Every finding on record at Advanced Health Care Providers, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new agency address at 6470 Foothill Blvd. Unit H Tujunga CA. 91406 from 8/16/2022 to 8/18/2022. Representing the California Department of Public Health: Surveyor #43979, Health Facility Evaluator Nurse Surveyor #43929, Health Facility Evaluator Nurse Unduplicated Admissions: 60 Active patients: 18 Sample Size: 7 Home Visits: 3 Old Address: 17620 Sherman Way suite 215 Van Nuys, CA. 91406 New Address: 6470 Foothill Blvd. Unit H Tujunga CA. 91042

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure each patient received treatment or services in accordance with the written plan of care (POC) for two of seven sampled patients (Patient 6 and Patient 7) by not monitoring or recording their blood sugar levels. This failure had the potential to result in delay in healing that could lead to hospitalization and/or death and delay in care and services. During an interview on 8/18/2022 at 12:20 a.m. the Administrator (ADM), ADM stated regarding blood sugar monitoring/documentation, “Its important to document, to make sure its within normal level, taking their medications, and following the proper diet”. A review of the HHA’s undated policy and procedure titled, “Home Glucose Monitoring”, indicated, “C. Testing…3. Blood glucose results will be recorded on the skilled nursing note.” A review of the HHA’s undated policy and procedure titled, “Ongoing Assessments”, indicated, “Procedure: 1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for…m. compliance with treatment and/or medications…” A review of the HHA’s undated policy and procedure titled, “Care Planning Process”, indicated, “Procedure…5. The plan of care will be based upon the physician’s…orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” A review of the HHA’s undated policy and procedure titled, “Daily Skilled Nursing Visit Note-Guidelines in Documentation”, indicated, “Policy…Instructions on how to fill out the form: 3. Record vital signs (TPR/BP as appropriate. 4. Record blood sugar (if applicable) ….”. A review of the Patient Information Sheet, indicated Patient 6, was admitted to the HHA on 3/24/22, with diagnoses including type 2 diabetes mellitus with hyperglycemia (a condition when the body does not make enough insulin, a hormone, to help keep blood sugar levels normal. Hyperglycemia-blood sugar levels exceed normal levels). A review of the Patient Information Sheet, indicated Patient 7, was admitted to the HHA on 6/18/22, with diagnoses including hypertensive heart disease without heart failure (chronic high blood pressure). During an observation of the home visit on 8/17/22, at 12:30 p.m., Licensed Vocational Nurse 1 (LVN 1) was observed giving care to Patient 7. During the visit, LVN 1 did not assess or monitor the blood glucose (blood sugar) levels of Patient 7. During an interview on 8/17/22, at 1:05 p.m., LVN 1 stated it was a mistake that she did not ask Patient 7 what the blood sugar level was. LVN 1 stated “the POC (plan of care) was to check blood sugar, but I’m not going to do it because the family already did it this morning.” During an interview on 8/18/22, at 12:20 p.m., the Administrator (ADM) stated it was important to monitor the blood sugar to make sure the medications the patient's taking were effective and agency's nursing staff has to know the lblood sugar evels was within the ranges. The ADM stated the blood sugar levels were supposed to be documented in the nursing notes. A review of Patient 6’s record titled, “Home Health Certification and Plan of Care”, for certification period 5/23/22 to 7/21/22, indicated “Orders and Treatments SN (skilled nursing) 2w2 (two visits a week for two weeks), 1w7 (one visit per week for 7 weeks)…SN to perform:....2) BS (blood sugar) monitoring with use of glucometer (a machine used to check blood sugar levels)…”. A review of Patient 6’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 6/18/22, did not indicated blood sugar monitoring was done. A review of Patient 6’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 6/25/22, did not indicated blood sugar monitoring was done. A review of Patient 6’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 7/9/22, did not indicated blood sugar monitoring was done. A review of Patient 7’s record titled, “Home Health Certification and Plan of Care”, for certification period 6/18/22 to 8/16/22, indicated “Orders and Treatments SN (skilled nursing) 1w1 (one visit a week for one week), 2w2 (two visits a week for two weeks), 1w6 (one visit per week for 6 weeks)…SN to perform:....2) BS (blood sugar) monitoring with use of glucometer (a machine used to check blood sugar levels)…” A review of Patient 7’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 7/4/22, did not indicated blood sugar monitoring was done. A review of Patient 7’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 7/12/22, did not indicated blood sugar monitoring was done. A review of Patient 7’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 7/24/22, did not indicated blood sugar monitoring was done. A review of Patient 7’s record titled, “LPN/LVN Skilled Nursing Visit”, dated 8/4/22, did not indicated blood sugar monitoring was done.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure there was written information regarding the state home health hours of operation and purpose of the hot line toll free number for seven of seven sampled patients (Patient 1, Patient 2, patient 4, Patient 5, Patient 6 and Patient 7). This failure resulted in omission of information where patients can call to report concerns with their care. A concurrent interview and record review on 8/18/2022 at 2:30 a.m. with Administrator (ADM) of HHA patient admission packet, ADM was unable to locate the purpose and the hours of operation listed for the state home health complaint department. ADM stated, “I cannot find it. It is important for them to feel safer and if they need, they will now who to contact in case of a complaint”. A review of the HHA’s undated policy and procedure titled, “Admission Criteria and Process”, indicated, “Procedure…7. If eligibility criteria are met, the patient and family/caregiver will be provided with an information on: a. nature and goals of care and service…j. complaint/grievance process…” A review of the HHA’s undated policy and procedure titled, “Rights/Responsibilities”, indicated, “Policy: Each patient will be an active, informed participant in his/her plan of care… l. The right to voice a complaint or concern regarding care or service. The availability of other sources to receive questions and complaints and assist in resolution…q. The availability of the applicable toll-free home health agency hotline and other sources to receive questions or complaints and assist in resolution…”

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to document the refusal of weight measurement as well as to document informing the physician of the refusal for one of seven sampled patients (Patient 1). This failure had the potential to result in placing the patient at risk for health complications and no interventions by not having information regarding their current health status in their medical record. A review of P1’s “Home Health Certification and Plan of Care (POC)” dated 8/8/20222 to 10/6/2022 indicated P1 was a 92-year-old female admitted to HHA on 6/9/2022. The POC indicated, P1 was oriented to person, place, time and was forgetful and had visits scheduled for skilled nurse (SN) 2w2 and 1w7 and CHHA 1w9. The POC indicated, SN was to weight the patient once a week and report to Medical Doctor (MD) if gain of 3-5 pounds per week or 2 pounds in a day. A review of P1’s “OASIS start of care” dated 6/9/2022 did not indicate and has no documentation of the patient's weight. Patient 1's OASIS “weight”., was left blank. A review of P1’s “OASIS recertification” dated 8/4/2022 indicated P1’s primary diagnosis was hypertensive heart disease with heart failure (high blood pressure) and Edema (swelling caused by excess fluid). Under the "cardiovascular" section it indicated P1 had edema of the ankles. The record did not indicated and has no documented patient's weight under “weight” area of the form. The weight parameters under “Notify physician of:” were “weight greater than 165 pounds or less than 160 pounds”. Under “Goals and Intervention” indicates “patient weight will be maintained between 165 and 160 lbs. during the episode”. A review of P1’s “Skilled Nursing Visit” dated 8/10/2022 and 8/13/2022 indicated there was nothing under “Weight”. A review of P1’s “Skilled Nursing Visit” dated 7/16/2022, 7/21/2022, and 7/24/2022 indicated 163 was written under “Weight”. During a joint home visit to P1’s home on 8/17/2021 at 11 a.m. with License Vocational Nurse 1 (LVN1), P1 noted sitting on dining room chair, alert and oriented to name and place. An interview on 8/17/2022 