Every finding on record at Alaphia Care Home Health Services, Inc.

The following reflects the findings of the California Department of Public Health during a complaint validation survey conducted on July 17, 2023 through July 20, 2023. Representing the Department: Surveyors: 46119, 35183 Census: 111 Unduplicated Admissions: 488 Home Visits with record reviews: 3 Record Reviews without home visits: 9 Sample Size: 12 The following Conditions of Participation were not met: G 510 484.55 Comprehensive assessment of patients G 570 484.60 Care planning, coordination, quality of care G 700 484.75 Skilled Professional Services

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G510 484.55 Comprehensive assessment of patients was in compliance as follows: Based on interview and record review the agency failed to ensure the initial assessment (evaluation to determine the immediate care and support needs of the patient) was completed within 48 hours of the physician’s referral date or on the physician’s ordered start of care date for three of 12 sampled patients (Patients 4, 8, and 9) when: The initial assessment was conducted 14 days after the physician’s referral date for Patient 4. (Refer to G 514) The initial assessment was conducted 11 days after the physician’s referral date for Patient 8. (Refer to G 514) The initial assessment was conducted 4 days after the physician’s referral date for Patient 9. (Refer to G 514) Based on interview and record review, the agency failed to ensure the comprehensive assessment (a thorough assessment completed with information from multiple sources such as nursing, physical therapy, and social services, to determine the medical and personal needs of the patient) was completed within 5 calendar days of the start of care for three of 12 sampled patients (Patients 4, 9, and 11) when: A medical social worker (MSW) evaluation visit was not conducted as ordered for Patient 4. This failure had the potential to cause a delay in the identification and management of Patient 4’s psychosocial needs. (Refer to G 520) A MSW evaluation was not conducted for Patient 9, after the need for a MSW had been identified during the initial assessment. This failure caused Patient 9 to not receive the necessary resources and assistance from a MSW to address psychosocial and financial distress. (Refer to G 520) A physical therapy (PT) evaluation was not conducted as ordered for Patient 11. This failure had the potential to cause a decline in Patient 11’s mobility and physical safety. (Refer to G 520) Based on interview and record review, the agency failed to ensure a discharge assessment (an assessment completed to ensure the discharge process meets the needs of the patient) was completed by a registered nurse (RN) for one of 12 sampled patients (Patient 1). (Refer to G 522) Based on interview and record review, the agency failed to complete a recertification assessment (a patient evaluation done prior to another certification period beginning) within the last five days of the 60-day certification period for four of 12 sampled patients (Patients 5, 6, 8, and 9). (Refer to G 546) The cumulative effect of these systemic practices resulted in patients not being adequately assessed by licensed medical professionals, potentially causing a significant decline in health and safety.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure the initial assessment (evaluation to determine the immediate care and support needs of the patient) was completed within 48 hours of the physician’s referral date or on the physician’s ordered start of care date for three of 12 sampled patients (Patients 4, 8, and 9) when: The initial assessment was conducted 14 days after the physician’s referral date for Patient 4. The initial assessment was conducted 11 days after the physician’s referral date for Patient 8. The initial assessment was conducted 4 days after the physician’s referral date for Patient 9. These failures caused a delay in medical care and increased the risk of a decline in health and safety for Patients 4, 8 and 9. 1. During a review of Patient 4’s clinical record, the face sheet (a document that gives a summary of patient’s information) indicated a start of care date of March 8, 2023, with a certification period of March 8, 2023 to May 6, 2023. There were no diagnoses indicated for Patient 4 on the face sheet of the recertification period. A review of Patient 4’s referral order dated February 22, 2023 indicated a request for “…dc [discharge] home with home health, PT [physical therapy], 2 liters [unit of measurement] O2 [oxygen] by NC [nasal cannula – tube used to allow oxygen to flow into the nose] continuous…” A review of Patient 4’s initial assessment, dated March 8, 2023, indicated the initial assessment had been conducted on March 8, 2023, 14 days after the physician’s referral order. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 4’s clinical record was reviewed. The Admin and DPCS confirmed Patient 4 did not have an initial assessment within 48 hours of the physician’s referral order and should have. The Admin and DPCS stated they did not know why the initial assessment was not done until 14 days after the referral date. 2. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with a certification period of January 31, 2023 to March 31, 2023. Patient 8 had no diagnoses indicated on the face sheet or the plan of care. A review of Patient 8’s referral order dated January 20, 2023, indicated a request for home health services. A review of Patient 8’s initial assessment dated January 31, 2023, indicated the initial assessment had been conducted on January 31, 2023. (The initial assessment had been completed 11 days after the physician’s referral order) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 1:56 PM, Patient 8’s clinical record was reviewed. The Admin and DPCS verified Patient 8 did not have an initial assessment within 48 hours of the referral to the agency and should have. 3. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a certification period of February 17, 2023 to April 17, 2023. Patient 9 had no diagnoses indicated on the face sheet or the plan of care. A review of Patient 9’s referral order dated February 13, 2023, indicated a request for home health services. A review of Patient 9’s initial assessment dated February 17, 2023, indicated the initial assessment had been conducted on February 17, 2023. (The initial assessment had been completed four days after the physician’s referral order) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 11:42 AM, Patient 9’s clinical record was reviewed. The Admin and DPCS verified Patient 9 did not have an initial assessment within 48 hours of the referral to the agency and should have. During a review of the agency’s policy and procedure (P&P) titled, “2.12 Referral and Acceptance of Patients/Client”, dated 2016, the P&P indicated, “…Upon receipt of a referral, an evaluation by an RN and/or appropriate therapist will be made to determine that care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility…”

