Every finding on record at Agape Home Care, Inc

The following reflects the findings of the California Department of Public Health for Emergency Preparedness during a recertification survey conducted February 3, 2025, through February 6, 2025. All Conditions of Participation were met. No deficiencies were issued during this survey

The following reflects the findings of the California Department of Public Health during a recertification survey conducted February 3, 2025, through February 6, 2025. Census: 29 Unduplicated Admissions: 95 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All Conditions of Participation were met. Three deficiencies were issued during this survey.

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 observation, interview, and record review, the facility failed to ensure the plan of care was implemented for two of seven sampled patients (Patient 1 and Patient 3) when: 1. Home Health Aide 1 (HHA 1) did not perform range of motion exercises (exercises done either independently or with assistance to improve joint flexibility and movement) or take Patient 1’s vital signs (blood pressure, temperature, pulse, respiratory rate) during a home health aide visit on February 4, 2025. This failure resulted in Patient 1 to not receive care and services as was specified in Patient 1’s plan of care including monitoring of vital signs to identify a change in the patients status and range of motion services to help improve mobility and patient independence. 2. The facility failed to notify the physician regarding two patients (Patient 1 and Patient 3) missed home health visits when: 2a. For Patient 1, there was no evidence of physician notification for a missed skilled nursing visit on December 24, 2024, and a missed Home Health Aide (HHA) visit on December 9, 2024. 2b. For Patient 3, there was no evidence of physician notification for a missed HHA visit on January 7, 2025. This failure resulted in the physician to be unaware of the missed visits and for the physician to not have an opportunity to provide additional orders for any potentially unmet care needs for Patients 1 and 3. Findings: 1. During a review of Patient 1’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of August 8, 2024, and diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue in the absence of trauma or surgery), hypertension (high blood pressure), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. During an observation on February 4, 2025, at 9:40 AM, in Patient 1’s home, HHA 1 did not perform range of motion exercises with Patient 1 and did not take Patient 1’s vital signs at any point during the home health aide visit. During an interview on February 4, 2025, at 10:15 AM, with HHA 1, HHA 1 stated she did not perform range of motion exercises with Patient 1 and stated she was not aware Patient 1’s plan of care included instructions to perform range of motion exercises. HHA 1 further stated she did not take Patient 1’s vital signs because she did not have the equipment with her which was required to take Patient 1’s vital signs. During a concurrent interview and record review on February 4, 2025, at 10:20 AM, with HHA 1, Patient 1’s “Home Health Aide Care Plan,” dated February 3, 2025, was reviewed. The care plan indicated, “Homebound status…weakness…Orders for service/treatment: Obtain BP [blood pressure], TPR [temperature, pulse, respirations] every visit…Range of Motion Exercises…special instructions: 1. Notify RN Sup. [supervisor] if Temp [temperature] > [greater than] or = [equal to] 99.5 (axilla [underarm]) or 100 (oral [by mouth]) Fahrenheit [unit of measure]; if Pulse is [greater than] 110/min; if respiratory rate is 25/min and blood pressure if systolic is [greater than] 160 mmgh and a diastolic of 100 mmhg…” Further review of the document indicated Patient 1 had the following problems listed, “…Problems…personal care…mobility and transfer…maintaining a safe environment.” HHA 1 acknowledged Range of motion exercises and vital signs were indicated as tasks on the Home Health Aide Care Plan and again confirmed she did not do them with Patient 1. During an interview on February 6, 2025, at 1:05 PM, with the Director of Patient Care Services (DOPCS), the DOPCS stated the home health aides were supposed to follow the home health aide care plan when providing services to patients during visits. The DOPCS further stated HHA 1 should have performed range of motion exercises with Patient 1 and should have taken Patient 1’s vitals during the visit conducted February 4, 2025. The DOPCS further stated the importance of taking vital signs of patients was to help identify any changes in the patients condition and range of motion exercises were important to