Every finding on record at A's Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 24, 2023, through April 26, 2023. Representing the Department: Surveyors: 46119, 47110 Census: 46 Unduplicated Admissions: 173 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 24, 2023, through April 26, 2023. Representing the Department: Surveyors: 46119, 47110 Census: 46 Unduplicated Admissions: 173 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a comprehensive assessment was completed for one of seven sampled patients (Patient 5) when physical therapy did not evaluate the patient within 5 days of the start of care. This had the potential to cause a decrease in mobility and function for Patient 5. During a review of Patient 5’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of February 10, 2023, with a certification period of February 10, 2023, to April 10, 2023. Patient 5 had diagnoses which included Type 2 Diabetes Mellitus (body’s decreased ability to regulate blood sugar levels), hypertensive heart disease (heart condition as a result of high blood pressure), and osteoarthritis (inflammation and pain in the bone joints). A review of Patient 5’s plan of care for the certification period February 10, 2023, to April 10, 2023 was conducted. The plan of care indicated, “…Physical Therapy: For assessment/evaluation and follow-up visits if indicated. PT to evaluation on the week of 2/12/2023 – 2/14/2023…” A review of Patient 5’s clinical record from February 10, 2023, to April 10, 2023 was conducted. The record indicated Patient 5 was evaluated by physical therapy staff on February 17, 2023, seven days after the start of care. There was no documented evidence in the clinical record that the physician had been notified of the delay of physical therapy services. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on April 26, 2023, at 11:35 AM, the facility’s policy and procedure (P&P) titled “Initial Assessments/Comprehensive Assessments”, revised 2015,” …2. The comprehensive assessment will identify the patient’s need for home care and meet the patient’s need for: Medical, Rehabilitative, Nursing, Social, Discharge Planning…6. Completion of the Comprehensive Assessment: 1. Must be completed in a timely manner consistent with the patient’s needs, but no later than five (5) calendar days after the start of care…” The ADM/DPCS stated the did not follow their policy. The ADM/DPCS further stated Patient 5 was not evaluated by physical therapy within 5 days, and they should have been. During a continued interview and record review with the ADM/DPCS, the facility’s policy and procedure (P&P) titled “Plan of Care – CMS #485 and Physician/Practitioners Orders”, revised February 2022, “…30…If the agency misses a visit or a treatment or services as required by the pant of care, which results in any potential for clinical impact upon the patient, then the Agency must notify the responsible physician/practitioner of such missed treatment or service. The physician/practitioner decides whether the treatment or service may be skipped or whether additional intervention is required by the Agency due to the clinical impact on the patient…” The ADM/DPCS stated they did not follow their policy. The ADM/DPCS further stated the MD was not notified of the delay in physical therapy services and should have been.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care consisted of the frequency for certified home health aide (CHHA) visits for one of seven sampled patients (Patient 2). This failure had the potential for Patient 2’s health and personal care needs to go unmet. During a review of Patient 2’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of January 28, 2023, with a certification period of January 28, 2023, to March 28, 2023. Patient 2 had diagnoses which included Alzheimer’s Disease (a progressive disease that destroys memory and other important mental functions), dementia (impairment of memory and thoughts, causing a disruption in daily functioning), and muscle weakness. A review of Patient 2’s plan of care from January 28, 2023, to March 28, 2023 was conducted. The plan of care indicated, “…CHHA to assist patient with personal care/hygiene, grooming and ADL [activities of daily living] Assistance and other assigned tasks as per CHHA Practice Standard”. The plan of care did not indicate how often the CHHA would provide home care visits for Patient 2. A review of Patient 2’s physician’s orders from January 28, 2023, to February 28, 2023 was conducted. There was no documented evidence that a physician’s order had been obtained for CHHA visit frequencies since the start of care for Patient 2. During a concurrent interview and record review with the Administrator/Director of Patient Care Services (ADM/DPCS) on March 25, 2023, at 3:20 PM, Patient 2’s plan of care. The ADM/DPCS verified the plan of care did not include the CHHA visit frequencies, and it should have, to ensure that Patient 2’s care needs were being met. During a continued interview and record review with the ADM/DPCS, the facility’s policy and procedure (P&P) titled “Plan of Care – CMS #485 and Physician/Practitioners Orders”, revised February 2022, was reviewed. The P&P indicated “…4. The individualized plan of care must include the following:…the frequency and duration of visits to be made., including Skilled Nursing, Home Health Aides, Rehab, Social Services and other…” The ADM/DPCS stated they did not follow their policy.