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 the comprehensive assessment (a thorough assessment completed with info from multiple sources such as nursing, physical therapy, and social services to determine the medical and personal needs of the patient) was completed within 5 calendar days of the start of care for three of 12 sampled patients (Patients 4, 9, and 11) when: A medical social worker (MSW) evaluation visit was not conducted as ordered for Patient 4. This failure had the potential to cause a delay in the identification and management of Patient 4’s psychosocial needs. A MSW evaluation was not conducted for Patient 9, after the need for a MSW had been identified during the initial assessment. This failure caused Patient 9 to not receive the necessary resources and assistance from a MSW to address psychosocial and financial distress. A physical therapy (PT) evaluation was not conducted as ordered for Patient 11. This failure had the potential to cause a decline in Patient 11’s mobility and physical safety. These failures caused Patient 4, 9, and 11 to not receive the necessary quality care and services, which increased the risk of a decline in their physical and psychosocial health. 1. During a review of Patient 4’s clinical record, the face sheet (a document that gives a summary of patient’s information) indicated a start of care date of March 8, 2023, with a certification period of March 8, 2023 to May 6, 2023. There were no diagnoses indicated for Patient 4 on the face sheet of the recertification period. A review of Patient 4’s care plan addendum dated March 8, 2023 to May 6, 2023, indicated Patient 4 was to be evaluated by a medical social worker (MSW). A review of Patient 4’s MSW evaluations was conducted for the certification period of March 8, 2023 to May 6, 2023. There was no indication a MSW evaluation had been completed during the certification period. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 4’s clinical record was reviewed. The Admin and DPCS verified Patient 4 had not received a MSW evaluation as ordered. The Admin and DPCS stated the MSW evaluation should have been completed within five days of the start of care. 2. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a certification period of February 17, 2023 to April 17, 2023. Patient 9 had no diagnoses indicated on the face sheet or the plan of care. During a home visit on July 18, 2023, at 4:42 PM, with a Registered Nurse (RN 1) and in the presence of Patient 9, RN 1 stated she had requested Medical Social Worker (MSW) services because Patient 9 was disabled and could not work. Patient 9 stated she had not had an income since 2010 and her elderly mother supported her. A review of Patient 9’s initial assessment ((evaluation to determine the immediate care and support needs of the patient) dated February 17, 2023, indicated the initial assessment had been conducted on February 17, 2023. A review of a “Communicate Note,” dated February 20, 2023, indicated the admitting Registered Nurse (RN 1) recommended MSW services. A review of Patient 9’s physician orders from February 20, 2023, to July 20, 2023, was conducted. There was no documented evidence to show a physician’s order for a MSW evaluation and services as needed. A review of Patient 9’s MSW evaluations was conducted on July 20, 2023. There was no documented evidence to show a MSW evaluation had been conducted. One hundred and fifty-three days had past without a MSW evaluation. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 11:42 AM, Patient 9’s clinical record was reviewed. The Admin and DPCS verified Patient 9 had not received a MSW evaluation therefore a MSW had not provided services to Patient 9. 3. During a review of Patient 11’s clinical record, the face sheet (a document that gives a summary of patient’s information) indicated a start of care date of July 8, 2022, with a certification period from July 8, 2022 to September 5, 2022. There was no diagnosis indicated for Patient 11 on the face sheet or care plan for the certification period. A review of Patient 11’s care plan for the certification period of July 8, 2022 to September 5, 2022 indicated a PT evaluation had been ordered at the start of care. A review of Patient 11’s PT evaluations from July 8, 2022 to September 5, 2022 was conducted. There was no documented evidence a PT evaluation had been completed for Patient 11. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 11’s clinical record was reviewed. The Admin and DPCS verified a PT evaluation had not been completed. The Admin and DPCS stated the agency did not notify PT staff that Patient 11 needed to be evaluated, and they did not know why. The Admin and DPCS further stated the ordered PT evaluation should have occurred within five days of the start of care date for Patient 11. During a review of the agency’s policy and procedure (P&P) titled, “2.7 Guidelines for Assessment”, dated 2016, the P&P indicated, “Initial Comprehensive Assessment…b. Determine the need for care and services and the type of care and services to be provided…c. Determine whether or not the patient/client needs additional services offered by the Agency…” During a review of the agency’s policy and procedure (P&P) titled, “2.9 Service Policies – Other Health Care Professional Services”, dated 2016, the P&P indicated, “…2.All therapy/social work referrals must be seen within 5 days of referral, unless otherwise stated by state regulations requiring earlier initial visit..."

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge assessment (a component of the comprehensive assessment completed to ensure the discharge process meets the needs of the patient) was completed by a registered nurse (RN) for one of 12 sampled patients (Patient 1). This failure caused Patient 1 to not receive a proper evaluation of their physical and personal needs by a licensed medical professional, which increased the risk of an unsafe discharge. During a review of Patient 1’s clinical record, the face sheet (a document that gives a summary of patient’s information), indicated a start of care date of March 19, 2023, with a certification period from March 19 2023, to May 17, 2023. The clinical record further indicated Patient 1 was admitted with diagnosis of central cord syndrome (a spinal cord injury in which the ability to transmit to or from the brain is damaged). A review of Patient 1’s discharge assessment dated May 10, 2023 was conducted. The discharge assessment indicated it was completed on May 10, 2023, and digitally signed by an office staff employee (OS 1). There was no documented evidence to indicate a RN had completed a discharge assessment at the time of discharge for Patient 1. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 1’s clinical record was reviewed. The Admin and DPCS verified the discharge assessment was completed by OS 1, and confirmed OS 1 was not a RN. The Admin and DPCS stated the discharge assessment should have been completed by a RN. During a review of the agency’s policy and procedure (P&P) titled, “2.17 Discharge/Transfer Policy”, dated 2016, the P&P indicated, “…3. Discharge planning shall begin at the time of admission…Re-Evaluation by the RN and additional planning with the patient/client shall occur…” During a review of the agency’s policy and procedure (P&P) titled, “2.46 (OASIS) Outcome and Assessment Information Set”, dated 2016, the P&P indicated, “The Outcome and Assessment Information Set [OASIS – a set of assessments done at specific points throughout the course of home health services] will be completed by an RN…at specific time points on all Medicare/Medicaid adult home care patients…The Discharge Assessment of the OASIS data set questionnaire contains all Medicate/Medicaid mandatory questions as well as other added questions to allow for a comprehensive assessment..."

