Survey Report for 391736

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	391736	A. BUILDING __________ B. WING ______________	01/26/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HERITAGE HOSPICE, LLC	2400 LEECHBURG ROAD, NEW KENSINGTON, PA, 15068
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
E0006
E0006	37775 Based upon review of facility Emergency Preparedness Plan and staff interview (EMP), it was determined agency failed to establish, maintain and review an emergency preparedness plan to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings included: Review of facility Emergency Preparedness Plan policy and procedures conducted on 1/26/2021 at approximately 12:50 PM revealed the following: There was not documented evidence of a facility-based and community-based risk assessment, utilizing an all-hazards approach. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
E0019
E0019	37775 Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview, it was determined the facility failed to ensure procedures were included in the EPP that informed State and local emergency preparedness officials about homebound patients in need of evacuation from their residence based on patients medical and psychiatric conditions and home environments. Findings Included: Review of facility Emergency Preparedness Plan policy and procedures conducted on 1/26/2021 at approximately 12:50 PM revealed the following: There was not documented evidence of a facility procedure to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residence based on patients medical and psychiatric conditions and home environments. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
E0039
E0039	37775 Based upon review of facility Emergency Preparedness Plan and staff interview (EMP), the facility failed to ensure exercises were conducted annually in 2018 and 2019. Findings included: Review of facility Emergency Preparedness Plan policy and procedures conducted on 1/26/2021 at approximately 12:50 PM revealed the following: There was not documented evidence of facility exercises (participation in a full scale exercise, facility based exercise, emergency event, or tabletop exercise) conducted in 2018 and 2019. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
L0546
L0546	37775 Based on a review of agency policies, clinical records (CRs), and staff interview (EMP), the agency failed to ensure that the individualized written plan of care included interventions for symptom management and/or medical conditions for six (6) of seven (7) clinical records reviewed with completed written plans of care (CR1,CR2, CR4 - CR7). Findings Included: Review of facility policies on 1/26/2021 at approximately 1:15 PM revealed: "...Patient care Policies...PC.P55...PLAN OF CARE - CONTENT...Policy: The plan of care specifies the...care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment...Procedure:..2. The hospice must develop an individualized written plan of care...must reflect...interventions based on the problems identified in the initial...and updated comprehensive assessments...must include all services necessary...including the following:..b...identification of services to be provided including management of discomfort and symptom relief...e. Interventions to manage pain and symptoms..." "...Patient Care Policies...PC.P50 PLAN OF CARE...Procedure...6. The...interdisciplinary plan of care is developed and individualized...based upon problems identified in the initial/updated assessments...10. A revised plan of care must include information from the patient's updated comprehensive assessment..." Review of CR1 at approximately 1:30 PM on 1/21/2021 and completed on 1/22/2021 revealed election of hospice benefit 7/2/2018. Review of three certification periods for CR1 revealed the following: CR1, 2/22/2019, SN (Skilled Nursing) visit, " Type of visit: Comprehensive ...Medical History: Dementia, Heart Disease ... General ...Heart Disease ...Marked limitation of physical activity ...c. history of unexplained syncope ...Neurological ...Mental Status: Confused-continuously ...Genitourinary ...Voiding Method: Incontinent...Musculoskeletal ...Mobility: Needs assistance of others to transfer ...to ambulate ...Gait unsteady/unsafe ...Fall Risk Assessment Tool ...A score of 4 or more is considered at risk for falling ...Score: 7 ... " CR1 Plan of Care (POC) certification period 2/27/2019 to 4/27/2019, "... Functional limitations ...Bowel/Bladder (Incontinence), Endurance, Ambulation ...Treatments ...SN...Assess/Instruct Patient/Patient Caregiver in cardiac disease process and management of symptoms ... " There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to cardiac disease processes and dementia disease process (mental status), specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. CR1, 4/22/2019, SN visit, " Type of visit: Comprehensive ...Medical History: CHF, Dementia ... General ...Heart Disease ...Marked limitation of physical activity ...Neurological ...Mental Status: Dementia, Lethargic ...Gastrointestinal Assessment: Constipation, Bowel Sounds Hypo-active ...Genitourinary ...Voiding Method: Incontinent...Musculoskeletal ...Mobility: Needs assistance of others to transfer, Requires use of assistive device, Poor endurance ...Fall Risk Assessment Tool ...A score of 4 or more is considered at risk for falling ...Score: 9 ... " CR1 POC certification period 4/28/2019 to 6/26/2019, "...Functional limitations ...Bowel/Bladder (Incontinence), Endurance, Ambulation ...Treatments ...SN...Assess/Instruct Patient/Patient Caregiver in cardiac disease process and management of symptoms ... " There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to cardiac disease processes and dementia disease process (mental status), specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, specific interventions to assess, manage symptoms, and provide instruction on constipation, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. CR1, 6/20/2019, SN visit, " Type of visit: Comprehensive ...Medical History: Dementia, Hypertension ... General ...Heart Disease ...Marked limitation of physical activity ...Neurological ...Mental Status: Confused - Intermittently, Dementia, Flat, Lethargic ...Gastrointestinal Assessment: Constipation, Bowel Sounds - Present ...Genitourinary ...Voiding Method: Incontinent...Musculoskeletal ...Mobility: Needs assistance of others to transfer, Requires use of assistive device, Gait unsteady/unsafe Poor endurance...Fall Risk Assessment Tool ...A score of 4 or more is considered at risk for falling ...Score: 7 ... " CR1 POC certification period 6/27/2019 to 8/2/2019, " Functional limitations ...Bowel/Bladder (Incontinence), Endurance, Ambulation ...Treatments ...SN...Assess/Instruct Patient/Patient Caregiver in cardiac disease process and management of symptoms ... " There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to cardiac disease processes and dementia disease process (mental status), specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, specific interventions to assess, manage symptoms, and provide instruction on constipation, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. Review of CR2 at approximately 9:30 AM on 1/25/2021 revealed election of hospice benefit 10/18/2019. Review of certification period 12/11/2020 to 2/8/2021 revealed the following: CR2 12/10/2020, SN visit, "...Type of visit: Comprehensive...Medical history: Cancer,,,Emphysema...Heart Disease...Gastrointestinal Assessment: Constipation...Musculoskeletal...Mobility: Gait unsteady/unsafe...General safety...Functional factors of concern: Ambulation, Transfer, Unwilling to use assistive devices...Fall Risk Assessment: A score of 4 or more is considered at risk for falling...Score Total 4..." CR2, POC certification period 12/11/2020 to 2/8/2021, "...Diagnosis: malignant neoplasm...right lung...Functional Limitations...Endurance...Dyspnea with minimal exertion...Treatments...SN...Assess/Instruct Patient Family in disease process/progression and management of symptoms...Assess for impaction, remove impaction if present/follow up with fleet enema..." There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to malignant neoplasm of right lung and associated dyspnea, specific interventions to assess, manage symptoms, and provide instruction on constipation, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. Review of CR4 at approximately 12:10 PM on 1/25/2021 revealed election of hospice benefit 11/17/2020. Review of certification period 11/18/2020 to 2/15/2021 revealed the following: CR4, SN visit 11/18/2020, "...Type of visit: Comprehensive...Medical history:..CHF (congestive heart failure)...Diabetes...Heart disease...Tachycardia-Bradycardia syndrome...Ischemic Cardiomyopathy...Dyspnea Screening: Dyspnea when walking...Gastrointestinal Assessment: Constipation, Incontinence...Detailed Skin Assessment: Braden Scale...