a.m. to 7 p.m. shift and 09/17/2021 for the 7 p.m. to 7 a.m. shift.

In interview on 11/10/2021 at 1:15 p.m., S9RN verified the missing records.

Patient #26
Review of the medical record of Patient #26 revealed missing Daily Nursing Documentation on 09/15/2021, 09/18/2021, 09/22/2021, and 09/28/2021 for the 7 a.m. to 7 p.m. shift.

Interview on 11/10/2021 at 1:25 p.m., S9RN verified the missing records.

Patient #29
Review of the medical record of Patient #29 revealed missing Daily Nursing Documentation on 09/08/2021, 09/09/2021, 09/14/2021, 09/15/2021, and 09/17/2021 for the 7 a.m. to 7 p.m. shift.

Interview on 11/10/ 2021 at 12:47 p.m., S9RN verified the missing records.

In interview on 11/10/2021 at 12:47 p.m., S2DON stated she was not sure how often the Daily Nursing Documentation should be filled out and she was not aware of a policy related to documenting daily assessments.

Based on record reviews and interviews, the hospital failed to ensure that verbal/telephone orders were used infrequently and was not a common practice according to hospital policy as evidenced by the frequent use of verbal/telephone orders by the admitting physicians for 4 (#4, 7, 8, 13) of 4 (#4, 7, 8, 13) records reviewed for verbal/ telephone orders.

Findings:

A review of Patient #4's medical record revealed orders dated 10/29/2021 at 2:53 p.m. and 4:30 p.m. as telephone orders read back from S20NP and taken by S7IC.

A review of Patient #7's medical record revealed:
1) Orders dated 07/28/2021 at 5:00 p.m.as telephone order read back from S20NP and signed by S17RN.
2) Orders dated 08/03/2021 at 10:40 a.m., 12:37 p.m. and 3:12 p.m. written as telephone order read back from S20NP and taken by S23RN.
3) Orders dated 08/11/2021 at 6:00 p.m. written a telephone order read back from S20NP and signed by S17RN.

A review of Patient #8's medical record reveled:
1) Orders dated 08/06/2021 at 3:20 p.m. written a by S17RN as received from S20NP.
2) Orders dated 08/11/2021 at 7:59 p.m. written as a telephone order read back from S20NP written by S24LPN.
3) Order dated 08/13/2021 at 08:00 a.m. written as a telephone order read back x 2 from S20NP written by S16RN.

A review of Patient #13's medical records revealed orders dated 07/02/2021 at 2:00 p.m. written as telephone order read back from S20NP and written by S16RN.

In an interview on 11/10/2021 at 10:40 a.m.; S1Adm stated all orders are verbal; either in person or via phone and the MD comes to sign the orders. She also verified the above verbal orders.

Based on record review and interview the facility failed to ensure safe self-administration of home medications. This deficiency is evidenced by the failure of nursing staff to properly identify the home medication and failure to document the self- administration of home medications in the Medication Administration Record in 1 (#29) of 1(#29) patient allow to self-administer home medications.
Findings:

Review of the policy titled, "Medication Administration," revealed in part, "All medication administration will be documented in the Medication Administration Record (MAR)."

Review of the medical record of Patient #29 revealed an order dated 9/06/2021 at 6:50 p.m. by the licensed provider to allow the patient to self-administer all home medications except alprazolam from the patient's "medication dispense machine."
Review of the Medication Administration Record revealed no documentation that the medications were self-administered or the time they were administered.

In interview on 11/10/2021 at 1:02 p.m., S2DON verified the nurse should have watched the self-administration and documented the medication in the Medication Administration Record.

On 11/10/2021 at 1:30 p.m., S5CFO and S1Adm were asked for the medication self-administration policy. It was not produced for review by the time of exit.

In interview on 11/10/2021 at 2:25 p.m., S7IC revealed that the patient had a "HERO" dispenser and she verified the medications were brought from home and the medications were not inspected and accurately identified prior to allowing the patient to self-administer them. She was also asked to locate the medication self administration policy.

Based on record review and interview, the hospital failed to have medical record service appropriate for the scope and complexity of the services performed. This deficient was evidenced by the hospital failing to provide an accurate list of patients for admission and discharges in the last 6 months and an accurate list of transferred patients in the last 6 months. Findings:

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:00 a.m. She reported the medical record are hybrid, part paper medical record and part EHR. She further reported not everyone felt comfortable charting in the EHR.

A list of discharge and admitted patients were requested on entrance to the hospital on 11/08/2021 at 9:00 a.m. The list was provided to the surveyors on 11/09/2021.