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete a recertification assessment (a patient evaluation done prior to another certification period beginning) within the last five days of the 60-day certification period for four of 12 sampled patients (Patients 5, 6, 8, and 9). These failures caused Patient 5, 6, 8 and 9 to receive continued care that was not properly assessed by a licensed professional and reviewed and approved by a physician. 1a. During a review of Patient 5’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of March 1, 2023, with a recertification period of March 27, 2023 to May 25, 2023. There were no diagnoses indicated for Patient 5 on the face sheet of the recertification period. A review of Patient 5’s recertification assessments for recertification period March 27, 2023 to May 25, 2023 was conducted. There was no documented evidence to show a recertification assessment had been completed. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 5’s clinical record was reviewed. The Admin and DPCS verified the recertification assessment had not been completed for Patient 5’s recertification period of March 27, 2023 to May 25, 2023. The Admin and DPCS stated they did not know why a recertification assessment was not completed. 1b. During a review of Patient 6’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of January 27, 2022, with a recertification period of March 23, 2023 to May 21, 2023. The clinical record further indicated Patient 6 was admitted with a diagnosis of spina bifida (a birth defect where the spine does not develop properly). A review of Patient 6’s recertification assessments for recertification period March 23, 2023 to May 21, 2023 was conducted. There was no documented evidence to show a recertification assessment had been completed. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 6’s clinical record was reviewed. The Admin and DPCS verified the recertification assessment had not been completed for Patient 6’s recertification period of March 23, 2023 to May 21, 2023. The Admin and DPCS stated they did not know why a recertification assessment was not completed. 1c. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with recertification periods of April 1, 2023 to May 30, 2023, and May 31, 2023 to July 29, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care for either recertification period. A review of Patient 8’s recertification assessments for recertification period April 1, 2023 to May 30, 2023, was conducted. There was no documented evidence to show a recertification assessment had been conducted. (The window for the agency to conduct Patient 8’s recertification assessment for recertification period April 1, 2023, to May 30, 2023, was March 28, 2023, through April 1, 2023) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:14 PM, Patient 8’s clinical record was reviewed. The Admin and DPCS verified Patient 8 had not received a recertification assessment for the recertification period of April 1, 2023, to May 30, 2023. The Admin and DPCS stated they did not know why Patient 8 had not received a recertification assessment. A review of Patient 8’s recertification assessments for recertification period May 31, 2023 to July 29, 2023, indicated a recertification assessment was conducted on June 7, 2023. (The window for the agency to conduct Patient 8’s recertification assessment for recertification period May 31, 2023, to July 29, 2023, was May 27, 2023, through May 31, 2023. The agency conducted Patient 8’s recertification assessment seven days late) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:26 PM, Patient 8’s clinical record was reviewed. The Admin and DPCS verified Patient 8’s recertification assessment for recertification period May 31, 2023, to July 29, 2023, was conducted on June 7, 2023. The Admin and DPCS stated Patient 8’s recertification assessment was seven days late and they did not know why. 1d. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a recertification period of April 18, 2023 to June 16, 2023. Patient 9 had no diagnoses indicated on the face sheet or the plan of care for the recertification period. A review of Patient 9’s recertification assessments for recertification period April 18, 2023 to June 16, 2023 was conducted. There was no documented evidence to show a recertification assessment had been conducted. (The window for the agency to conduct Patient 9’s recertification assessment for recertification period April 18, 2023, to June 16, 2023, was April 14, 2023, through April 18, 2023) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 11:42 AM, Patient 9’s clinical record was reviewed. The Admin and DPCS verified Patient 9 had not received a recertification assessment for the recertification period of April 18, 2023, to June 16, 2023. The Admin and DPCS stated they had a case manager who would do the scheduling but quit and had not been replaced. The Admin and DPCS stated this was why the recertification assessment had been missed. During a review of the agency’s policy and procedure (P&P) titled, “2.7 Guidelines for Assessment”, dated 2016, the P&P indicated, “…Reassessment…To ensure that the patient/client’s current problems and needs are continuously evaluated and the care provided is adjusted accordingly, the patient/client’s status is reviewed periodically…Reassessment occurs: …4. Every 60 days when the patient/client is receiving skilled services…”

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G 570 484.60: Care planning, coordination, quality of care was in compliance as follows: Based on interview and record review, the agency failed to ensure an individualized care plan (a document that provides direction on the type of medical care a patient needs) was created and followed for five of 12 sampled patients (Patients 3, 5, 6, 8, and 9). (Refer to G 572) Based on interview and record review, the agency failed to ensure the individualized care plan (a document that provides direction on the type of medical care a patient needs) contained all of the required elements for four of 12 sampled patients (Patients 8, 9, 10, and 11) when: The individualized care plan did not contain all pertinent diagnoses and psychosocial status for Patient 8. (Refer to G 574) The individualized care plan did not contain necessary components for two recertification periods, for Patient 9. (Refer to G 574) The individualized care plan did not contain all pertinent diagnoses, psychosocial status, and the types of services, supplies, and equipment required, for Patient 10. (Refer to G 574) The individualized care plan did not contain all pertinent diagnoses for Patient 11. (Refer to G 574) Based on interview and record review, the agency failed to provide services as ordered by the physician for three of 12 sampled patients (Patient 1, 4, and 8). (Refer to G 578) Based on interview and record review, the agency failed to ensure a physician’s order had been obtained for services rendered to five of 12 sampled patients (Patient 5, 6, 8, 9, and 10) when: Skilled Nursing (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) visits were provided without a physician’s order, for Patients 5, 6, 9 and 10. (Refer to G 580) SN and Certified Home Health Aide (CHHA) visits were provided without a physician’s order for Patient 8. (Refer to G 580) The cumulative effect of these systemic practices resulted in patients receiving care that was not reviewed and approved by a physician, potentially preventing their medical and psychosocial needs from being met.

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 (a document that provides direction on the type of medical care a patient needs) was created and followed for five of 12 sampled patients (Patients 3, 5, 6, 8, and 9). This failure caused Patients 3, 5, 6, 8, and 9 to receive medical care that was not reviewed or approved by a physician. 1a. During a review of Patient 3’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of August 15, 2022, with three following recertification periods from October 14, 2022 to April 11, 2023. There were no diagnoses indicated for Patient 3 on the face sheets of the three recertification periods. During further review of Patient 3’s clinical record, the care plans for each recertification period were reviewed as follows: a. For Patient 3’s recertification period of October 14, 2022 to December 12, 2022, there was no documented evidence to show a care plan had been created. b. For Patient 3’s recertification period of December 13, 2022 to February 10, 2023, there was no documented evidence to show a care plan had been created. c. For Patient 3’s recertification period of February 11, 2023 to April 11, 2023, there was no documented evidence to show a care plan had been created. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 3’s clinical record was reviewed. The Admin and DPCS verified Patient 3 did not have a care plan for three consecutive recertification periods from October 2022 to April 2023. The Admin and DPCS stated they did not know why the three care plans were not created for Patient 3. The Admin and DPCS further stated there should be a care plan for each recertification period, to ensure the patient’s needs are being met. 1b. During a review of Patient 5’s clinical record, the face sheet indicated a start of care date of March 1, 2023, with a recertification period of March 27, 2023 to May 25, 2023. There were no diagnoses indicated for Patient 5 on the face sheet of the recertification period. A review of Patient 5’s care plans for the recertification period of March 27, 2023 to May 25, 2023 was conducted. There was no documented evidence to show a care plan had been created. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 5’s clinical record was reviewed. The Admin and DPCS verified Patient 5 did not have a care plan for the recertification period of March 27, 2023 to May 25, 2023. The Admin and DPCS stated they did not know why a care plan had not been created for Patient 5. 1c. During a review of Patient 6’s clinical record, the face sheet indicated a start of care date of January 27, 2022, with seven consecutive recertifications periods to follow, from March 2022 to May 2023. The clinical record further indicated Patient 6 was admitted with a diagnosis of spina bifida (a birth defect where the spine does not develop properly). During further review of Patient 6’s clinical record, the care plans for each recertification period were reviewed as follows: For Patient 6’s recertification period of March 28, 2022 to May 26, 2022, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of May 27, 2022 to July 25, 2022, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of July 26, 2022 to September 23, 2022, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of September 24, 2022 to November 22, 2022, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of November 23, 2022 to January 21, 2023, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of January 22, 2023 to March 22, 2023, there was no documented evidence to show a care plan had been created. For Patient 6’s recertification period of March 23, 2023 to Mary 21, 2023, there was no documented evidence to show a care plan had been created. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 6’s clinical record was reviewed. The Admin and DPCS verified Patient 6 did not have a care plan for seven consecutive recertification periods from March 2022 to May 2023. The Admin and DPCS stated they did not know why the seven care plans were not created for Patient 6. The Admin and DPCS further stated there should be a care plan for each recertification period. 1d. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with recertification periods of April 1, 2023 to May 30, 2023, and May 31, 2023 to July 29, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care for either recertification period. A review of Patient 8’s care plans for recertification period April 1, 2023 to May 30, 2023, was conducted. There was no documented evidence to show a care plan had been created. (The window for the agency to create Patient 8’s care plan for recertification period April 1, 2023, to May 30, 2023, was April 2, 2023, through April 6, 2023) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:14 PM, Patient 8’s clinical record was reviewed. The Admin and DPCS verified Patient 8 did not have a care plan for the recertification period of April 1, 2023, to May 30, 2023. The Admin and DPCS stated they did not know why a care plan had not been created for Patient 8. A review of Patient 8’s care plans for recertification period May 31, 2023 to July 29, 2023, was conducted. There was no documented evidence to show a care plan had been created. (The window for the agency to create Patient 8’s care plan for recertification period May 31, 2023, to July 29, 2023, was June 1, 2023, through June 5, 2023) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:26 PM, Patient 8’s clinical record was reviewed. The Admin and DPCS verified Patient 8 did not have a care plan for the recertification period of May 31, 2023, to July 29, 2023. The Admin and DPCS stated they did not know why a care plan had not been created for Patient 8. 1e. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a recertification period of April 18, 2023 to June 16, 2023. Patient 9 had no diagnoses indicated on the face sheet or the plan of care for the recertification period. A review of Patient 9’s care plans for recertification period April 18, 2023 to June 16, 2023 was conducted. There was no documented evidence to show a care plan had been created. (The window for the agency to create Patient 9’s care plan for recertification period April 18, 2023, to June 16, 2023, was April 19, 2023, through April 23, 2023) During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 11:42 AM, Patient 9’s clinical record was reviewed. The Admin and DPCS verified Patient 9 did not have a care plan for the recertification period of April 18, 2023, to June 16, 2023. The Admin and DPCS stated they did not know why a care plan had not been created for Patient 9. During a review of the agency’s policy and procedure (P&P) titled, “2.8 Care Plan”, dated 2016, the P&P indicated, “In order to ensure that a patient/client’s needs are being met adequately and appropriately, and services are adapted and adjusted within an individual patient/client situation as needed, a care plan is essential. A care plan is started upon initiation of service by the RN, based upon the plan of treatment and an assessment of the patient’s needs, resources, family and environment. Continuing evaluation and service modifications is provided as indicated as an integral part of the ongoing provision of Agency services…The patient care plan shall be updated as often as the patient/client’s condition indicates but at least every sixty (60) days for skilled patient/clients. The plan shall be maintained as a permanent part of the patient/client’s record…”

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 individualized care plan (a document that provides direction on the type of medical care a patient needs) contained all of the required elements for four of 12 sampled patients (Patients 8, 9, 10, and 11) when: The individualized care plan did not contain all pertinent diagnoses and psychosocial status for Patient 8. The individualized care plan did not contain necessary components for two recertification periods, for Patient 9. The individualized care plan did not contain all pertinent diagnoses, psychosocial status, and the types of services, supplies, and equipment required, for Patient 10. The individualized care plan did not contain all pertinent diagnoses for Patient 11. These failures caused Patients 8, 9, 10, and 11 to receive care which potentially did not meet their medical and psychosocial needs. 1. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with certification period of January 31, 2023 to March 31, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care. A review of Patient 8’s care plan and care plan addendum dated January 31, 2023 to March 31, 2023 was conducted. There was no documented evidence to show the following areas had been care planned: a. All pertinent diagnoses b. Psychosocial status During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 1:56 PM, Patient 8’s care plan and care plan addendum were reviewed. The Admin and DPCS confirmed all pertinent diagnoses, and the psychosocial status were missing. The Admin and DPCS stated the care plan had been returned to the Registered Nurse (RN) for correction, but the corrections were not made. (Patient 8’s care plan had remained incomplete for 169 days) 2. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a certification period of February 17, 2023 to April 17, 2023 and a recertification period of June 17, 2023 to August 15, 2023. For the recertification period of June 17, 2023, to August 15, 2023, Patient 9 had a diagnosis of diabetes mellitus (a disease that results in too much sugar in the blood). A review of Patient 9’s care plan and care plan addendum dated February 17, 2023 to April 17, 2023 was conducted. There was no documented evidence to show the following areas had been care planned: a. All pertinent diagnoses b. Mental, psychosocial and cognitive status c. The types of services, supplies, and equipment required. d. Prognosis (the likely course of a disease) e. Rehabilitation potential f. Functional limitations g. Nutritional requirements During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 11:42 AM, Patient 9’s care plan and care plan addendum were reviewed. The Admin and DPCS confirmed: all pertinent diagnoses, mental, psychosocial, and cognitive status, the types of services, supplies, and equipment required, prognosis, rehabilitation potential, functional limitations, and nutritional requirements were missing. The Admin and DPCS stated the care plan had been returned to the Registered Nurse (RN) for correction, but the corrections were not made. (Patient 9’s care plan had remained incomplete for 153 days) A review of Patient 9’s care plan and care plan addendum dated June 17, 2023, to August 15, 2023 was conducted. There was no documented evidence to show the following areas had been care planned: a. All pertinent diagnoses b. Psychosocial status c. Rehabilitation potential During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:45 PM, Patient 9’s care plan and care plan addendum were reviewed. The Admin and DPCS confirmed: all pertinent diagnoses, psychosocial status, and rehabilitation potential were missing. The Admin and DPCS stated the care plan had been returned to the Registered Nurse (RN) for correction, but the corrections were not made. (Patient 9’s care plan had remained incomplete for 33 days) 3. A review of Patient 10’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of June 6, 2023, with certification period of June 6, 2023 to August 4, 2023. Patient 10 had diagnoses that included psoriasis vulgaris (a condition in which skin cells build up and form scales and itchy, dry patches). A review of Patient 10’s care plan and care plan addendum dated June 6, 2023 to August 4, 2023 was conducted. There was no documented evidence to show the following areas had been care planned: a. All pertinent diagnoses b. Psychosocial status c. The types of services, supplies, and equipment required. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 2:30 PM, Patient 9’s care plan and care plan addendum were reviewed. The Admin and DPCS confirmed: all pertinent diagnoses, psychosocial status, and the types of services, supplies, and equipment required, were missing. The Admin and DPCS stated the care plan had been returned to the Registered Nurse (RN) for correction, but the corrections were not made. (Patient 10’s care plan had remained incomplete for 44 days) 4. During a review of Patient 11’s clinical record, the face sheet (a document that gives a summary of patient’s information) indicated a start of care date of July 8, 2022, with a certification period from July 8, 2022 to September 5, 2022. There was no diagnosis indicated for Patient 11 on the face sheet for the certification period. A review of Patient 11’s care plan for certification period July 8, 2022 to September 5, 2022 was conducted. There was no documented evidence to show the care plan included all pertinent diagnoses of Patient 11. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 11’s clinical record was reviewed. The Admin and DPCS confirmed Patient 11’s care plan for the certification period July 8, 2022 to September 5, 2022 did not contain any pertinent diagnoses. The Admin and DPCS stated they did not know why the care plan was missing the important component. During a review of the agency’s policy and procedure (P&P) titled, “2.8 Care Plan”, dated 2016, the P&P indicated, “In order to ensure that a patient/client’s needs are being met adequately and appropriately, and services are adapted and adjusted within an individua patient/client situation as needed, a care plan is essential…Steps to be taken in developing the care plan include: 1. Collection of baseline data including all pertinent diagnosis, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, ability to perform basic activities of daily living, activities permitted, the family’s or other caregiver’s ability to provide care, patient/client and family’s teaching needs, instructions for timely discharge or referral and any other appropriate items…4. Determination of the nature of home care service(s) needed…6. Determination of the goals to be achieved…9. Establishment of a schedule for the provision of services which lists the description and frequency of each health care service, the required treatment and procedure, as well as the medication and diet regimen to be provided…”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide services as ordered by the physician for three of 12 sampled patients (Patient 1, 4, and 8). These failures had the potential for Patients 1, 4, and 8 to not receive adequate care to meet their medical and personal needs. 1a. During a review of Patient 1’s clinical record, the face sheet (a document that gives a summary of patient’s information), indicated a start of care date of March 19, 2023, with a certification period from March 19 2023, to May 17, 2023. The clinical record further indicated Patient 1 was admitted with diagnosis of central cord syndrome (a spinal cord injury in which the ability to transmit to or from the brain is damaged). A review of Patient 1’s care plan addendum dated March 19, 2023 to May 17, 2023, indicated skilled nursing (SN – a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) visits were to be provided to the patient one time a week. A review of Patient 1’s SN visit notes for certification period March 19, 2023 to May 17, 2023 was conducted. The SN notes indicated only one SN visit was provided to Patient 1, on March 23, 2023 by a LVN, over the entire nine week certification period. During a concurrent interview and record review with the Administrator (Admin) and the Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 1’s clinical record was reviewed. The Admin and DPCS confirmed there was only one SN visit provided to Patient 1 for the certification period from March 19, 2023 to May 17, 2023, and stated there should have been nine visits total. The Admin and DPCS stated they did not know why the visits were not provided once per week, per the physician’s orders. 1b. During a review of Patient 4’s clinical record, the face sheet indicated a start of care date of March 8, 2023, with a certification period of March 8, 2023 to May 6, 2023. There were no diagnoses indicated for Patient 4 on the face sheet of the recertification period. A review of Patient 4’s care plan addendum, dated March 8, 2023 to May 6, 2023, indicated SN visits were to be provided to Patient 4 three times a week, for nine weeks. A review of Patient 4’s SN visit notes for the certification period of March 8, 2023 to May 6, 2023 was conducted. The SN visit notes indicated Patient 4 was not provided SN visits from an RN or LVN for the nine weeks after the start of care date. During a concurrent interview and record review with the Administrator (Admin) and the Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 4’s clinical record was reviewed. The Admin and DPCS confirmed there were no SN visits from an RN or LVN for the nine weeks after the start of care date, for the certification period of March 8, 2023 to May 6, 2023. The Admin and DPCS stated they did not know why the visits were not provided three times a week by an RN or LVN, per the physician’s orders. 2. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with certification period of January 31, 2023 to March 31, 2023 and a recertification period of May 31, 2023 to July 29, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care for either certification period. A review of Patient 8’s care plan addendum dated January 31, 2023 to March 31, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 8, one time a week for six weeks. A review of Patient 8’s SN visit notes for certification period January 31, 2023 to March 31, 2023, was conducted. The SN visit notes indicated the following visits were made: a. January 29, 2023, to February 4, 2023, one SN visit was ordered, one SN visit was made. b. February 5, 2023, to February 11, 2023, one SN visit was ordered, three SN visits were made. c. February 12, 2023, to February 18, 2023, one SN visit was ordered, two SN visits were made. d. February 19, 2023, to February 25, 2023, one SN visit was ordered, one SN visit was attempted. e. February 26, 2023, to March 4, 2023, one SN visit was ordered, zero SN visits were made. f. March 5, 2023, to March 11, 2023, one SN visit was ordered, three SN visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 1:56 PM, Patient 8’s care plan addendum and SN visit notes for the certification period of January 31, 2023, to March 31, 2023, were reviewed. The Admin and DPCS confirmed the SN visits did not follow the physician’s order. The Admin and DPCS stated they did not know why the visits did not follow the physician’s order but probably the visit frequency was changed, and a new order was not obtained. A review of Patient 8’s care plan addendum dated May 31, 2023 to July 29, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 8, one time a week for nine weeks. A review of Patient 8’s SN visit notes for certification period May 31, 2023 to July 29, 2023, was conducted. The SN visit notes indicated the following visits were made: a. May 28, 2023, to June 4, 2023, one SN visit was ordered, two SN visits were made. b. June 4, 2023, to June 10, 2023, one SN visit was ordered, two SN visits were made. c. June 11, 2023, to June 17, 2023, one SN visit was ordered, three SN visits were made. d. June 18, 2023, to June 24, 2023, one SN visit was ordered, three SN visits were made. e. June 25, 2023, to July 1, 2023, one SN visit was ordered, two SN visits were made. f. July 2, 2023, to July 8, 2023, one SN visit was ordered, three SN visits were made. g. July 9, 2023, to July 15, 2023, one SN visit was ordered, three SN visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:26 PM, Patient 8’s care plan addendum and SN visit notes for the certification period of May 31, 2023, to July 29, 2023, were reviewed. The Admin and DPCS confirmed the SN visits did not follow the physician’s order. The Admin and DPCS stated they did not know why the visits did not follow the physician’s order but probably the visit frequency was changed, and a new order was not obtained. During a review of the agency’s policy and procedure (P&P) titled, “2.8 Care Plan”, dated 2016, the P&P indicated, “Home health services from members of the Agency staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan..."