(Braden Scale) Total Score: Total Score 18 (AT RISK)...Genitourinary Voiding Method: Toilet, incontinent...Metabolic Symptoms: Yes-Hyperglycemia...Diabetes Detail: Document Diabetes...Fall Risk Assessment: A score of 4 or more is considered at risk for falling...Score Total 5..." CR4, POC certification period 11/18/2020 to 2/15/2021, "...Diagnosis: Ischemic Cardiomyopathy...Type 2 Diabetes...Slow transit constipation...Functional Limitations: Bowel/Bladder (Incontinence)...Endurance...Ambulation...Dyspnea with minimal exertion...Treatments...SN...Assess/Instruct Patient/Patient Caregiver in cardiac disease process and management of symptoms..." There was no documented evidence in the plan of care (POC) that identified specific individualized SN interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to cardiac disease processes and associated dyspnea, specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, specific interventions to assess, manage symptoms, and provide instruction on constipation, specific interventions to assess, manage symptoms, and provide instruction for Diabetes, specific interventions to assess, monitor, and provide instruction for skin breakdown risk of patient, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. Review of CR5 at approximately 12:45 PM on 1/25/2021 revealed election of hospice benefit 10/30/2020. Review of certification period 10/31/2020 to 1/28/2021 revealed the following: CR5, SN visit 10/31/2020, "...Type of visit: Comprehensive...Gastrointestinal Assessment: Constipation...Genitourinary: Voiding Method: Incontinent...Musculoskeletal...Mobility: Needs assistance of others to transfer, Requires use of assistive device...Pain Screening: Patient has pain, patient needs ongoing education and reinforcement of pain regimen...Fall Risk Assessment: A score of 4 or more is considered at risk for falling...Score Total 8..." CR5, POC certification period 10/31/2020 to 1/28/2021, "...Diagnosis: Alzheimer ' s disease...Functional Limitations: Bowel/Bladder (Incontinence)...Treatments...SN...Assess/Instruct Patient Family in disease process/progression and management of symptoms..." There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to Alzheimer ' s disease processes, specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, specific interventions to manage symptoms and provide instruction for pain management, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. Review of CR6 at approximately 10:00 AM on 1/26/2021 revealed election of hospice benefit 11/20/2020. Review of certification period 11/20/2020 to 1/18/2021 revealed the following: CR6, SN visit 11/11/2020, "...Type of visit: Comprehensive...Mental Status: Confused - Continually, Dementia, Lethargic...Gastrointestinal Assessment: Incontinence...Genitourinary: Voiding Method: Incontinent...Musculoskeletal...Mobility: Bedbound...Pain Screening: Pain is well controlled...Pain Active Problem: Yes...Fall Risk Assessment: A score of 4 or more is considered at risk for falling...Score Total 8..." CR6, POC certification period 11/20/2020 to 1/18/2021, "...Diagnosis: Alzheimer ' s disease...Functional Limitations: Endurance...Total Assist bed to...wheelchair by Hoyer...Treatments...SN...Assess location, intensity, duration, frequency, precipitating factors, and character of pain..." There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to Alzheimer ' s disease processes, specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence, specific interventions to manage symptoms and provide instruction for pain management, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. Review of CR7 at approximately 10:40 AM on 1/26/2021 revealed election of hospice benefit 11/8/2020. Review of certification period 11/8/2020 to 2/5/2021 revealed the following: CR7, SN visit 11/8/2020, "...Type of visit: Comprehensive...Respiratory: Oxygen support...Other Medication, Oxygen...Tracheostomy...Gastrointestinal Assessment: Gastrostomy...PEG (percutaneous endoscopic gastrostomy-feeding tube placed through abdomen)...Detailed Skin Assessment: Braden Scale...