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: 94941 Representing the California Department of Public Health: Surveyor: 35183 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Five deficiencies were issued as a result of the investigation for complaint number 94941

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to complete the comprehensive assessment within five days of the start of care for one of three sampled patients (Patient 1) when the Registered Nurse (RN) did not complete Patient 1's initial admission assessment. This failure caused Patient 1 to suffer a delay in identifying needed wound care. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022 to February 10, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood) and non-pressure chronic (persisting for a long time or constantly recurring) ulcer (an open sore that fails to heal) of left foot. Patient 1 was discharged to the hospital on December 21, 2022. A review of Patient 1’s initial admission assessment dated December 13, 2022, by a Registered Nurse (RN 1), was conducted on January 9, 2023. Patient 1’s initial admission assessment was blank. (Twenty-seven days passed without a completed initial admission assessment). During an interview with RN 1 on January 9, 2023, at 12:34 PM, RN 1 stated she had conducted Patient 1’s initial admission assessment. RN 1 stated she had one to two weeks to complete the assessment. RN 1 stated, “I have not completed the assessment yet.” RN 1 stated she had not followed up with the agency because she thought the agency decided not to admit Patient 1. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 9, 2023, at 2:36 PM, The DPCS stated RN 1 should have completed Patient 1’s initial admission assessment (a part of the comprehensive assessment) within five days of the start of care and had not. The DPCS stated RN 1 did not follow the agency’s policy and procedure titled, “Initial Assessments/Comprehensive Assessments,” dated, revised, 2015. A review of the agency’s policy and procedure titled, “Initial Assessments/Comprehensive Assessments,” dated, revised, 2015, indicated, “POLICY: Each patient admitted by the Agency will have appropriate initial assessments performed and documented. PROCEDURE: 1. Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient's current health status and include information to demonstrate the patient's progress toward achievement of desired outcomes. … Completion of the Comprehensive Assessment: 1. Must be completed in a timely manner consistent with the patient's needs, but no later than five (5) calendar days after the start of care. 2. RN must complete the comprehensive assessment and determine eligibility for home health benefit (for Medicare patients), including homebound status when skilled nursing is ordered. …”

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the comprehensive assessment was updated by a discharge assessment and transfer summary within two days of the discharge for one of three sampled patients (Patient 1) when Patient 1 was discharged to an acute care hospital with a wound infection. This failure caused a break in Patient 1’s continuity of care when the acute care hospital staff were unaware of the care and services the home health agency had provided; Patient 1’s current physical and psychosocial status; Patient 1’s reconciled medication list; advance directives, and continuing symptom management needs. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022 to February 10, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood) and non-pressure chronic (persisting for a long time or constantly recurring) ulcer (an open sore that fails to heal) of the left foot. A review of Patient 1’s physician’s order dated December 21, 2022, indicated to discharge Patient 1 from home health services. A review of Patient 1’s “Transfer/Discharge Assessment,” dated December 21, 2022, was conducted. The “Transfer/Discharge Assessment,” dated December 21, 2022, was blank. A review of Patient 1’s “Transfer Summary,” from December 21, 2022, to January 9, 2023, was conducted. There was no documented evidence to show a Transfer Summary had been completed. (Nineteen days passed without a Transfer/Discharge Assessment or Transfer Summary). During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 9, 2023, at 2:36 PM, the Admin/DPCS stated Patient 1 had been transferred and discharged to an acute care