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 a physician’s order had been obtained for services rendered to five of 12 sampled patients (Patient 5, 6, 8, 9, and 10) when: Skilled Nursing (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) visits were provided without a physician’s order, for Patients 5, 6, 9 and 10. SN and Certified Home Health Aide (CHHA) visits were provided without a physician’s order for Patient 8. These failures caused Patients 5, 6, 8, 9 and 10 to receive care that was not approved and reviewed by a physician. 1a. During a review of Patient 5’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of March 1, 2023, with a recertification period of March 27, 2023 to May 25, 2023. There were no diagnoses indicated for Patient 5 on the face sheet of the recertification period. A review of Patient 5’s physician’s orders from March 27, 2023 to May 25, 2023 was conducted. There was no documented evidence to show a physician’s order had been obtained to specify the frequency of SN visits for Patient 5. A review of Patient 5’s SN Visit notes from March 27, 2023 to May 25, 2023 was conducted. The SN visit notes indicated 15 SN visits were made and six more visits were attempted. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 5’s clinical record was reviewed. The Admin and DPCS confirmed there were no physician’s orders for the SN visits provided to Patient 5 from March 27, 2023 to May 25, 2023. The Admin and DPCS further stated they did not know why the SN visits were being provided without a physician’s order. 1b. During a review of Patient 6’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of January 27, 2022, with a recertification period of March 23, 2023 to May 21, 2023. The clinical record further indicated Patient 6 was admitted with a diagnosis of spina bifida (a birth defect where the spine does not develop properly). A review of Patient 6’s physician’s orders from March 23, 2023 to May 21, 2023 was conducted. There was no documented evidence to show a physician’s order had been obtained to specify the frequency of SN visits for Patient 6. A review of Patient 6’s SN visit notes from March 23, 2023 to May 21, 2023 was conducted. The SN visit notes indicated 23 SN visits were made during that time. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 6’s clinical record was reviewed. The Admin and DPCS confirmed there were no physician’s orders for the SN visits provided to Patient 6 from March 23, 2023 to May 21, 2023. The Admin and DPCS further stated they did not know why the SN visits were being provided without a physician’s order. 1c. A review of Patient 9’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 17, 2023, with a recertification period of April 18, 2023 to June 16, 2023. Patient 9 had no diagnoses indicated on the face sheet or plan of care for the recertification period. A review of Patient 9’s physician’s orders from April 18, 2023 to June 16, 2023, was conducted. There was no documented evidence to show a physician’s order for SN visit frequencies. A review of Patient 9’s SN visit notes for the recertification period of April 18, 2023 to June 16, 2023, was conducted. The SN visit notes indicated the following visits were made: a. April 16, 2023, to April 22, 2023, no SN visits were ordered, two SN visits were made. b. April 23, 2023, to April 29, 2023, no SN visits were ordered, three SN visits were made. c. April 30, 2023, to May 6, 2023, no SN visits were ordered, three SN visits were made. d. May 7, 2023, to May 13, 2023, no SN visits were ordered, three SN visits were made. e. May 14, 2023, to May 20, 2023, no SN visits were ordered, three SN visits were made. f. May 21, 2023, to May 27, 2023, no SN visits were ordered, three SN visits were made. g. May 28, 2023, to June 3, 2023, no SN visits were ordered, three SN visits were made. h. June 4, 2023, to June 10, 2023, no SN visits were ordered, three SN visits were made. i. June 11, 2023, to June 17, 2023, no SN visits were ordered, four SN visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:10 PM, Patient 9’s physician’s orders, and SN visit notes for the certification period of April 18, 2023, to June 16, 2023, were reviewed. The Admin and DPCS stated there were no physician’s orders for SN visits and the SN made visits to Patient 8 without an order. The Admin and DPCS stated they did not know why there was no physician’s order for SN visits. 1d. A review of Patient 10’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of June 6, 2023, with a certification period of June 6, 2023 to August 4, 2023. Patient 10 had diagnoses that included psoriasis vulgaris (a condition in which skin cells build up and form scales and itchy, dry patches). During a home visit on July 18, 2023, at 11:24 AM, with a Licensed Vocational Nurse (LVN 1) and in the presence of Patient 10, Patient 10 stated on July 11, 2023 the nurse did not show up. Patient 10 stated she waited all day, but no one came. Patient 10 stated she called the office on July 12, 2023, and was told her visits had run out. Patient 10 stated she was anxious because she did not know if the agency was going to stop her visits again without notice and she misses one of her injections. LVN 1 stated Patient 10 had not been put on her visit schedule on July 11, 2023 so she did not come that day. A review of Patient 10’s care plan addendum dated June 6, 2023 to August 4, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 10, one time a week for four weeks starting on week two. A review of Patient 10’s physician’s orders from June 6, 2023 to August 4, 2023, was conducted. There was no documented evidence to show a physician’s order for SN visit frequencies for weeks six and seven. A review of Patient 10’s SN visit notes for the certification period June 6, 2023 to August 4, 2023 (weeks six and seven), was conducted. The SN visit notes indicated the following visits were made: a. (Week Six) July 9, 2023, to July 15, 2023, no SN visits were ordered, zero SN visits were made. b. (Week Seven) July 16, 2023, to July 22, 2023, no SN visits were ordered, one SN visit was made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 2:30 PM, Patient 10’s care plan addendum, physician’s orders, and SN visit notes for the recertification period of June 6, 2023, to August 4, 2023, were reviewed. The Admin and DPCS stated there were no physician’s orders for SN visits for weeks six and seven and the SN made visits to Patient 10 without an order. The Admin and DPCS stated there had been a mistake on the visit frequency, the frequency should have been one SN visit once a month not once a week. The Admin and DPCS stated the four visits authorized by the insurance company had been used up too quickly and this was why Patient 10’s visits just stopped. 2. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with certification period of January 31, 2023 to March 31, 2023 and recertification periods of April 1, 2023 to May 30, 2023 and May 31, 2023 to July 29, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care for any of the certification periods. A review of Patient 8’s care plan addendum dated January 31, 2023 to March 31, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 8, one time a week for six weeks. A review of Patient 8’s physician’s orders from January 31, 2023 to March 31, 2023, was conducted. There was no documented evidence to show a physician’s order for SN visit frequencies for weeks seven, eight and nine. A review of Patient 8’s SN visit notes for the certification period January 31, 2023 to March 31, 2023 (weeks seven, eight and nine), was conducted. The SN visit notes indicated the following visits were made: a. (Week Seven) March 12, 2023, to March 18, 2023, no SN visits were ordered, two SN visits were made. b. (Week Eight) March 19, 2023, to March 25, 2023, no SN visits were ordered, two SN visits were made. c. (Week Nine) March 26, 2023, to April 1, 2023, no SN visits were ordered, two SN visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 1:56 PM, Patient 8’s care plan addendum, physician’s orders, and SN visit notes for the certification period of January 31, 2023, to March 31, 2023, were reviewed. The Admin and DPCS stated there were no physician’s orders for SN visits for weeks seven, eight and nine and the SN made visits to Patient 8 without an order. The Admin and DPCS stated they did not know why there was no physician’s order for SN visits for weeks seven, eight and nine. A review of Patient 8’s physician’s orders from April 1, 2023 to May 30, 2023, was conducted. There was no documented evidence to show physician’s orders