(Braden Scale) Total Score: Total Score 17 (AT RISK)...Musculoskeletal...Mobility: Gait unsteady/unsafe...Nutritional Assessment: Nothing by mouth...Tube feedings...Nutritional education...Pain Screening: Pain is well controlled...Pain Active Problem: Yes...Fall Risk Assessment: A score of 4 or more is considered at risk for falling...Score Total 6..." CR7, POC certification period 11/8/2020 to 2/5/2021, "...Diagnosis: Malignant neoplasm of Larynx...Functional Limitations: Bowel/Bladder (Incontinence)...Speech...Dyspnea...Treatments...SN...Assess/Instruct Patient Family in disease process/progression and management of symptoms..." There was no documented evidence in the plan of care (POC) that identified specific SN individualized interventions/specified treatments based on symptoms and/or medical conditions identified in the comprehensive assessment that included but was not limited to: Specific interventions to assess, manage symptoms, and provide instruction related to malignant neoplasm of larynx and associated tracheostomy, specific interventions to assess, manage symptoms, and provide instruction on gastrostomy-PEG tube and associated nutrition needs, specific interventions to manage symptoms and provide instruction for pain management, specific interventions to assess, monitor, and provide instruction for skin breakdown risk of patient, and specific interventions to assess, monitor, and provide instruction related to fall risk of patient. There were no specific interventions to assess, manage symptoms, and provide instruction on bowel/bladder incontinence as identified under POC "Functional limitations". An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
L0549
L0549	37775 Based on a review of facility job description, agency policies, clinical record (CR), staff (EMP) interviews, it was determined the facility failed to ensure that the individualized written plan of care included medications treatments necessary to meet the needs of the patient for one (1) of seven (7) clinical records reviewed with completed written plan of care (CR7). Findings Included: Review of facility policies on 1/26/2021 at approximately 1:15 PM revealed: "...Patient care Policies...PC.P55...PLAN OF CARE - CONTENT...Policy: The plan of care specifies the...care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment...Procedure:..2. The hospice must develop an individualized written plan of care...must reflect...interventions based on the problems identified in the initial...and updated comprehensive assessments...must include all services necessary...including the following:..b...identification of services to be provided including management of discomfort and symptom relief...h. Drugs and treatments necessary to meet the needs of the patient..." "...Patient Care Policies...PC.P50 PLAN OF CARE...Procedure...6. The...interdisciplinary plan of care is developed and individualized...based upon problems identified in the initial/updated assessments...including the following:..h. Treatments, drugs, biologicals...including dosage/frequency/route...10. A revised plan of care must include information from the patient's updated comprehensive assessment..." Review of CR7 at approximately 10:40 AM on 1/26/2021 revealed election of hospice benefit 11/8/2020. Review of certification period 11/8/2020 to 2/5/2021 revealed the following: CR7, SN visit 11/8/2020, "...Type of visit: Comprehensive...Respiratory: Oxygen support...Other Medication, Oxygen...Tracheostomy...Gastrointestinal Assessment: Gastrostomy...PEG (percutaneous endoscopic gastrostomy-feeding tube placed through abdomen)...Nutritional Assessment: Nothing by mouth...Tube feedings...Nutritional education..." CR7, POC certification period 11/8/2020 to 2/5/2021, "Medications...Terazosin...By Mouth Capsule 2 mg (milligram) at bedtime PO (by mouth)...Sennosides By Mouth 8.6 mg 1 Tablet at bedtime Gastrostomy tube...Melatonin By Mouth 3 mg Tablet at bedtime Gastrostomy tube...Diltiazem By Mouth 30 mg Tablet, 90 mg every 6 hours Gastrostomy tube...Docusate Sodium By Mouth Liquid...100 milligram every AM Gastrostomy tube...Acetaminophen By Mouth Suspension...640 Milligram every 6 hours Gastrostomy tube...Oxycodone By Mouth Solution...5 milligram every 6 hours Gastrostomy tube...Lorazepam By Mouth 125 mg Tablet every hour Gastrostomy tube...Levsin By Mouth 0.125 mg Tablet every 4 hours SL (Sublingual)...Haloperidol Lactate By Mouth Concentrate...1 milligram every hour Gastrostomy tube..." The above listed medications did not specifically disseminate the patient route of administration (By mouth, Gastrostomy tube) and whether patient was specifically to have "Nothing by mouth" as identified in comprehensive assessment. POC medication list also did not document "Oxygen" (dose, route, time) as was identified in comprehensive assessment. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