hospital due to a wound infection. The Admin/DPCS stated it had been her responsibility to conduct and complete Patient 1’s Transfer/Discharge Assessment and Transfer Summary and she had not done it. The Admin/DPCS stated she had not followed the agency’s policies and procedures titled “Reassessments/Update of the Comprehensive Assessment,” dated, revised, 2014 and “Transfer/Referral Criteria,” dated, revised, 2014. A review of the agency’s policy and procedure titled, “Reassessments/Update of the Comprehensive Assessment,” dated, revised, 2014, indicated, “POLICY: Each patient will have appropriate reassessments performed and documented. PROCEDURE: 1. The comprehensive assessment (…) must be updated and revised as frequently as the patient's condition warrants due to a major improvement or decline in health status. Minimally, the comprehensive assessment must be updated and revised: …Transferred to inpatient facility - discharged from Agency: within 2 calendar days of the discharge/transfer/death date or knowledge of a qualifying transfer to inpatient facility. …” A review of the agency’s policy and procedure titled, “Transfer/Referral Criteria,” dated, revised, 2014, indicated, “PURPOSE: To establish guidelines for the transfer or referral of patients from the Agency. PROCEDURE: Patients are transferred or referred to alternative care situations when the following conditions exist: The medical condition or treatment warrants a different level of care … 3. Appropriate parties will be informed immediately as the need for transfer becomes evident. This is accomplished by: a written Transfer Summary concerning the Agency's involvement with the patient, e.g., summary of care/services provided, patient's current physical and psychosocial status, instructions/referrals provided to patient, current reconciled medication list (with an explanation of how to obtain clarification), advance directives, any continuing symptom management needs, e.g., pain, nausea or dyspnea, and reasons for transfer or referral will be forwarded to the new health care provider. Transfer Summary will be provided to receiving organization within seventy-two (72) hours of transfer when Agency is actively involved in the transfer process. …”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure an individualized care plan was created and indicated skilled nursing visit frequencies within three days from admission for one of two sampled patients (Patient 1). This failure had the potential to cause adverse reactions to or ineffective use of medications; prolonged and/or failed wound healing; and a decline in health status due to providing care that was not approved by a physician. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022 to February 10, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood) and non-pressure chronic (persisting for a long time or constantly recurring) ulcer (an open sore that fails to heal) of the left foot. A review of Patient 1’s physician’s order dated December 21, 2022, indicated to discharge Patient 1 from home health services. A review of Patient 1’s Plans of Care from December 13, 2022, to January 9, 2023, was conducted. There was one Plan of Care dated December 13, 2022, but it was blank. (Twenty-seven days passed without a Plan of Care for Patient 1) A review of Patient 1’s physician’s orders from December 13, 2022, to January 9, 2023, was conducted. There was no documented evidence to show a physician’s order for skilled nursing visit frequencies. (Twenty-seven days passed without a physician’s order for skilled nursing visit frequencies for Patient 1) During an interview with a Registered Nurse (RN 1) on January 9, 2023, at 12:34 PM, RN 1 stated she had conducted Patient 1’s initial admission assessment on December 13, 2022 but did not create or document a plan of care, “It’s not my responsibility.” RN 1 stated had not called the physician for a verbal order for wound care or skilled nursing visit frequencies, “I thought she was a non-admit [not admitted to the agency].” During an interview with a Licensed Vocational Nurse (LVN 1) on January 9, 2023, at 1:04 PM, LVN 1 stated she had visited Patient 1 on December 15, 17, and 20, 2022. LVN 1 stated she performed wound care to Patient 1’s right lower leg and left foot on all three days. LVN 1 stated RN 1 had verbally told her how to do the wound care and she had not seen a care plan or a physician’s order for wound care. LVN 1 stated she had not documented her visit notes. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 9, 2023, at 2:36 PM, the Admin/DPCS stated RN 1 should have created and documented Patient 1’s plan of care within three days from admission and had not. The Admin/DPCS stated the plan of care indicated the skilled nursing visit frequencies but since it was not done there was no physician’s order for skilled nursing visit frequencies. The Admin/DPCS stated RN 1 did not follow the agency’s policy and procedure titled, “Care Planning Process,” dated, revised, 2014. A review of the agency’s policy and procedure titled, “Care Planning Process,” dated, revised, 2014, indicated, “Policy: In order to assure that care provided is appropriately planned to meet each patient’s specific needs and problems; the Agency will utilize data/information gathered during patient assessments in the care planning process. PURPOSE: To define the-care planning process and documentation of care planning. Procedure: … The patient care plan for Skilled Nursing will be: Initial care plan will be […] Plan of Care, which is developed and implemented with physician. Demonstrates problems (diagnoses), interventions (physician orders) and long-range goals. The initial plan of care will be developed within 72 hours. … The assignment sheet/plan of care will include: Type service/procedure to be provided, Frequency of visits, Diagnosis/prognosis, if relevant to care, Functional limitation, Patient's mental status, Activities permitted, Nutritional requirements, Specific procedure to be performed including amount, frequency and duration. Safety measures including use of specific equipment, Instructions for completion of documentation, Reporting changes in patient's condition and needs, Allergies. …”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure treatments were administered only as ordered by a physician for one of three sampled patients (Patient 1) when there was no physician's order for a wound treatment to Patient 1's right leg and the Licensed Vocational Nurse (LVN) did not follow the physician’s order for wound treatment to Patient 1's left foot. This failure had the potential to cause prolonged and/or failed wound healing and a decline in health status due to no treatment orders for Patient 1’s right lower leg and providing care that was not approved by a physician. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022 to February 10, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood) and non-pressure chronic (persisting for a long time or constantly recurring) ulcer (an open sore that fails to heal) of the left foot. A review of Patient 1’s physician’s order dated December 21, 2022, indicated to discharge Patient 1 from home health services. A review of Patient 1’s “Progress Note,” dated December 15, 2022, by a Physician’s Assistant (PA), indicated, a. “Anatomical Location [position on the human body]: Left Dorsal [upper side] 5th Toe, Foot Etiology[the cause]: Diabetic Ulcer with fat layer exposed Measurement (L [length]xW [width] xD [depth]): 1 [one].0 x [by] 0.6 [six] x 0.1 cm [centimeter-a unit of measurement] Wound Bed: 0% [percent] Slough [dead tissue]/ 0% Necrotic [dead tissue]/ 100% Granulation [newly formed tissue] / 0% Epithelial Tissue [skin] … The pain level: Pain Free (0) Wound Assessment Parameters: Odor (None); Exudate [oozing fluid] Amount (None) Infection: None Periwound [tissue surrounding the wound] Skin: Intact; Fragile Wound Edge: Attached Treatment Start Date: 12/15/2022 [December 15, 2022] Procedure: Non-surgical cleansing w/o [without] Debridement [removal of dead tissue] Depth of Tissue Destruction: Full Thickness (Chronic) b. “Anatomical Location: Left Medial [middle] Plantar [sole], Foot Etiology: Diabetic Ulcer with necrosis [dead tissue] of muscle Pre-Debridement Measurement (LxWxD): 13.9 x 14.9 x UTD [unable to determine] cm Wound Bed: 40% Slough/ 50% Necrotic/ 10% Granulation/0% Epithelial Tissue … Wound Assessment Parameters: Odor (None); Exudate Amount (Mild) Infection: Suspected Exudate Type: Serous Peri wound Skin: Intact; Fragile; Erythema [redness] (Mild) Wound Edge: Demarcated [boundary] Treatment Start Date: 12/15/2022 Procedure: Excisional [to surgically remove] Debridement Depth of Tissue Destruction: Full Thickness (Chronic) Post [after] Debridement Measurement (LxWxD): 14.0 x 15.0 x 0.2 cm … Pain