ensure the patient can maintain mobility. During a review of the facility’s policy and procedure (P&P) titled, “Certified Home Health Aide Job Description Summary.” dated December 2006, the P&P indicated, “…The home health aide is responsible for observing patients, reporting these observations and documenting observations and care performed…Responsibilities of the home health aide include, but are not limited to, the following: …4. Taking and recording oral, rectal and axillary temperatures, pulse, respiration and blood pressure when ordered…5. Assisting in ambulation and exercise according to the plan of care. 6. Performing range of motion and other simple procedures as an extensional therapy service as ordered…10. Reporting on patient’s condition and significant changes to the assigned nurse…” 2a. A review of Patient 1’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of August 8, 2024, and diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain tissue in the absence of trauma or surgery), hypertension (high blood pressure), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. During a review of Patient 1’s “Home Health Certification and Plan of Care,” with a certification period of December 6, 2024, to February 3, 2025, the plan of care indicated a physician’s order for skilled nursing visits to occur every week for nine weeks and HHA visits two times a week for eight weeks. Further review of the “Home Health Certification and Plan of Care,” indicated nursing services was to include observation/assessment of vital signs and all body systems, provide teaching instructions on disease process, management and appropriate actions to take control of disease, activity level, diet and medication regimen, pain control and management, identify and evaluate s/s reportable to medical doctors, and for the evaluation of the patient’s need for possible modifications of treatment or initiation of additional medical procedures until the patient’s treatment is stabilized. Home Health aid services were ordered to provide assistance with personal care and activities of daily living (ADL’s - a term used to collectively describe fundamental skills required to care for oneself, such as eating, bathing, and mobility). During a review of Patient 1’s Electronic Health Record (EHR – an electronic health record), the EHR indicated Patient 1 had a missed skilled nursing visit on December 24, 2024, and a missed HHA visit on December 9, 2024. There was no documented evidence in Patient 1’s EHR which indicated the physician was made aware of the missed visits. 2b. A review of Patient 3’s “Patient Profile,” undated, indicated Patient 3 had a start of care date of August 8, 2023, and diagnoses which included rheumatoid arthritis (condition that causes pain, swelling and stiffness in the joints), hypertension, and abnormalities of gait (walking) and mobility. During a review of Patient 3’s “Home Health Certification and Plan of Care,” with a certification period of January 29, 2025, to March 29, 2025, the plan of care indicated a physician’s order for HHA visits one time a week for nine weeks and the purpose of the visits was to provide assistance with personal care and ADL’s. During a review of Patient 3’s EHR, the EHR indicated Patient 3 had a missed HHA visit on January 7, 2025. There was no documented evidence in Patient 3’s EHR which indicated the physician was made aware of the missed visit. During an interview on February 5, 2025, at 12:28 PM, with the Office Manager (OM), the OM stated the physician was supposed to be notified of all missed visits and she was the individual who usually notified the physicians of the missed visits. During a concurrent interview and record review on February 5, 2025, with the OM, the OM reviewed Patient 1’s and Patient 3’s EHR and stated there was no evidence a physician was made aware of Patient 1’s missed visits on December 24, 2024 (skilled nursing visit) and December 9, 2024 (home health aide visit) or Patient 3’s missed visit on January 7, 2025 (home health aide visit) During an interview on February 6, 2025, at 4:10 PM, with the Director of Patient Care Services (DOPCS), the DOPCS stated when there was a missed home health visit, the physician was supposed to be notified. During a concurrent interview and record review on February 5, 2025, at 12:25 PM, with the Administrator (ADMIN), the ADMIN stated the facility did not have a policy and procedure (P&P) regarding notifying the physician about missed home health visits but stated it would fall under the P&P titled, “Monitoring Patient’s Response/Reporting to physician,” undated, the P&P was reviewed and indicated, “…3. The patient’s physician will be contacted on the same day when any of the following occur: …F. When there is a problem implementing the plan of care.” The ADMIN stated he considered a missed visit to be a time in which there was a problem implementing the plan of care.