at 11:30 a.m. with License Vocational Nurse 1 (LVN), LVN1 stated, “I asked her if she weighed herself this morning, she said no. She is stubborn and gets angry if you tell her that you are going to weigh her”. P1 was not weighed by LVN1. A record review on 8/18/2022 at 9 a.m. of P1’s electronic medical record indicated there was no documented evidence P1 has been refusing to be weighed or documented evidence the physician was notified of P1s refusal to be weighed. A concurrent interview and record review on 8/18/2022 at 12:10 p.m. with Administrator (ADM) of P1’s electronic medical record, ADM stated regarding P1’s weekly weight measurement, “We weigh her to know if patient is gaining weight, there could be water retention. The doctor was not made aware she was refusing; (LVN1) did not mention it to me. There is no documentation in the patients record”. A review of the HHA’s undated policy and procedure titled, “Daily Skilled Nursing Visit Note-Guidelines in Documentation”, indicated, “Policy…Instructions on how to fill out the form: 3. Record vital signs (TPR/BP as appropriate. 4. Record blood sugar (if applicable) …” A review of the HHA’s undated policy and procedure titled, “Measuring, Recording and Reporting Weight”, indicated, “Policy/guidelines…7. Notify the patient’s physician of a 3–4-pound weight gain in a week or as ordered otherwise. 8. Appropriate intervention and care coordination must be documented is all cases of weight abnormality. 9…. Document physician notification of inappropriate weight gain or signs and symptoms of respiratory distress, as appropriate. 10. Update the plan of care.” A review of the HHA’s undated policy and procedure titled, “Physician Communication”, indicated, “Policy…will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. Procedure…1…b. When there are changes in the patient’s condition, parameters of reporting as stipulated on the plan of care…f. When there is any problem implementing the plan of care…i. When there is missed visit…2. All conferences or attempts to communicate with physician will be documented in the clinical record.”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to maintain and document an accurate medication profile/list, and ensure the medicaation available for the patient was check for expiration date, for three of 7 sampled patients (Patient 1, 2, and 7). 1. The HHA failed to review and document all the current medications of Patient 1 and Patient 2. 2. The HHA failed to ensure the patient's medication listed in the medication profile were not expired, for Patient 7. This failure placed patients at risk of adverse drug reactions, medication errors, and harm. A review of the Patient Information Sheet, indicated Patient 7, was admitted to the HHA on 6/18/22, with diagnoses including hypertensive heart disease without heart failure (chronic high blood pressure). During a home visit on 8/17/22, at 12:55, with Licensed Vocational Nurse 1 (LVN 1), the process of reviewing medications at home were observed. Medication Hydralazine Hydrochloride (to treat high blood pressure) 50 mg (milligrams-unit of measurement) 1 tablet every 6 hours as needed for high blood pressure, was observed to be expired. The label read “discard 5/12/22”. During an interview on 8/17/22, at 12:58 p.m., LVN 1 stated medications are supposed to be reviewed weekly. During an interview on 8/17/22, at 1:05 p.m., LVN 1 stated it was important to check medications for expiration dates because the medication can loose integrity, it will not work well and patient can get harmed if she takes a lot of doses of the expired medication. A review of the HHA’s undated policy and procedure titled, “Identification of Medication for Administration”, indicated, “Procedure…8. All medications will be checked for stability by visually examining the medication and observing for: …e. expiration date…”. A review of Patient 1’s (P1s) “Patient Information” indicated P1 is a 92-year-old female admitted to the Home Health Agency (HHA) on 6/9/2022 and current episode was 8/8/2022 to 10/6/2022. Admitting diagnosis was Hypertensive heart disease with heart failure (high blood pressure). It also indicated P1’s frequencies included: Skilled Nurse (SN) 2w2 (twice a week for two weeks) and 1w7 and Certified Home Health Aide (CHHA) 1w9. A review of P1’s “OASIS recertification” dated 8/4/2022 indicated P1 was “partially visually impaired and cannot see medication labels…” During a joint home visit to P1’s