level during the procedure: Pain Free (0) Anesthesia [loss of sensation]: 4% Lidocaine [brand name of a numbing agent] Spray Silver Nitrate [a medication used to burn off tissue]: None Nature of Tissue Removed: Muscle Debridement lnstrument(s): Curette [surgical instrument used to remove tissue] Pain level after the procedure: Pain Free (0) Procedure Description: The patient was positioned in the usual manner. Excisional Debridement was performed at the bedside to remove devitalized [dead] tissue to the depth described previously in the note to healthy bleeding tissue. Hemostasis [bleeding stopped] was then achieved. The procedure was tolerated well.” A review of Patient 1’s physician’s order dated December 15, 2022, indicated, “Left Dorsal [upper side] 5th Toe, Foot, … Cleanse with wound cleanser. Apply xeroform [a gauze wound dressing that does not stick to the wound], ABD [abdominal] pad, roll gauze; Change dressings Q [every] 1 [one]- [to] 2 [two] days or PRN [as needed] for loss of integrity/Soiling. Left Medial [middle] Plantar [sole of foot], Foot … Cleanse with wound cleanser. Paint with betadine [an antiseptic], apply mupirocin [an antibiotic] to open wounds, cover gauze, ABD pad, secure roll gauze; Change dressings Q1-2 days or PRN for loss of integrity/soiling.” A review of Patient 1’s physician’s orders from December 13, 2022, to January 9, 2023, was conducted. There was no documented evidence to show a physician’s order for Patient 1’s right lower leg. During an interview with a Registered Nurse (RN 1) on January 9, 2023, at 12:34 PM, RN 1 stated she had conducted Patient 1’s initial admission assessment on December 13, 2022. RN 1 stated she performed wound care during the initial admission assessment as follows: The right leg shin: cleanse with Normal Saline (NS), pat dry, RN 1 stated Patient 1 had some packing strips (long, slender, continuous pieces of a fine mesh, intended to fill wounds that extend into the skin) in her right leg, “I didn't have the packing strips. I left the strips in place.” I cleansed with NS over the top. 4 (four) x (by) 4 gauze wrap with kerlix (brand name gauze) and secured with tape. Left foot cleanse with NS, pat dry, applied mupirocin ointment, Adaptic (brand name non-adherent dressing), 4x4 kerlix and taped to secure. RN 1 stated, “This is all the wound care I did, and the right shin had two or three stitches.” RN 1 stated she had not called the physician for a wound care order. During an interview with a Licensed Vocational Nurse (LVN 1) on January 9, 2023, at 1:04 PM, LVN 1 stated she had visited Patient 1 on December 15, 17, and 20, 2022. LVN 1 stated she performed wound care for Patient 1’s right lower leg and left foot. LVN 1 stated RN 1 had verbally told her how to do the wound care and she had not seen a care plan or a physician’s order for wound care. LVN 1 stated on the right leg Patient 1 had packing strips, but Patient 1 pulled out the packing strips on the right leg. LVN 1 stated she performed wound care as follows: the right leg LVN 1 cleaned with NS, applied mupirocin ointment, 4x4, wrapped with kerlix and secured with tape; the left foot LVN 1 cleaned with NS, pat dry, applied Adaptic, 4x4 gauze and wrapped with kerlix and taped to secure. LVN 1 stated she had not called the physician for a wound care order. During an interview with a Physician’s Assistant (PA) on January 10, 2023, at 11:50 AM, the PA stated she worked for a wound care company that was contracted by the agency to perform wound assessments and care. The PA stated she debrided (removed dead skin) Patient 1’s wound (medial sole of left foot) removing slough (dead tissue) and then cleaned and dressed the wound (Cleansed with wound cleanser. Applied betadine, gauze, kerlix). The PA stated she gave wound care orders to the home health agency (Left sole of foot: cleanse with wound cleanser. Paint with betadine, apply mupirocin to open wounds, cover gauze, ABD pad, secure roll gauze; Change dressings Q1-2 days or PRN for loss of integrity/Soiling). The PA stated she saw Patient 1 on December 15, 2022, only and not after that. The PA stated, “I didn't give any order for the right leg stitches.” The PA stated, Patient 1 had poor circulation and diabetes so healing of the wound was not good. The PA stated there was no pus in the wound when she was there. The PA stated, “I’m not surprised the foot was amputated.” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 9, 2023, at 2:36 PM, the Admin/DPCS confirmed there were no physician’s orders for wound care for Patient 1’s right lower leg. The Admin/DPCS stated RN 1 should have called the physician for a wound care verbal order and had not. The Admin/DPCS stated LVN 1 should have followed the physician’s orders for wound care for Patient 1’s left foot and had not. The Admin/DPCS stated LVN 1 should not have performed wound care on Patient 1’s right leg without a physician’s order for wound care. The Admin/DPCS stated RN 1 and LVN 1 had not followed the agency’s policy and procedure titled “Plan of Care – […] and Physician Orders,” dated, revised, 2015.” A review of the agency’s policy and procedure titled “Plan of Care – […] and Physician Orders,” dated, revised, 2015, indicated, “Procedure: … 16. Care and services provided will be provided according to physician orders. Orders are current and updated. 17. Drugs and treatments are administered by staff only as ordered by physician. 18. Verbal orders are: Put in writing, signed, and dated with the date of receipt by a RN or therapist responsible for furnishing or supervising ordered services. It is the RN' s or therapist's responsibility to make any necessary revisions to the Plan of Care based on that order(s). 19. Orders are verified when: There are questions or discrepancies with orders [or] a person taking a verbal order is not qualified to review the order for appropriateness. 20. Physician services will be provided by a licensed Doctor of Medicine, Osteopathy or Podiatry and include: Diagnosing and treating medical conditions, Prescribing medications and therapeutic regimens, Developing and/or authorizing the Plan of Care, Approving additions or modifications to original plan recommended by professional home care staff, Performing periodic review for necessary revisions and changes, Submitting signed orders for Plan of Care and changes in accordance with required time frames, Reviewing and/or preparing clinical and progress notes, [and] Staff consultation, as indicated. 21. All clinical services are implemented only in accordance with a Plan of Care established by a physician's written order. …”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to ensure a Licensed Vocational Nurse (LVN 1) prepared clinical notes within 72 hours of the date of the visit for one of three sampled patients (Patient 1). This failure had the potential to cause distribution of inaccurate or outdated clinical information to other clinicians reviewing the clinical record. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 13, 2022, with a certification period of December 13, 2022 to February 10, 2023. Patient 1 had diagnoses that included diabetes mellitus (a disease that results in too much sugar in the blood) and non-pressure chronic (persisting for a long time or constantly recurring) ulcer (an open sore that fails to heal) of the left foot. A review of Patient 1’s physician’s order dated December 21, 2022, indicated to discharge Patient 1 from home health services. A review of Patient 1’s Skilled Nursing (SN) visit notes from December 13, 2022, to January 9, 2023, was conducted. There was no documented evidence to show SN visit notes had been documented. During an interview with a Licensed Vocational Nurse (LVN 1) on January 9, 2023, at 1:04 PM, LVN 1 stated she had visited Patient 1 on December 15, 17, and 20, 2022. LVN 1 stated she had not documented her clinical notes for December 15, 17, and 20, 2022. LVN 1 stated she was behind in her documentation due to holidays and working at her other job. LVN 1 stated she had one to two weeks to get her documentation into Patient 1’s clinical record. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on January 9, 2023, at 2:36 PM, the Admin/DPCS confirmed LVN 1’s clinical notes for Patient 1 on December 15, 17, and 20, 2022 were not in the clinical record. The Admin/DPCS stated LVN 1 had three business days to submit her notes into Patient 1’s clinical record and had not. The Admin/DPCS stated LVN 1 had not followed the agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” dated, revised, 2014. A review of the agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” dated, revised, 2014, indicated, “POLICY: The Agency will ensure the timely and proper submission of patient documentation. … PROCEDURE: … Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, …”