for SN and Certified Home Health Aide (CHHA) visit frequencies. A review of Patient 8’s SN and CHHA visit notes for the recertification period April 1, 2023 to May 30, 2023, was conducted. The SN and CHHA visit notes indicated the following visits were made: a. March 26, 2023, to April 1, 2023, no SN visits were ordered, one SN visit was attempted. b. April 2, 2023, to April 8, 2023, no CHHA visits were ordered, two CHHA visits were attempted, and one was made. c. April 9, 2023, to April 15, 2023, no SN or CHHA visits were ordered, one SN visit was made and two CHHA visits were made. d. April 16, 2023, to April 22, 2023, no SN or CHHA visits were ordered, two SN visits were attempted, and one SN visit was made and three CHHA visits were made. e. April 23, 2023, to April 29, 2023, no SN or CHHA visits were ordered, two SN visits were made and three CHHA visits were made. f. April 30, 2023, to May 6, 2023, no SN or CHHA visits were ordered, two SN visits were made and three CHHA visits were made. g. May 7, 2023, to May 13, 2023, no SN or CHHA visits were ordered, two SN visits were made and three CHHA visits were made. h. May 14, 2023, to May 20, 2023, no SN or CHHA visits were ordered, one SN visit was made and three CHHA visits were made. i. May 21, 2023, to May 27, 2023, no SN or CHHA visits were ordered, two SN visits were made and three CHHA visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:14 PM, Patient 8’s physician’s orders, SN visit notes and CHHA visit notes for the recertification period of April 1, 2023, to May 30, 2023, were reviewed. The Admin and DPCS stated there were no physician’s orders for SN and CHHA visits and the SN and CHHA made visits to Patient 8 without an order. The Admin and DPCS stated they did not know why there was no physician’s order for SN and CHHA visits. A review of Patient 8’s physician’s orders from May 31, 2023 to July 29, 2023, was conducted. There was no documented evidence to show physician’s orders for CHHA visit frequencies. A review of Patient 8’s CHHA visit notes for the recertification period May 31, 2023 to July 29, 2023, was conducted. The CHHA visit notes indicated the following visits were made: a. May 28, 2023, to June 3, 2023, no CHHA visits were ordered, two CHHA visits were made. b. June 4, 2023, to June 10, 2023, no CHHA visits were ordered, one CHHA visit was attempted and two were made. c. June 11, 2023, to June 17, 2023, no CHHA visits were ordered, three CHHA visits were made. d. June 18, 2023, to June 24, 2023, no CHHA visits were ordered, one CHHA visit was attempted and two were made. e. June 25, 2023, to July 1, 2023, no CHHA visits were ordered, two CHHA visits were made. f. July 2, 2023, to July 8, 2023, no CHHA visits were ordered, three CHHA visits were made. g. July 9, 2023, to July 15, 2023, no CHHA visits were ordered, three CHHA visits were made. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:26 PM, Patient 8’s physician’s orders and CHHA visit notes for the recertification period of May 31, 2023, to July 29, 2023, were reviewed. The Admin and DPCS stated there were no physician’s orders for CHHA visits and the CHHA made visits to Patient 8 without an order. The Admin and DPCS stated they did not know why there was no physician’s order for CHHA visits. During a review of the agency’s policy and procedure (P&P) titled, “2.8 Care Plan”, dated 2016, the P&P indicated, “Home health services from members of the Agency staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan…” During a review of the agency’s policy and procedure (P&P) titled, “2.21 Physician’s Plan of Treatment”, the P&P indicated, “…5. A physician’s plan of treatment…must include:…b. The type and frequency of services needed:… v. Specific orders and frequency of visits…”

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: The agency failed to ensure that the Condition of Participation: G 700 484.75 Skilled Professional Services was in compliance as follows: Based on interview and record review, the agency failed to ensure skilled nursing (SN – a Registered Nurse- RN or Licensed Vocational Nurse-LVN) visits were performed by professionals with appropriate qualifications for four of 12 sampled patients (Patients 3, 4, 11 and 12). (Refer to G 702) Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for five of 12 sampled patients (Patients 5, 6, 7, 8, and 10). (Refer to G726) The cumulative effect of these systemic practices had the potential for the patients to suffer substandard care practices from unlicensed medical assistants and Licensed Vocational Nurses.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled nursing (SN – a Registered Nurse- RN or Licensed Vocational Nurse-LVN) visits were performed by professionals with appropriate qualifications for four of 12 sampled patients (Patients 3, 4, 11 and 12). This failure caused Patients 3, 4, 11, and 12 to receive care from an unlicensed medical professional, which increased the risk of a decline in health and safety. 1a. During a review of Patient 3’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of August 15, 2022, with three recertification periods to follow, from October 14, 2022 to April 11, 2023. The clinical record further indicated Patient 3 was admitted with a diagnoses of a urinary tract infection (an infection of any part of the urinary system, including bladder and kidneys) and left foot open wound (a break in the skin that leaves the internal tissue exposed). A review of Patient 3’s physician’s orders for the certification period of August 15, 2022 to October 13, 2022 indicated Patient 3 was to receive SN visits three times a week, for seven weeks. A review of Patient 3’s SN visit notes for the certification period of August 15, 2022 to October 13, 2022 indicated Patient 3 had been visited by a Medical Assistant (MA – an unlicensed medical professional, who performs non-invasive services) 62 times, and two visits by a licensed nurse. Further review of the SN visit notes indicated the following: a. The visit note dated October 12, 2022, indicated the MA performed care for Patient 3’s Peripherally Inserted Central Catheter (PICC - a long, thin tube inserted into a vein in the upper arm and passed through to the larger veins near the heart, for the purpose of administering medications directly into the blood stream). b. The visit note dated October 14, 2022, indicated the MA administered a suppository (a form of medication inserted into the rectum) to Patient 3. A review of Patient 3’s physician’s orders for the certification period of October 14, 2022 to December 12, 2022 was conducted. There was no documented evidence to show physician’s orders for SN visits. A review of Patient 3’s SN visit notes for the certification period of October 14, 2022 to December 12, 2022 indicated Patient 3 had been visited by a MA 20 times, and four visits by a licensed nurse. Further review of the SN visit notes indicated the following: a. The visit note dated November 1, 2022, indicated the MA performed a straight catheterization (a catheter briefly inserted into the bladder to drain urine, then removed) A review of Patient 3’s physician’s orders for the recertification periods of December 13, 2022 to February 10, 2023, and February 11, 2023 to April 11, 2023 was conducted. There was no documented evidence to show physician’s orders for SN visits for either recertification period. A review of Patient 3’s SN visit notes for the recertification period of December 13, 2022 to February 10, 2023 was conducted. The SN visit notes indicated Patient 3 was provided 32 visits by a MA, and zero visits by a licensed nurse. The SN visit notes further indicated the medical assistants provided wound care to Patient 3. A review of Patient 3’s SN visit notes for the recertification period of February 11, 2023 to April 11, 2023 was conducted. The SN visit notes indicated Patient 3 was provided 47 visits by a MA, and one visit by a licensed nurse. The SN visit notes further indicated the medical assistants provided wound care to Patient 3. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 3’s clinical record was reviewed. The Admin and DPCS verified the SN visits were being provided by medical assistants. The Admin and DPCS stated PICC line care, suppository administration, straight catheterization, and wound care should be provided to the patient by a RN or LVN only. The Admin and DPCS further stated they were short staffed, so the MA was sent in place of a licensed nurse. 