home on 8/17/2021 at 11 a.m. with Licensed Vocational Nurse 1 (LVN1), P1 noted sitting on dining room chair, alert and oriented to name and place. LVN1 was asked the reason she did not review P1’s medication. LVN1 stated, “I go through the patients medication profile on a weekly basis, not every visit. We go through it because sometimes they forget to tell me if there is any changes or new medications”. LVN1 did not reconcile P1’s medication. A review of P2’s “Home Health Certification and Plan of Care” dated 8/9/20222 to 10/7/2022 indicated P2 was a 73-year-old female with a start of care date of 6/10/2022. It indicated P2 was oriented to person, place, time and was forgetful and had visits scheduled for SN 2w2 and 1w7 and CHHA 1w9. It also indicated, SN was to remove any duplicate or expired medications to prevent confusion with medication regimen. A review of P2’s “OASIS recertification” dated 8/4/2022 indicated P2 was “partially visually impaired and cannot see medication labels…” During a joint home visit to P2’s home on 8/17/2021 at 11:45 a.m. with LVN1, P2 noted sitting on single recliner in living room, alert and oriented to name, time and place. LVN1 stated, “I put medications once a week in the medication container for her”. LVN 1 did not reconcile P2’s medication. An interview on 8/18/2022 at 12:20 p.m. with Administrator (ADM), ADM stated in regard to patient’s medication reconciliation, “I do it once a week. It is important to be medication safe, like avoid mistakes. Like missing dose sometimes. I check for name, dosage, and expiration date. Expired medication is dangerous for patients”. A review of the HHA’s undated policy and procedure titled, “Ongoing Assessments”, indicated, “Procedure: 1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for…m. compliance with treatment and/or medications…” A review of the HHA’s undated policy and procedure titled, “Identification of Medication for Administration”, indicated, “Procedure…8. All medications will be checked for stability by visually examining the medication and observing for: …e. expiration date…”. A review of the HHA’s undated policy and procedure titled, “Safe/effective use of Medications:”, indicated, “Procedure…6. Documentation of patient and family/caregiver instruction in the clinical record will include…e. updating medication profile.” A review of the HHA’s undated policy and procedure titled, “Medication Profile”, indicated, “Policy…Medication profiles will be updated for each to reflect current medication and new and/or discontinued medications…. Procedure…4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes but will not be limited to…c. using the medication profile as a communication tool for other clinicians involved in care.”

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 Home Health Agency (HHA) failed to ensure each patient received treatment or services in accordance with the written Plan of Care (POC) for two of seven sampled patients (Patient 4 and 7). This failure had the potential to result in delay in healing that could lead to hospitalization, physical discomfort, negative psychological effect and delay in care and services. A review of the HHA’s undated policy and procedure titled, “Care Planning Process”, indicated, “Procedure…5. The plan of care will be based upon the physician’s…orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” A review of Patient 4’s Patient Information Sheet, indicated, Patient 4 was admitted to the Home Health Agency (HHA) on 6/25/22, with diagnoses including hypertensive heart disease without heart failure. During an interview on 8/18/22, at 2:00 p.m. the Administrator (ADM) stated Patient 4 should have been seen once a week by a skilled nurse on the week of 7/24/22. The ADM stated she did not know why there was no visit notes for the week of 7/24/22. The ADM stated there should have been notes as evidence the agency visited the patient. The ADM stated for missed visits, there should have also been a communication note that indicated the doctor was notified of the missed visit. A review of Patient 7's record titled "Home Health Certification and Plan of Care", for certification period 6/25/22 to 8/23/33, indicated "Orders an Treatments SN (skilled nursing)...1w6 (1 visit per week for 6 weeks)...". A review of Patient 7’s record titled “Master Calendar”, dated 6/24/22-8/23/22, did not indicate a skilled nursing visit was scheduled for the week of 7/24/22. Further review of Patient 7’s electronic medical record did not indicate nursing visits were documented and communication notes were present for the week of 7/24/22.