L0579
L0579	37775 Based on review of hospice policy, facility tour observation, and staff interview, the facility failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in accordance with facility policy of disposal of needles, syringes and sharp items. Findings included: Review of facility policies on 1/26/2021 at approximately 1:15 PM revealed: " Infection Control Policies...5.25 DISPOSAL OF NEEDLES, SYRINGES AND SHARP ITEMS...5.26 HAZARDOUS WASTE DISPOSAL...3. Medical Wastes will be stored in the agency in a secured (locked) area that has proper bio hazard labeling. 4. The Agency will properly and safely dispose of or arrange for disposal of all hazardous waste to protect health care personnel...and the environment from unnecessary exposure..." During a facility tour with clinical manager (EMP4) on 1/21/2021 at approximately 12:30 PM, Sureyor1 and Surveyor2 observed the following: EMP4 opened door (unlocked) to janitorial closet in facility hallway. Surveyor1 and Surveyor2 observed two red sharps containers in closet; Surveyors observed one red 8 quart BD container with clear lid on top sitting on a box with used syringes filled to the top of container, approximately 3 - 4 inches above marked container fill line, with lid opened. Surveyors observed second 1 quart red Mckesson sharps container with clear lid laying on floor sideways filled to the top of the container with used syringes, approximately 2 inches above marked fill line, with lid open. EMP4 confirmed facility did not have a dedicated locked space for biohazard waste and that observed sharps containers were over filled and not secured. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.
L0782
L0782	37775 Based on a review of facility policy, facility documentation, and staff (EMP) interview, it was determined the facility staff failed to assure hospice philosophy orientation was provided to skilled nursing facility staff furnishing care to facility hospice patients with which the facility had established service agreements (contracts). Findings included: Review of facility policies on 1/26/2021 at approximately 1:15 PM revealed: "...Patient Care Policies...PC.C85 CONTRACTED SERVICES...Procedure: 1. Written service contracts with individuals and/or other entities are signed and dated by authorized principals of each party and are reviewed annually. the executed document stipulates the terms of the contract which include:..q. Documentation of training and professional qualifications may be maintained by the Hospice or by the contracted organization. If maintained by the contracted organization, verification by the agency will occur at least annually 2. Documentation will be maintained by the contracted organization or the agency for at least the following items: a. Successful completion of an approved training course b. Demonstration of skills competency c. Completion of organization's orientation..." On 1/26/2021, Surveyor1 requested list of skilled nursing facilities that hospice facility had active service contracts currently. At approximately 11:45 AM, facility administrator (EMP1) provided Surveyor1 and Surveyor2 with a list identified by EMP1 as current list of contracted SNF's that was titled "Full Contracts A1:I88" and contained thirty one facilities with the facility's names and addresses on the list. EMP1 confirmed the facility had active hospice patients residing in skilled nursing facilities. Surveyor1 requested facility documentation confirming staff orientation to the hospice philosophy for the SNF's with current active patients. EMP1 provided Surveyor1 with facility binder with the title "In-Services" and identified binder as documentation of hospice training for contracted facilities. Review of "In-Service" binder period of January 1, 2020 to December 31, 2020 revealed no documented evidence of SNF training/professional qualifications, organization maintained training verification, and/or coordination with SNF representatives related to hospice philosophy orientation for the period reviewed. An exit conference was conducted on 1/26/2021 at approximately 2:05 PM with the following staff members: Directly with the facility Administrator (EMP1), Clinical Manager (EMP4), HR director (EMP11) and via phone with regional vice president (EMP12), director , regional compliance (EMP13), director, regulatory affairs (EMP14). Findings were reviewed.