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure they had a performance improvement project (PIP – a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress or in development. This failure resulted in the facility to have missed opportunities for the examination and improvement in care or services in areas that the facility identifies as needing attention. Findings: During a concurrent interview and record review on February 6, 2025, at 11:40 AM, with the Administrator (ADMIN), the ADMIN stated the facility did not have a performance improvement project in progress or in development. The ADMIN further stated the facility only had quality metrics which they have been collecting data for since 2006 (falls, hospitalizations, infections etc.) and the data was reviewed quarterly (every 3 months). The facility’s QAPI binder was reviewed and there was no documentation of a performance improvement project either in development, in progress, or previously completed. The ADMIN stated he was not aware of the requirement to have a performance improvement project and the facility did not have any policies or procedures (P&P) relating to performance improvement projects.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure employee files for staff included completed orientation checklists, reference verification checks, and background checks as specified in the facility’s policies and procedures (P&P) when: 1. A home health aide (HHA 1), two Licensed Vocational Nurses (LVN 1 and LVN 2), and a Registered Nurse (RN 1), did not have completed orientation checklists. 2. The Director of Patient Care Services (DOPCS), LVN 1, and RN 1, did not have verification of references documented. 3. RN 1 did not have a background check on file. These failures resulted in the facility to not have documented evidence that all staff underwent orientation training and background checks prior to being hired. This had the potential for staff to be unfamiliar regarding organizational processes for patient quality of care and safety and for potential mistreatment or abuse of patients. Findings: 1. During an interview on February 3, 2025, at 3:17 PM, with the Administrator (ADMIN), the ADMIN stated all staff were supposed to complete orientation training upon hire which included the completion of an orientation checklist titled, “Personnel Orientation Checklist,” dated December 2006. During a review of the facility document titled, “Personnel Orientation Checklist,” dated December 2006, the document included four columns. The first column had multiple topics listed which included but was not limited to “…criminal background check…general orientation to organization…organization safety review…infection prevention and control within the organization…confidentiality of organization and patient information…home safety issues…infection control practices (specific to the home setting)…screening for abuse and neglect…patient rights and responsibilities…emergency preparedness…and cultural diversity and sensitivity. The second column indicated “Date completed”, the third column indicated “ Orientation by whom” and the fourth column indicated, “Personnel initials." During a record review of six employee files, four of six staff had incomplete orientation documentation as indicated below: 1a. HHA 1’s “Personnel Orientation Checklist,” undated, located in the employees personnel file was completely blank in all four columns (date completed, orientation by whom, and personnel initials). In addition, the form did not have the employees name or date of hire indicated anywhere on the form. 1b. LVN 1’s “Personnel Orientation Checklist,” had LVN 1’s name on it and was dated March 07, 2018 (approximately 7 years prior) and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. 1c. LVN 2’s “Personnel Orientation Checklist,” had LVN 2’s name on it and was dated November 23, 2015 (approximately 9 years prior and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. 