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 1:00 p.m. She reported the list is not an all-inclusive list; the surveyor would need to compare the list to a handwritten list the nurses maintain.

Review of the list provided revealed Patient #29 was not on the admissions and discharge list for the last 6 months.

A list of transferred patients for the last 6 months were requested on entrance to the hospital on 11/08/2021 at 9:00 a.m. The list was provided on 11/10/2021 at 10:00 a.m. to the surveyor by S5CFO. He reported they had to review each medical records individually to obtain who had been transferred to another hospital, which is why it took so long to obtain the list.

Review of Patient #15 medical record revealed he was admitted on 5/06/2021 and transferred to another hospital on 05/31/2021 for hallucinations. Patient #15 was not listed on the patient admission and discharge list for the last 6 months or the transfer list of patients for the last 6 months.

An interview was conducted with S9EHR consultant on 11/10/2021 at 2:00 p.m. When requested to review Patient #11 (admit date10/22/2021) medical record in EHR, she reported she was unable to find a record for Patient #11 in the EHR.

An interview was conducted with S5CFO on 11/09/2021 at 10:00 a.m. He reported the medical records staff member had been out sick for the last 10 days.

Based on interview, the hospital failed to have a system in place to code and index medical records to allow for timely retrieval by diagnosis and procedure in order to support medical care evaluation studies. Findings:

An interview was conducted with S3MR/QAPI consultant on 11/09/2021 at 11:30 a.m. She reported she could not retrieve medical records by diagnosis and or procedure.

Based on record review, observation and interview, the hospital failed to ensure patients' paper medical records were stored in a secured area.
Findings:

Observations were conducted from 9:00 a.m. to 11:20 a.m. on 11/08/2021 of the medical records closet being unlocked. The medical records were stored in unlocked shelving in the closet.

S5CFO confirmed the observation on 11/08/2021 at 11:20 a.m.

Based on record review and interview, the hospital failed to ensure the ordering practitioner signed telephone/ verbal orders within 72 hours per hospital policy for 4 ( #4, 7, 8, 13) of 4 (#4, 7, 8, 13) records reviewed for signature by the ordering practitioner.

Findings:

A review of the hospital policy titled Nursing: Signing Verbal Orders reads in part:
All verbal orders will be signed within 72 hours of documentation in the patient's medical record.

A review of Patient #4's medical record revealed orders dated 10/29/2021 at 2:53 p.m. and 4:30 p.m. as telephone orders read back from S20NP and taken by S7IC but failed to reveal S2NP ever signed the orders.

A review of Patient #7's medical record revealed:
1) Orders dated 07/28/2021 at 5:00 p.m.as telephone order read back from S20NP and signed by S17RN, but not signed by S20NP.
2) Orders dated 08/03/2021 at 10:40 a.m., 12:37 p.m. and 3:12 p.m. written as telephone order read back from S20NP and taken by S23RN, but not signed by S20NP.
3) Orders dated 08/11/2021 at 6:00 p.m. written a telephone order read back from S20NP and signed by S17RN.

A review of Patient #8's medical record reveled:
1) Orders dated 08/06/2021 at 3:20 p.m. written a by S17RN as received from S20NP, but failed to reveal the orders were signed off by S20NP.
2) Orders dated 08/11/2021 at 7:59 p.m. written as a telephone order read back from S20NP written by S24LPN, but not signed by S20NP.
3) Order dated 08/13/2021 at 08:00 a.m. written as a telephone order read back x 2 from S20NP written by S16RN but not signed by S20NP.

A review of Patient #13's medical records revealed orders dated 07/02/2021 at 2:00 p.m. written as telephone order read back from S20NP and written by S16RN, but not signed by S20NP.

In an interview on 11/10/2021 at 10:40 a.m.; S1Adm stated all orders are verbal; either in person or via phone and the MD comes to sign the orders. She also verified the above unsigned verbal orders.


44495


Based on record review and interview, the hospital failed to ensure all hospital orders were signed by the physician or licensed practitioner. This deficiency is evidenced by 6 (#10, #14, #25, #26, #28, #29) of 6 (#10, #14, #25, #26, #28, #29) closed medical records reviewed for unsigned orders.
Findings:

Review of hospital policy titled, "Content of all Medical Records," revealed in part, " telephone orders of authorized practitioners to members of the nursing staff shall be accepted and written by a licensed nurse only; and such actions limited to urgent circumstances. All diagnostic and therapeutic verbal orders associated with any potential hazard to the patient, as determined by the medical staff, must be authenticated by the responsible practitioner within 24 hours."