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure written information regarding the patient’s care was maintained, documented, and provided for three of seven sampled patients (Patient 1, Patient 2, and Patient 7). This failure placed these patients at risk of not fully understanding what services to expect from the HHA, the purpose of each service and when to expect the services. A review of the Patient Information Sheet, indicated Patient 7, was admitted to the HHA on 6/18/22, with diagnoses including hypertensive heart disease without heart failure (chronic high blood pressure). During an observation of the home visit on 8/17/22, at 12:30 p.m., Licensed Vocational Nurse 1 (LVN 1) was observed giving care to Patient 7. Patient 7’s patient folder was reviewed. No plan of care was observed in the patient’s home. During an interview on 8/18/22, at 12:20 p.m., the Administrator (ADM), stated regarding the plan of care, “Yes, it is supposed to be at home just in case they go to the emergency room, they’ll know their diagnosis”. A review of Patient 1’s (P1s) “Patient Information” indicated P1 is a 92-year-old female admitted to the Home Health Agency (HHA) on 6/9/2022 and current episode was 8/8/2022 to 10/6/2022. Admitting diagnosis was Hypertensive heart disease with heart failure (high blood pressure). It also indicated P1’s frequencies included: Skilled Nurse (SN) 2w2 (twice a week for two weeks) and 1w7 and Certified Home Health Aide (CHHA) 1w9. During a joint home visit to P1’s home on 8/17/2021 at 11 a.m. with License Vocational Nurse 1 (LVN1), P1 noted sitting on dining room chair, alert and oriented to name and place. Upon review of P1’s HHA folder, indicated there was no Plan of Care (POC) for P1. P1 was asked if she was provided a POC, P1 stated that she was not provided one. LVN1 confirmed P1’s POC was not in their HHA folder or in their home. A review of Patient 2s (P2s) “Patient Information” indicated P2 is a 73-year-old female admitted to the Home Health Agency (HHA) on 6/10/2022 and current episode was 8/9/2022 to 10/7/2022. Admitting diagnosis was Essential (primary) Hypertension (high blood pressure). It also indicated P2’s frequencies included: Skilled Nurse (SN) 2w2 (twice a week for two weeks) and 1w7 and Certified Home Health Aide (CHHA) 1w9. During a joint home visit to P2’s home on 8/17/2021 at 11:45 a.m. with LVN1, P2 noted sitting on single recliner in living room, alert and oriented to name, time and place. Upon review of P2’s HHA folder, indicated there was no Plan of Care (POC) for P2. P2 was asked if she was provided a POC, P2 did not know what a POC was. LVN1 confirmed P2’s POC was not in their HHA folder or in their home. An interview on 8/17/2022 at 12 p.m. with LVN1, LVN1, referring to patients POC, stated, “It should be in there. I think it is important because they can take it to their doctors’ visits and anybody that comes here like paramedics, will know their diagnosis. It is very important”. An interview on 8/18/2022 at 12:20 p.m. with Administrator (ADM), ADM stated regarding patients POC, “Yes, it is supposed to be at home just in case they go to the emergency room, they’ll know their diagnosis”. A review of the HHA’s undated policy and procedure titled, “Admission Criteria and Process”, indicated, “Procedure…7. If eligibility criteria are met, the patient and family/caregiver will be provided with an information on: a. nature and goals of care and service…” A review of the HHA’s undated policy and procedure titled, “Rights/Responsibilities”, indicated, “Policy: Each patient will be an active, informed participant in his/her plan of care…Procedure…c. The goals of care, the interventions that support those goals and the identification of the staff providing service…”. A review of the HHA’s undated policy and procedure titled, “Educational Resource”, indicated, “Procedure: 1. The organization will provide educational resources that include, but are not limited to…B. Written instructions developed by home health pertinent to services, treatments, medications, etc.…”.