1d. RN 1’s Personnel Orientation Checklist,” had RN 1’s name on it and was dated May 13, 2022 (approximately 2.5 years prior) and was blank next to all orientation topics in the columns where “date completed, orientation by whom, and personnel initials” were indicated. During a concurrent interview and record review on February 3, 2025, at 3:17 PM, with the ADMIN, HHA 1, LVN 1, LVN 2, and RN 1’s “Personnel Orientation Checklists,” were reviewed. The ADMIN stated the orientation checklists were incomplete and were supposed to be completed when the staff were first hired, but they were not completed and it was an oversight. During a review of the facility’s policy and procedure (P&P) titled, “Orientation,” dated December 2006, the policy indicated, “Purpose. To provide guidelines for the organization’s orientation process. Policy – All staff will be required to attend an initial orientation program upon employment. Staff orientation promotes safe and effective job performance…All staff will demonstrate knowledge and proficiency in skills appropriate to their assigned roles and responsibilities during the orientation period…2. The orientation process, for all staff will consist of both didactic and field supervision. Observation visits will be made by a supervisor to assess the skills demonstrated by new staff as well as reinforce the information presented during classroom time…5. A personnel Checklist (see “Personnel Orientation Checklist” Addendum 1-010.A) will be completed for all new staff. New staff will sign and date when their orientation has been completed. 6. The assigned supervisor will sign and date when new staff have completed all the required activities for all patients receiving intermittent home health services…” 2. During an interview on February 3, 2025, at 3:05 PM, with the ADMIN, the ADMIN stated staff were supposed to have reference checks performed as part of the hiring process. The ADMIN further stated an individual from the facility was supposed to call the staff members reference contacts and ask questions and complete the “Evaluator” section of the reference check form titled, “Verification of Employment”. The ADMIN stated reference checks were either done via phone, fax or mail. During a concurrent interview and record review on February 3,2025, at 3:06 PM, with the ADMIN, the employee files for six staff members were reviewed. Three of the six staff members (DOPCS, LVN 1, and RN 1) had “Verification of Employment” forms, which were blank in the “performance evaluation” section. The “performance evaluation” section included six questions which were unanswered [left blank] (skill level, cooperation, initiative, attendance, attitude, appearance) and blanks were indicated where “over the phone…via fax…or via email,” where indicated. Furthermore, the “name of evaluator…position…date” was also left blank and was not completed. The ADMIN acknowledged the verification of employment forms were blank in the “evaluator” section and stated someone was supposed to check on references and complete the “evaluator” section of the forms for the DOPCS, LVN 1, and RN 1, but they did not. During an interview on February 3, 2025, at 3:31 PM, with the ADMIN, the ADMIN stated a previous employee (who no longer worked at the facility) used to do the reference checks but now it was the responsibility of either him (the ADMIN), or the Office Manager (OM). During a review of the facility’s policy and procedure (P&P) titled, “Selection/Hiring of Personnel,” dated December 2006, the policy indicated, “Purpose – To specify the criteria for selection of staff to meet the care needs of appropriate patients. Policy – The organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals…Hiring…1. An individual seeking employment will complete an application, including information and verification about education, work experience, competencies, job history, and references, and have a personal interview…6. At least one (1) preferably two (2) references, either telephone and/or written, will be obtained prior to an offer of employment…15. Verification of the above will be documented.” 3. During a concurrent interview and record review on February 3, 2025, at 3:48 PM, with the ADMIN, RN 1’s employee file was reviewed. There was no evidence a background check was obtained by the facility at any time prior to employing RN 1 and no evidence a background check was performed for RN 1 at any time after employment. The ADMIN stated it was his responsibility to perform background checks on staff upon hire. The ADMIN further stated the facility should have had a background check done for RN 1 but they did not, and it was an oversight. During a review of the facility’s policy and procedure (P&P) titled, “Selection/Hiring of Personnel,” dated December 2006, the policy indicated, “Purpose – To specify the criteria for selection of staff to meet the care needs of appropriate patients. Policy – The organization defines the qualifications and competencies for staff positions based on its mission, population and care, treatment and service goals…Hiring…2. A criminal background check will be obtained for positions required by law, regulation or organizational policy…15. Verification of the above will be documented.”