Review of Medical Staff Rules and Regulations reveals in part, "All orders dictated by telephone shall be signed by the responsible practitioner within 72 hours."

Review of hospital policy titled, "Incomplete Medical Record Notification and Suspension," revealed in part "Medical records are to be completed within 30 days of discharge."

Patient #10
Review of the medical record of Patient revealed admission on 09/02/2021 and discharge on 09/28/2021.
Further review of the medical record revealed no of the telephone orders were signed.
Interview on 11/10/2021 at 3:25 p.m., S9RN verified no telephone orders were signed.

Patient #14
Review of the medical record of Patient #14 revealed admission on 06/28/2021 and discharge on 07/16/2021.
Further review of the medical record revealed no telephone orders were signed.
Interview on 11/10/2021 at 3:48 p.m., S9RN verified no telephone orders were signed.

Patient #25
Review of the medical record of Patient #25 revealed admission on 09/07/2021 and discharge on 09/23/2021.
Further review of the medical record revealed no telephone orders were signed.
Interview on 11/10/2021 at 1:12 p.m., S2DON verified the orders were not signed.

Patient #26
Review of the medical record of Patient #26 revealed admission on 09/06/2021 and discharge on 10/04/2021.
Further review of the medical record revealed no telephone orders were signed.
Interview on 11/10/2021 at 1:25 p.m., S2DON verified the orders were not signed.

Patient #28
Review of the medical record of Patient #28 revealed admission on 09/11/2021 and discharge on 10/09/2021.
Further review of the medical record revealed no telephone orders were signed.
Interview on 11/10/2021 at 1:32 p.m., S2DON verified the orders were not signed.

Patient #29
Review of the medical record of Patient #29 revealed admission on 09/06/2021 and discharge on 09/22/2021.
Further review of the medical record revealed no telephone orders were signed.
Interview on 11/10/2021 at 1:00 p.m., S2DON verified the orders were not signed.

Based on record reviews and interview, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating practitioner completed a discharge summary for 3 (#15, #16, #21) out 5 (#13, #15, #16, #17, #16, #21) EHR reviewed for discharge summaries. Findings:

Review of the medical staff rules and regulations revealed in part, staff members who fail to complete their patient's record within thirty (30) days of discharge shall voluntarily relinquish elective admitting and clinical privileges.

Review of Patient #15 EMR revealed no discharge summary was completed for the patient. The patient was discharged on 05/24/2021.

Review of Patient #16 EMR revealed no discharge summary was completed for the patient. The patient was discharged on 05/17/2021.

Review of Patient #21 revealed no discharge summary was completed for the patient. The patient was discharged on 05/31/2021.

The above EHR were navigated by S9EHR consultant. S9EHR confirmed the above patients did not have discharge summaries.

44495


Based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of the patients. This deficiency is evidenced by:
1) Failure to stock prescribed medication for 6 nonconsecutive days for 1( #25) of six (#10, #14, #25, #26, #28, and #29) closed patient records reviewed for medication shortages and for 1 (#4) patient out out of 6 (#1, #2, #3, #4, #5, #6, ) current records reviewed for medications shortages; and
2) Failure to stock glucometer strips needed to provide daily patient care affecting 1 (#26) of 3 (#25, #28, #29) patients reviewed for blood glucoses performed.
Findings:

1) Failure to stock prescribed medication for 6 nonconsecutive days for 1 (#25) of six (#10, #14, #25, #26, #28, and #29) closed patient records reviewed for medication shortages

Patient #25
Review of the medical record of Patient #25 revealed an order on 09/07/2021 at 6:00 p.m. for Novalog 30 units subcutaneous three times a day.

Review of the Medication Administration Record revealed Novalog was not available on 09/08/2021 at 5:24 a.m., 9/11/2021 at 5:36 a.m., 09/11/2021 at 11:16 a.m., 09/11/2021 at 3:40 p.m., 09/12/2021 at 5:00 a.m., 09/13/2021 at 5:30 a.m., 09/16/2021 at 5:30 a.m., and 09/17/2021 at 5:00 a.m. It was noted in the chart that they were waiting on pharmacy to deliver the medication.

Interview on 11/10/2021 at 1:10 p.m., DON indicated that she was not aware of the shortage, but was in orientation at that time.