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure written information regarding the patient’s medication regime was present for one of seven sampled patients (Patient 7). This failure resulted in the patient missing information regarding the treatment plan the HHA was providing. An interview on 8/18/2022 at 12:20 p.m. with Administrator (ADM), ADM stated regarding patients medication profile, “It was supposed to be at their home, I put it there. It is important to have in case there is an emergency they know the list of medications. I tell them they can also take it to their doctor”. A review of the HHA’s undated policy and procedure titled, “Admission Criteria and Process”, indicated, “Procedure…7. If eligibility criteria are met, the patient and family/caregiver will be provided with an information on: a. nature and goals of care and service…”. A review of the HHA’s undated policy and procedure titled, “Educational Resource”, indicated, “Procedure: 1. The organization will provide educational resources that include, but are not limited to…B. Written instructions developed by home health pertinent to services, treatments, medications, etc.…”. A review of the HHA’s undated policy and procedure titled, “Medication Profile”, indicated, “Policy…Medication profiles will be updated for each to reflect current medication and new and/or discontinued medications…. Procedure…4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes but will not be limited to…c. using the medication profile as a communication tool for other clinicians involved in care.” A review of the Patient Information Sheet, indicated Patient 7, was admitted to the HHA on 6/18/22, with diagnoses including hypertensive heart disease without heart failure (chronic high blood pressure). During an observation of the home visit on 8/17/22, at 12:30 p.m., Licensed Vocational Nurse 1 (LVN 1) was observed giving care to Patient 7. Patient 7’s patient folder was reviewed. No medication profile was observed in the patient’s home.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to ensure the clinical records, documentations of nursing notes, were complete and signed by the skilled nurse (SN) for three of seven sampled patients (Patient 1, Patient 2, and Patient 6). This failure resulted in patient care records not being validated for the care received and had the potential for missed and error of the care and services provided to the patients. A review of Patient 1’s (P1s) “Patient Information” indicated P1 is a 92-year-old female admitted to the Home Health Agency (HHA) on 6/9/2022 and current episode was 8/8/2022 to 10/6/2022. Admitting diagnosis was Hypertensive heart disease with heart failure (high blood pressure). It also indicated P1’s frequencies included: Skilled Nurse (SN) 2w2 (twice a week for two weeks) and 1w7 and Certified Home Health Aide (CHHA) 1w9. A review of P1’s Certified Home Health Aide (CHHA) visit notes dated 7/23/2022, 7/30/3022, 8/5/2022, and 8/10/2022 indicated there were not signed by the CHHA. A review of Patient 2’s (P2s) “Patient Information” indicated P2 is a 73-year-old female admitted to the Home Health Agency (HHA) on 6/10/2022 and current episode was 8/9/2022 to 10/7/2022. Admitting diagnosis was Essential (primary) Hypertension (high blood pressure). It also indicated P2’s frequencies included: Skilled Nurse (SN) 2w2 (twice a week for two weeks) and 1w7 and Certified Home Health Aide (CHHA) 1w9. A review of P2’s License Vocational Nurse (LVN) – Skilled Nursing Visit dated 6/15/2022 indicated it was not signed by the LVN. A review of P2’s Certified Home Health Aide (CHHA) visit notes dated 7/23/2022, 7/30/3022, and 8/4/2022 indicated there were not signed by the CHHA. An interview on 8/18/2022 at 10:30 a.m. with Administrator (ADM), ADM stated, “SN and Certified Home Health Aide (CHHA) have 1 week to sign their notes”. A review of the HHA’s undated policy and procedure titled, “Daily Skilled Nursing Visit Note-Guidelines in Documentation”, indicated, “Policy…Instructions on how to fill out the form: 3. Record vital signs (TPR/BP as appropriate. 4. Record blood sugar (if applicable) …Note…Staff should always sign clearly and indicate the title (RN or LVN) at all times.” A review of the Patient Information Sheet, indicated Patient 6, was admitted to the HHA on 3/24/22, with diagnoses including Type 2 diabetes mellitus with hyperglycemia (a condition when the body does not make enough insulin, a hormone, to help keep blood sugar levels normal. Hyperglycemia-blood sugar levels exceed normal levels). A review of Patient 6’s records titled “HHA (Home Health Aide) indicated there was no authentication (signature) of the care provided on: 6/21/22 6/26/22 7/5/22 7/12/22 7/18/22