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted January 24, 2022 through January 27, 2022. Representing the Department of Public Health: Surveyor: 41459 Census: 6 Unduplicated Admissions: 24 Home Visits with record reviews: 3 Record reviews without home visits: 5 Sample Size: 8

The following reflects the findings of the California Department of Public Health during a Recertification Survey conduced on January 24, 2022 through January 27, 2022 Representing the Department of Public Health: Surveyor: 41459 Census: 6 Home Visits with Record Review: 3 Record Reviews without Home Visits: 3 Sample Size: 8

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 agency failed to identify all the medications that a patient was taking for one of eight sampled patients (Patient 2) when: Four medications that Patient 2 was taking were not indicated on the Medication Profile (a list of medications the patient is taking). This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care of December 26, 2021, with a certification date of December 26, 2021 to February 23, 2022. Patient 2 had a diagnosis of displaced intertrochanteric fracture of left femur (a type of hip fracture – broken hip), displaced fracture of the upper end of left humorous (the bone of the left arm is not in proper alignment) due to history of falling. During a home visit on January 25, 2022 with Registered Nurse ( an individual who has graduated from a state approved school of nursing), Assistant Director of Nursing (an individual responsible for the nursing team and quality of patient service in the absence of the Director of Nursing) (RN1/ADON) and in the presence of Patient 2 and Patient 2’s daughter, an observation of Patient 2’s actual medication bottles available in the home were compared with Patient 2’s Medication Profile (MP – a current list of all medications prescribed for a specific patient). During an observation and interview with Patient 2’s daughter on January 25, 2022 at 9:50 AM, Patient 2’s daughter stated, she assists her mother with her medications. Patient 2’s daughter provided the following medication bottles: a. Claritin (a medication to treat allergy symptoms and hives), 10mg (milligrams – a unit of measure), take one tablet, by mouth, daily. Patient 2’s daughter stated, “Patient 2 has been taking Claritin since the doctor prescribed it on October 11, 2021.” b. Benzonatate (a medication used to relieve cough symptoms), 200mg capsule, take one capsule, by mouth, two times daily, prn (as needed). Patient 2’s daughter stated, “Patient 2 has had this medication since December 30, 2021.” c. Vitamin D 3 (a nutritional supplement), 2000 IU (international units – a unit of measure), take one tablet, by mouth daily. Patient 2’s daughter stated, “Patient 2 has had this medication since November 22, 2021.” d. Olmesartan (a medication to treat high blood pressure), 20mg, take one tablet, by mouth daily. Patient 2’s daughter stated, “Patient 2 needs to take two medications for her blood pressure. She saw her doctor and he told her she needed to continue taking this medication with her other blood pressure medication. Patient 2’s daughter stated, mother has had this medication since August 12, 2021. Patient 2’s MP did not indicate the Claritin, Benzonatate, Vitamin D 3, or Olmesartan. During an interview with RN 1/ADON 1 on January 25, 2022, at 10:00 AM, he stated, he did not know why these medications were not on the MP. RN 1 stated, he reviews medications when he does visits in the home, these medications were not given to him when he reviewed medications at his last visit to this home. During an interview with the Administrator on January 25, 2022, at 11:15 AM, he stated, he is aware that the medications are to be reviewed at each nursing visit to the home. He doesn’t know why these medications were missed. During a record review of the agency policy and procedure, titled, “Medication Profile”, Revised December 2006, indicted the following: “Purpose: To define the use of the medication profile in evaluating a patient’s medication regimen. Policy: Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Procedure: 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization. A comparison of the medications ordered for the patient will under the organization’s care will be made to those on the list. 2. The admitting nurse will initiate a medication profile to document the current medication regimen, including a diagnosis, condition, or indication for use for each medication ordered. 3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after a patient has bee placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. 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: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care.”