Interview on 11/10/2021 at 1:50 p.m., S14Pharmacist stated that he had not had shortages of Novalog. He stated the nurses are responsible for ordering sufficient amounts.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 10/28/2021. Review of his medications order on admit to the hospital revealed Aricept 10 mg i by mouth daily 0800, Trileptal 150 mg tab (1/2 =75 mg) by mouth TID, and Advair 100-50 Diskus administer puff twice a day.

Review of the Medication Administration Record for Patient #4 revealed Aricept was not available 10/28/21, 10/29/21, 11/01/21, 11/02/21, 11/03/21. With further review of the Medication Administration Record revealed Advair 100-50 Diskus was not available on 10/28/21, 10/29/21,10/31/21 at 2000, 11/01/21, 11/02/21, and 11/03/21. Triliptal was documented as not available on 10/28/21 and on 11/03/21.

An interview was conducted with S14Pharmacist on 11/09/2021 at 12:00 p.m. He reported if the courier comes to the facility at 1:00 p.m. and the physician orders at medication at 2:00 p.m., the hospital will have to wait to the next time the courier comes to deliver the medication. When questioned specifically about Patient #4's medications, he reported sometimes the patients comes from other facilities and they don't send their medications and it is too early for insurance to cover the cost of that medication. He reported that was the issue with the Aricept. He further reported he provided stock for Trileptal because he knew that medication was important for the patient to continue.

An interview was conducted with S1Adm on 11/09/2021 at 1:00 p.m. She reported if a medication is not available the nurses can obtain prescriptions from Walgreens for the patient.


2) Failure to stock glucometer strips needed to provide daily patient care affecting 1 (#26) of 3 (#25, #28, #29) patients reviewed for blood glucoses performed.


Review of the medical record for Patient #26 revealed orders on 09/06/2021 at 6:30 p.m. for accuchecks AC and HS with sliding scale.

Review of the Medication Administration Record for Patient #26 revealed on 09/30/2021 at 7:03 p.m. and 10/01/2021 at 5:30 a.m. accuchecks were not preformed because there were no glucose test strips.

Interview on 11/10/2021 at 1:50 p.m., S14Pharmacist said he was not aware that they had run out of glucose testing strips on 09/30/2021. He stated that the nurses are responsible for ordering the glucose strips from him before they run out.

Based on interview the hospital failed to ensure drugs and biologicals not specifically prescribed as to time or number of doses must automatically be stopped after a reasonable
time that is predetermined by the medical staff.

Findings:

In an interview on 11/10/2021 at 1:35 p.m. S14Pharmacist stated he was not aware of any stop order time frames approved by medical staff.

In an interview on 11/10/2021 at 2:30 p.m. S1Adm stated she would have to check the hospital By-Laws and Medical Executive Committee meeting minutes to see if medical staff had predetermined stop orders. None were provided prior to exit.

Based on record review and interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records and reported to the attending physician as evidenced by the hospital failing to document medication errors for 2 (#4, 25) of 2 (#4, 25) patient's medical records reviewed for medication errors.

Findings:

A review of hospital policy titled Nursing: Reporting Medication Errors revealed in part:

A review of the Nursing Policy Reporting Medication Errors states in part:
Medication error reports shall be written for the following incidences.
1) Medication errors involving- wrong dose, route of administration, dosage form, time interval, or administering a medication to the wrong patient, as well as failing to administer a medication or administering extra doses.
2) All omissions of scheduled medications without reason for omissions.
3) All medication errors shall be reported immediately to the attending physician and the pharmacist.

Copies of the Medication Variance Report form are sent to the Director of Nursing.
1) All medication variance reports are reviewed at the next Pharmacy and Therapeutics Committee Meeting.
2) .... Medication errors will be documented in the patients' medical record.

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 10/28/2021. Review of his medications order on admit to the hospital revealed Aricept 10 mg i by mouth daily 0800, Trileptal 150 mg tab (1/2 =75 mg) by mouth TID, and Advair 100-50 Diskus administer puff twice a day.

Review of the Medication Administration Record for Patient #4 revealed Aricept was not available 10/28/21, 10/29/21, 11/01/21, 11/02/21, 11/03/21. With further review of the Medication Administration Record revealed Advair 100-50 Diskus was not available on 10/28/21, 10/29/21,10/31/21 at 2000, 11/01/21, 11/02/21, and 11/03/21. Triliptal was documented as not available on 10/28/21 and on 11/03/21.