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review Patient 1’s current plan of care did not include a medication order from October 25, 2021, that was to be continued. The medication was missing from the recertification plan of care. This failure had the potential for Patient 1 to suffer inferior care practices from incomplete services due to an incomplete plan of care. Findings: A review of Patient 1’s face sheet (a document that gives a summary of patients information). Undated, indicated a start of care date of September 30, 2021, with a recertification period of November 29, 2021, to January 27, 2021, Patient 1 had a diagnosis of pressure ulcer of sacral region, stage 2 (open wound on the skin), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), end stage renal disease (the kidneys no longer function well enough to meet the needs of daily life), and dependence on renal dialysis (removes excess water and toxins from the blood). During a record review of the certification period from September 30, 2021, to November 28, 2021, under section 10 of the plan of care, medications: Dose/Frequency/Route/(N)ew/(C )changed, the medication Alprazolam 0.25mg tablet 1 oral every 6 hours as needed was present on the plan of care. During an interview on January 24, 2022 at 1:15 PM, with the Administrator, he stated, he thought he doesn’t know why the medication would have been dropped from the plan of care. Maybe the medication was to be on hold, waiting to see if the medical doctor wanted Patient 1 to continue with the medication or not. During a record review of the form titled, “Physician Orders: 10/25/21 7:35 PM. Reasons: Patient 1’s BP (blood pressure) today during SN (nursing staff) visit was initially 197/97mmhg (millimeters of mercury, blood pressure measured in units), Patient 1 though was asymptomatic. Repeat BP at end of SN visit was 170/90 mmHg. Patient still asymptomatic MD (medical doctor) was informed. Reported also to MD that PCG (primary caregiver) informed SN that every time patient has an appointment with Dialysis, patient always thinks and get anxious and that is the reason why she is awake for the whole night. MD made the following order. Physician Order: Continue Alprazolam 0.25 mg (milligram – a unit of measure) tablet 1 oral every 6 hours as needed for anxiety. No BP medications (new or changed) order at this time. MD received and signed the order November 19, 2021. During a record review of the certification period from November 29.2021 to January 27, 2022, under section 10 of the plan of care, medications: Dose/Frequency/Route/(N)ew/(C )hanged, the medication Alprazolam 0.25mg tablet 1 oral every 6 hours as needed was not present on the plan of care. During a record review of the policy and procedure, titled, “Medication Monitoring”, revised December 2006, indicated the following: “Purpose: to define the ongoing medication monitoring process for the home health patient. Policy: Ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, patients, and family/caregivers. The results of medication monitoring will be used to improve the patient’s medication regime. The ongoing monitoring will occur in accordance with the established goals of therapy and be used to: 1. Evaluate the continued use of a medication in the current regimen. 2. Evaluate patient adherence to the prescribed medication regimen. Procedure: 1. The clinician will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy, and noncompliance with drug therapy. 2. The clinical response to medication will be monitored according to the clinical needs of the patient and will include: A. Evaluating the patient’s and family/caregiver’s perceptions about side effects and efficacy. B. Physical assessment at each visit. C. Referencing other relevant data, such as laboratory findings and diagnostic studies. 3. The findings, conclusions and recommendations of medication monitoring will be communicated to the physicians, pharmacist, and other clinicians involved in the patient’s care. 4. The information obtained through patient medications monitoring will be documented in the patient’s clinical record and, if applicable, in the pharmacy record.” During a record review of the policy and procedure, titled, “Monitoring patient’s response/reporting to physician, undated, indicated the following: “Purpose: To provide guidelines for monitoring the patient’s response to care and for reporting to the patient’s physician. Policy: Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress toward goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. Procedure: 1. During each home visit, the clinician will monitor the patient’s response to care against the established goals, including, but not limited to: B. Medications. 2. During case conference as well as the recertification process, the care will be evaluated to determine achievement of goals. 3. The patient’s physician will be contacted on the same day when any of the following occur; E. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations. 4. All conferences or attempts to communicate with the physician will be documented in the clinical record. A. Documentation of physician notification will include: 1. Date and time contacted, 2. Patient name, 3. Name of physician notified or his/her representative, 4. Reason for notification, 5. Physician’s response, 6. Action taken, or orders obtained, 7. Professional’s signature and title.