An interview was conducted with S14Pharmacist on 11/09/2021 at 12:00 p.m. He reported if the courier comes to the facility at 1:00 p.m. and the physician orders at medication at 2:00 p.m., the hospital will have to wait to the next time the courier comes to deliver the medication. When questioned specifically about Patient #4's medications, he reported sometimes the patients comes from other facilities and they don't send their medications and it is too early for insurance to cover the cost of that medication. He reported that was the issue with the Aricept. He further reported he provided stock for Trileptal because he knew that medication was important for the patient to continue.

Patient #25
Review of the medical record of Patient #25 revealed an order on 09/07/2021 at 6:00 p.m. for Novalog 30 units subcutaneous three times a day.

Review of the Medication Administration Record revealed Novalog was not available on 09/08/2021 at 5:24 a.m., 9/11/2021 at 5:36 a.m., 09/11/2021 at 11:16 a.m., 09/11/2021 at 3:40 p.m., 09/12/2021 at 5:00 a.m., 09/13/2021 at 5:30 a.m., 09/16/2021 at 5:30 a.m., and 09/17/2021 at 5:00 a.m. It was noted in the chart that they were waiting on pharmacy to deliver the medication.

Interview on 11/10/2021 at 1:10 p.m., S2DON indicated that she was not aware of the shortage, but was in orientation at that time.

Interview on 11/10/2021 at 1:50 p.m., S14Pharmacist stated that he had not had shortages of Novalog. He stated the nurses are responsible for ordering sufficient amounts.


An interview was conducted with S1Adm on 11/09/2021 at 1:00 p.m. She reported if a medication is not available the nurses can obtain prescriptions from Walgreens for the patient.

In an interview on 11/10/2021 at 11:30 a.m., S2DON stated she was not aware of medication adverse events, errors or variances that have been documented or tracked and forwarded to the physician, pharmacy or the quality department.

In an interview on 11/10/2021 at 11:35 p.m., S1Adm stated she was aware of a policy for medication errors and a form to be completed for medication variance but could not locate any organized documentation as such.

Based on interviews, the hospital failed to ensure a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs.

Findings:

In an interview on 11/10/2021 at 1:45 p.m. S14Pharmacist stated he was not aware of a formulary.

In an interview on 11/10/2021 at 2:20 p.m. S2DON stated she was not aware of any formulary approved by the medical staff.

Based on record review and interview, the hospital failed to have a written description of services defining routine and stat labs. Findings:

Review of the policy provided by S5CFO on 11/09/2021 at 3:30 p.m. revealed no definition or explanation of stat and routine laboratory test.

In an interview with S5CFO on 11/09/2021 at 3:30 p.m., he confirmed there was no definition or explanation of stat and routine lab procedures in the policy.

Based on record review and interview, the hospital failed to ensure that the director of food and dietetic services ensured the daily management of dietary services as evidenced by failing to provide safe food handling policies and procedures.

Findings:

Safe food handling policies and procedures were not provided upon multiple requests.

Interview on 11/09/2021 at 1:27 p.m. S1Adm stated the CNAs (certified nurse aids) check the temperature of the food and then serve the meals. S1Adm did not provide safe food handling policies and procedures upon multiple requests.

Based on record review and interview, the hospital failed to have a therapeutic dietary manual as evidenced by not having a therapeutic diet manual readily available to all medical, nursing and food service personnel.

Findings:
A therapeutic diet manual was not provided upon multiple requests.

In an interview on 11/09/2021 at 1:27 p.m. S1Adm stated the registered dietitian has the therapeutic diet manual. When asked if there is a therapeutic dietary manual onsite, S1Adm confirmed she cannot find a therapeutic dietary manual.

Based on interview, the hospital failed to ensure the Utilization Review committee consisted of at least two doctors of medicine or osteopathy who do not have a direct financial interest in the hospital or was professionally involved in the care of the patient whose case was being reviewed. Findings:

An interview was conducted with S1Adm on 11/09/2021 at 2:10 p.m. She reported the Utilization Review committee consisted of S11Medical Director and S22PA. S1Adm confirmed these providers were the physician and PA that provided care to the patients in the hospital.

44763

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

The following observations were conducted on 11/08/2021:

Room a
Observation of Room a revealed the door to enter the room was splintered. There was a ceiling tile cracked. The sheetrock was separated from door frame on the right side. The bathroom in Room a revealed the paint on the wall behind the sink was bubbling. The toilet had appeared to be leaking due to a towel on floor next to toilet.

Room b
Observation of Room b revealed a broken outlet cover over an electric outlet by the patient's bed. The window was open and there was no window screen on the window.