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review the agency failed to follow infection control guidelines risking cross contamination in 1 of 8 sample patients (Patient 2) when: 1. A nursing supply bag was placed on Patient 2’s bedroom floor without a barrier. 2. Paperwork and a Lysol wipes container were placed on Patient 2’s bed without a barrier. This failure had the potential for patients to suffer inferior care practices risking transmission of infectious agents through cross contamination. Findings: A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care of December 26, 2021, with a certification date of December 26, 2022, to February 23, 2022. Patient 2 had a diagnosis of displaced intertrochanteric fracture of left femur (a type of hip fracture – broken hip), displaced fracture of the upper end of left humorous (the bone of the left arm is not in proper alignment), due to falling. During a home visit on January 25, 2022, at 9:40 AM, with the Registered Nurse (an individual who has graduated from a state approved school of nursing), Assistant Director of Nursing (an individual responsible for the nursing team and quality of patient service in the absence of the Director of Nursing) (RN1/ADON) and in the presence of Patient 2 and Patient 2’s daughter, an observation was made when RN1/ADON placed his nursing supply bag on Patient 2’s bedroom floor without a barrier (a device used to limit potentially infectious contact between health care providers and patients) to separate the nursing supply bag from the bedroom floor risking cross contamination of infectious agents. During the same home visit on January 25, 2022, at 9:42 AM, with RN1/ADON and in the presence of Patient 2 and Patient 2’s daughter, an observation was made when RN1/ADON placed paperwork and a Lysol wipe container on Patient 2’s bed without a barrier risking cross contamination of infectious agents. During an interview on January 25, 2022, at 10: 30 AM. After the home visit with Patient 2, RN1/ADON was asked about the policy and procedure in regards to infection control and placing items down in a patients home. The RN1/ADON did not respond. During a record review of the policy and procedure, titled, “Bag Technique’’, revised December 2006, indicated the following: “Purpose: To describe the procedure a clean patient care supply bag and preventing cross contamination. Policy: As part of the infection/exposure control plan, agency personnel will consistently implement principles to maximize efficient use of the patient care supply bag when used in caring for patients. Procedure: Bag Technique, 1. The bag will be placed on a clean dry surface (i.e., a surface that can be easily disinfected) in the car and in the home. 4. The bag will continue a designated clean and dirty area. The clean area carries unused or clean supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment etc.) 5. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. 7. If paper towels or newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded.”

Licensed Practical (Vocational) Nurse CFR(s): 484.115(e) Standard: Licensed practical (vocational) nurse. A person who has completed a practical (vocational) nursing program, is licensed in the state where practicing, and who furnishes services under the supervision of a qualified registered nurse. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to obtain the Cardiopulmonary Resuscitation (CPR) documentation card for 1 of 2 Licensed Vocational Nurse’s (LVN 1) who has direct patient contact. This failure had the potential to place Patients at risk and is against the requirements of an LVN to provide direct patient care. Findings: During an interview on January 27, 2022, at 1:00 PM, with the Administrator he stated, LVN 1 has not been able to find a CPR course due to COVID 19, the hospitals and facilities usually have classes just for their employees. He can’t find an independent course to take. During a record review of LVN1 personnel file on January 26, 2022 at 3:00 PM, LVN1 had an expired CPR card. The expiration date was from the year 2020. During a record review of a policy and procedure, titled, “Personnel Record Contents”, revised December 2006, indicated the following: “Purpose: To specify the content of the clinical personnel files for personnel and contract organization staff. Policy: Agency will maintain accurate and complete personnel files on all staff. Personnel files are confidential files of the organization. All health- related information on personnel will be kept in a separate file to maintain confidentiality according to the Americans with Disabilities Act. Upon request, the organization will provide personnel with a copy of all confidential information being placed in the file. If staff makes a written request to the Executive Director/Administrator, the staff may review and make notes regarding information contained within their file. Procedure: Regular Full or Part-time Clinical Personnel, 1. The content of the personnel files for active regular full or part-time clinical personnel will include but will not be limited to the following documents: B. Credentials (i.e., License, SSN, CPR, auto insurance, driver’s license, professional liability insurance (optional). “