Room d
An observation of Room d revealed a bowing ceiling tile and missing towel rack bar in the bathroom. There were numerous holes in the bathroom wall where previous grab bars and towel racks were located and moved. Paint was missing and peeling in the bathroom near the light fixture. Chair railing was missing in sections in the bathroom.

Room e
Observation of Room e revealed the over bed lights not working. A mini-blind in the window with 10 slacks broken. One floor tile broken in two spots. There were no screens on the window. The bathroom in Room e revealed the right side of the handrail was not secure.

Room g
Observation of Room g revealed the overhead lights in room did not work. The over bed lights did not work. There was a strip of insulation taped to the floor under the AC unit. The bathroom of Room g revealed a strip of insulation taped to floor under the sink. There was a stain that appeared to be a water stain on the ceiling tile. The sink faucet was not attached to the sink. There was paint bubbling on the wall behind the toilet.

Room h
Observation of Room h revealed a strip of insulation taped to floor under the AC unit. The over bed lights did not work. There was a mini-blind in the window with eight slacks broken. The bathroom of Room h revealed a strip of insulation taped to the floor under the sink. A water stain on the wall under the sink with water line visible on the wall.

Room i
Observation of Room i revealed a bedroom wall that was wavy. One over bed light did not have a cord to turn the light on with and the other over bed light did not work. An electrically outlet was missing a cover.

Room j
Observation of Room j revealed the over bed lights did not work. There was a strip of insulation taped to floor under the AC unit. The bathroom of Room j revealed a strip of insulation taped to floor under the sink.

Room k
Observation of Room k revealed the over bed lights did not work. The television cable wall plate is hanging off the wall not secured. The bathroom of Room k revealed two ceiling tiles with stains that appear to be water stains.

Room l
Observation of Room l revealed the over bed lights did not work. Part of the paneling wall on the left side of the room was not secured to the wall. The rubber of the bed tire was falling apart. The bathroom of Room l revealed a strip of insulation taped to floor under the sink.

Room m
Observation of Room m revealed a hole in the wall above the bed. The over bed lights did not work. There was an electrical wall plate missing. There were three ceiling tiles with stains that appeared to be water stains with one of them bulging.

Shower Room
Observation of the Shower Room revealed the door to toilet room was splintered and buckling. In shower #1, there were five missing wall tiles and one handrail was broken.

Rehab room
The back door to the rehab room had a crack in the glass door.

In an interview on 11/08/2021 S5CFO confirmed the above stated findings.

In an observation on 11/09/2021 at 3:38 p.m. of the laundry room S1Adm and S5CFO confirmed the following findings. The laundry room was located in a metal shed behind the facility. A black substance on majority of the ceiling tiles. The washing machine was plugged into an extension cord with standing water surrounding the backside of the washing machine. The water was approximately 6 inches away from where the plug on the extension cord was pushed under the washing machine. The same extension cord that the washing machine was plugged into was stretched approximately 15-20 feet from the washing machine to plug into the wall outlet. The right wall of laundry room had sheetrock and insulation missing which was sitting on the floor in large puddles of water, some insulation still between studs (the sheetrock was missing so the insulation and studs to the wall were exposed). The window frame above this section of the wall was buckling and falling out of place. There were no working lights throughout entire laundry room. There was a sink with a vanity (in which the sink sits in) was falling apart.

Based on record review and interview, the hospital failed to ensure the temperature of the patients' nourishment refrigerator was monitored to ensure safety.

Findings:

Review on 11/07/2021 at 11:30 a.m. of the hospital's Food Refrigerator Monitoring logs for October and November 2021 revealed temperatures had not been recorded since October 26th. The log also had instructions to place a check mark to indicate weekly cleaning. The log had not been checked indicating the refrigerator had been cleaned since October 18th.

In an interview on 11/07/2021 at 11:35 a.m. with S1Adm, she verified the Food refrigeration monitoring logs were not current.

44763


Based interview, the hospital failed to ensure a person qualified by education, experience and competency in infection control practices was designated as the infection control officer in the hospital. The deficient practice is evidenced by failure to have evidence of education and prior experience for the current infection control officer.
Findings:

An interview was conducted with S7IC on 11/10/2021 at 11:40 a.m. She reported she was the current infection control officer in the hospital. S24Former IC no longer works at the hospital. S7IC reported she works 2-3 days a week and she has no training or experience in infection control. S7IC also reported she had no documented evidence of the infection control program.

An interview was conducted with S10IC Consultant on 11/10/2021 at 12:31 p.m. She reported she has come onsite to the hospital on the following dates: June 1, 2021, July 27, 2021 and September 20, 2021. S10IC Consultant reported she had sent pictures of the infection control violations to S24Former IC. When questioned if she knew that S24Former IC was no longer employed at the hospital and she was no longer the infection control officer, she reported she did not know. S10IC Consultant further reported she had not provided training to S7IC as the infection control officer.

44763

Based on record review, observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital
1. failing to maintain a sanitary environment.
2. failing to implement procedures for screening staff and visitors for Covid
3. failing to develop emergency staffing procedures during the Covid pandemic.
Findings:

1. failing to maintain a sanitary environment
Review of the hospital's policy titled, Policy and Procedure: Infection Control, revealed in part, the facility is monitored for cleanliness routinely. The facility employs housekeeping staff that is trained on infection control practices.

Review of the hospital's policy titled, Environmental Services, revealed in part, all areas are cleaned all over, from the walls, beds, mattresses, trash cans, televisions, remotes, etc. the room is not to be utilized until the next patient is admitted to the room. When the staff has designated a room for patient admission, the room will be inspected for the need to be reclined or not.
Clean items are stored and kept covered in a dust proof protection.

The following observations were conducted on 11/08/2021:

Room a
Observation of Room a revealed no paper towels at the sink. There were dead bugs in the windowsill. There were stains, holes, and debris noted to the blanket on the bed.

Room b:
Observation of Room b revealed a rusty pipe from the wall to the toilet.

Room d;
Observation of Room d revealed a dead fly on the windowsill, a bedside table with chipped paint which had exposed wood (unable to be disinfected) and a yellow substance dripped in the sink. There was no paper towels available in the bathroom.


Room e
Observation of the bathroom in Room e revealed six floor tiles separated leaving gaps that could not be disinfected.

Room g
Observation of the bathroom in Room g revealed no soap, paper towels, or toilet paper in bathroom.

Room h
Observation of Room h revealed a bedside table that had missing laminate on the top of the table that could not be disinfected. The footboard of the bed was missing approximately 1 ½ inches of laminate trim board that could not be disinfected. Observation of the bathroom of Room h revealed a roll of paper towels was placed on top of the back of the toilet. There was no soap at the bathroom sink.

Room i:
Observation of room i revealed dead bugs in the overhead light fixtures. There was trash and debris on the floor. A positional wedge was on the floor under the bedroom sink. The bathroom had two ceiling tiles over the toilet saturated, sagging and bulging with a damp black substance.

Room j
Observation of Room j revealed no paper towels at the sink.

Room k
Observation of Room k revealed no paper towels and soap at the sink. The right side handrail to the bed was rusted and could not be disinfected. Approximately 5 inches of the laminate on the headboard of the bed was missing and could not be disinfected.

Room l
Observation of Room l revealed an opened razor left on the sink and a "No BP on left arm" sign above the bed. An opened bottle of shampoo/body wash was on top of paper towel dispenser. There were no paper towels at the sink.
Observation of the bathroom in Room l revealed a roll of paper towels and a roll of toilet paper propped on the handrail by the toilet and were not in dispensers. There was a washbasin on the floor and a cup on the bathroom sink. A patient did not occupy this room.

Room m
Observation of Room m revealed a blanket on the bed had stains and there were holes in the sheets. There was an opened bottle of shampoo/body wash on the sink. There were no paper towels at the sink.
Observation of the bathroom of Room m revealed an opened package of wet wipes. There was a roll of paper towels sitting on top of paper towel dispenser with the paper towel dispenser empty. There was a washbasin propped on the handrail by the toilet with a balled up rubber glove, balled up paper towel, and grapes in the washbasin. There were rolls of toilet paper sitting on the handrail by the toilet and on top of the toilet paper dispenser.

Equipment/Supply Room
There were multiple items of equipment not labeled clean or dirty and did not have a bag covering the equipment. There was an IV pump and a wedge on the floor. There was an IV pole with tape wrapped around it that could not be disinfected.

Shower Room
Observation of the Shower Room revealed the door frame to shower room was rusted. There was no soap or paper towels in the toilet room.

Hallway
5 of 5 hand sanitizer dispensers were empty. There were dead bugs in the light fixtures in the hallway.

Rehab room
An observation was conducted of the rehab room. Rust was noted on side chair, which could not be disinfected.
There was adhesive on the floor with black substance stuck to the adhesive and debris on the floor.

The patients' medical record binders had black substance stuck to the old adhesive on all the patient medical record binders.

In an interview on 11/08/2021 S5CFO confirmed the above stated findings.

In an interview on 11/10/2021 S7IC verified the last patient that occupied room l was discharged on 11/05/2021. S7IC stated she was the nurse who discharged the patient.

In an observation on 11/09/2021 at 3:38 p.m. of the laundry room S1Adm and S5CFO confirmed the following findings. There is general clutter throughout the entire laundry area. There was a washing machine that does not work. There was a table with clothes on top of it that could not be determined clean or dirty. There was a brown substance covering the entire floor surface. There was standing water along the right wall of the laundry area. When the bottom of the dryer was opened, there was a layer of lint approximately 2 inches thick that had not been cleaned.

In an observation and interview on 11/09/2021 at 3:38 p.m., S8CNA stated dirty gowns and bed linens were gathered in each patient's room and placed in a red colored laundry basket. The dirty gowns and bed linens were then brought to the laundry room and placed in washing machine and washed. S8CNA was observed taking the washed clean clothes out of the washing machine and placed the gowns and bed linens in the same red colored laundry basket that she stated she brought them into the laundry room when they were dirty. She was then observed putting the gowns and bed linens into the dryer and turned the dryer on.

During the observation of the laundry room, S1Adm stated the hospital uses a contracted service for cleaning linens in addition to the CNA (certified nurse aid) cleaning linens onsite. Numerous requests were made for the contract of the contracted linen service and was not provided by the hospital.

In an interview on 11/10/2021 at 12:31 p.m., S10IC Consultant stated the laundry area is "disgusting and should not be used". She stated she advised the hospital to get a contract for laundry service until the building could be fixed.


2. failing to implement procedures for screening staff and visitors for Covid

Observations were conducted from 11/08/2021, 11/09/2021 and 11/10/2021 of the surveyors not being screened or questioned about their symptoms or exposure to Covid prior to or after entrance to the hospital.

An interview was conducted with S7IC on 11/10/21 at 11:40 a.m. She reported the staff and visitors are not screened/questioned about their symptoms or exposure to Covid.


3 failing to develop an emergency staffing procedure during the Covid pandemic

Review of the Covid policies presented to the surveyor by the hospital as the hospital policies related to Covid revealed no policy related to an emergency staffing plan. The emergency staffing plan would address a procedure to implement if there was staffing shortages due to staff contracting or becoming exposed to Covid.

An interview was conducted with S7IC on 11/10/2021 at 11:40 a.m. She reported the hospital did not have an emergency staffing plan to implement if there was staffing shortages due to staff contracting or being exposed to Covid.

44763


Based on record review and interview, the Infection Control Officer failed to document infection surveillance, prevention and control activities. This deficient practice is evidenced by failing to show any evidence of ongoing activities of tracking and trending infections, handwashing surveillance, and environmental rounds.
Findings:

The hospital failed to provide any evidence of ongoing infection control surveillance, prevention, and control activities upon request.

In an interview on 11/10/2021 at 11:40 a.m., S7IC confirmed she had no documented evidence of infection control activity. This included tracking and trending infections, environmental rounds and handwashing surveillance.

Based on record review and interview, the hospital failed to maintain documented evidence of training for nursing personnel assigned to perform specific respiratory procedures. This deficient practice was evidenced by failure of the hospital to maintain documented evidence of respiratory service training for 5 of 5 (S4LPN, S15RN, S16RN, S17RN, S18LPN) nursing personnel records reviewed.
Findings:

Review of hospital policy titled, "Respiratory Therapy General" revealed in part, the nursing staff will perform respiratory therapy within the scope and practice of their training. These services are provided according to the needs of the patients as prescribed by the physician in accordance with acceptable standards of practice.

Review of the personnel records for S4LPN, S15RN, S16RN, S17RN, and S18LPN revealed no documented evidence of respiratory service training.

An interview was conducted with S21HR on 11/10/2021 at 2:00 p.m. She reported the competencies should had been in the nurses and CNA's personnel record.

Numerous requests were made from S1Adm and S2DON on 11/10/2021 for the nurses's and CNAs' competencies and no documentation was provided.

Based on interviews the hospital failed to maintain a list of HHA's, SNF's, IRF's, or LTCH's that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient.

Findings:

In an interview on 11/10/2021 at 10:10 a.m. S2DON stated she is not aware of any list of HHA's, SNF's, IRF's, or LTCH's that are participating in the Medicare program that exist to be given to the patient or guardian to select from as part of the patient's discharge planning.