1b. During a review of Patient 4’s clinical record, the face sheet indicated a start of care date on March 8, 2023, with a certification period of March 8, 2023 to May 6, 2023. There were no diagnoses indicated for Patient 4 on the face sheet of the recertification period. A review of Patient 4’s care plan addendum, dated March 8, 2023 to May 6, 2023, indicated SN visits were to be provided to Patient 4 three times a week, for nine weeks. A review of Patient 4’s SN visit notes for the certification period of March 8, 2023 to May 6, 2023 was conducted. The SN visit notes indicated Patient 4 was provided 11 visits by a MA, and one visit from a licensed nurse. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 4’s clinical record was reviewed. The Admin and DPCS verified the SN visits were being provided by medical assistants. The Admin and DPCS stated SN visits should be performed by a RN or LVN only. The Admin and DPCS further stated they were short staffed, so the MA was sent in place of a licensed nurse. 1c. During a review of Patient 11’s clinical record, the face sheet indicated a start of care date of July 8, 2022, with a certification period from July 8, 2022 to September 5, 2022. There was no diagnosis indicated for Patient 11 on the face sheet or care plan for the certification period. A review of Patient 11’s care plan addendum dated July 8, 2022 to September 5, 2022 indicated SN visits were to be provided to Patient 11 one time a week for one week. A review of Patient 11’s SN visit notes for the certification period July 8, 2022 to September 5, 2022 was conducted. The SN visit notes indicated Patient 11 was provided nine visits by a MA, and one visit from a licensed nurse. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 11’s clinical record was reviewed. The Admin and DPCS verified the SN visits were being provided by medical assistants. The Admin and DPCS stated SN visits should be performed by a RN or LVN only. The Admin and DPCS further stated they were short staffed, so the MA was sent in place of a licensed nurse. 1d. During a review of Patient 12’s clinical record, the face sheet indicated a start of care date of April 10, 2023 with a certification period from April 10, 2023 to April 28, 2023. The face sheet further indicated Patient 12 was admitted with a diagnosis of hypertension (high blood pressure). A review of Patient 12’s care plan addendum dated April 10, 2023 to April 28, 2023 indicated SN visits were to be provided to Patient 12 one time a week, for four weeks. A review of Patient 12’s SN visit notes for the certification period April 10, 2023 to April 28, 2023 was conducted. The SN visit notes indicated Patient 12 was provided one visit by a MA, and one visit from a licensed nurse. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 12:25 PM, Patient 12’s clinical record was reviewed. The Admin and DPCS verified the SN visits were being provided by medical assistants. The Admin and DPCS stated SN visits should be performed by a RN or LVN only. The Admin and DPCS further stated they were short staffed, so the MA was sent in place of a licensed nurse. During a review of the agency’s policy and procedure (P&P) titled, “2.6 Services Policies Nursing Service”, dated 2016, the P&P indicated, “…1.Definitions: a.Nursing Services shall mean the services provided by nurses within the practice of the profession of nursing…2a. Nursing services is provided by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs)…” During a review of the agency’s policy and procedure (P&P) titled, “2.11 Delegation of Tasks to Unlicensed Personnel”, dated 2016, the P&P indicated, “…Tasks which may not be delegated include: a. Sterile Procedures (i.e. catheterization)…b. Formulation of the plan of nursing care and evaluation of that care…c. non-sterile procedures such as dressings or cleaning penetrating wounds or burns…e. Invasive procedures such as inserting tubes in a body cavity…f. Administration of medications…g. Care of broken skin which requires more than first aid..."

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for five of 12 sampled patients (Patients 5, 6, 7, 8, and 10). This failure had the potential to cause Patients 5, 6, 7, 8, and 10 to receive substandard LVN care practices. 1a. During a review of Patient 5’s clinical record, the face sheet (contains demographic and admission information) indicated a start of care date of March 1, 2023, with a recertification period of March 27, 2023 to May 25, 2023. There were no diagnoses indicated for Patient 5 on the face sheet of the recertification period. A review of Patient 5’s physician’s orders from March 27, 2023 to May 25, 2023 was conducted. There was no documented evidence to show physician’s orders for skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) visits. A review of Patient 5’s SN Visit notes from March 27, 2023 to May 25, 2023 was conducted. The SN visit notes indicated 15 SN visits were made by a LVN. During further review of the SN notes, there was no documented evidence to indicate a RN supervisory visit for the LVN had been completed during the 60-day certification period. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 5’s SN visit notes for the certification period of March 27, 2023 to May 25, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. 1b. During a review of Patient 6’s clinical record, the face sheet indicated a start of care date of January 27, 2022, with a recertification period of March 23, 2023 to May 21, 2023. The clinical record further indicated Patient 6 was admitted with a diagnosis of spina bifida (a birth defect where the spine does not develop properly). A review of Patient 6’s physician’s orders from March 23, 2023 to May 21, 2023 was conducted. There was no documented evidence to show physician’s orders for SN visits. A review of Patient 6’s SN visit notes from March 23, 2023 to May 21, 2023 was conducted. The SN visit notes indicated 23 SN visits were made by an LVN. During further review of the SN notes, there was no documented evidence to indicate a RN supervisory visit for the LVN had been completed during the 60-day certification period. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 6’s SN visit notes for the certification period of March 23, 2023 to May 21, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. 1c. During a review of Patient 7’s clinical record, the face sheet indicated a start of care date of January 20, 2023 with a certification period from January 20, 2023 to March 20, 2023. The clinical record further indicated Patient 7 was admitted with a diagnosis of a concussion (injury to the head sometimes causing loss of consciousness and confusion). A review of Patient 7’s care plan addendum, dated January 20, 2023 to March 20, 2023, indicated SN visits were to be provided one time a week, for seven weeks. A review of Patient 7’s SN visit notes from January 20, 2023 to March 20, 2023 was conducted. The SN visit notes indicated six SN visits were made by an LVN. During further review of the SN notes, there was no documented evidence to indicate a RN supervisory visit for the LVN had been completed during the 60-day certification period. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:45 PM, Patient 7’s SN visit notes for the certification period of January 20, 2023 to March 20, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. 1d. A review of Patient 8’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of January 31, 2023, with certification period of January 31, 2023 to March 31, 2023 and recertification periods of April 1, 2023 to May 30, 2023 and May 31, 2023 to July 29, 2023. Patient 8 had no diagnoses indicated on the face sheets or the plans of care for any of the certification periods. A review of Patient 8’s care plan addendum dated January 31, 2023 to March 31, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 8, one time a week for six weeks. A review of Patient 8’s LVN visit notes indicated visits were made on: a. February 2, 6, 8, 10, 14, and 16, 2023 b. March 8, 10, 16, 17, 21, 23, 28, and 30, 2023 A review of Patient 8’s RN visit notes from January 31, 2023 to March 31, 2023, was conducted. There was no documented evidence to show an RN supervisory visit for the LVN had been conducted. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 1:56 PM, Patient 8’s LVN visit notes and RN visit notes for the certification period of January 31, 2023, to March 31, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. A review of Patient 8’s physician’s orders from April 1, 2023 to May 30, 2023, was conducted. There was no documented evidence to show physician’s orders for SN visits. A review of Patient 8’s LVN visit notes indicated visits were made on: a. April 13, 19, 25, and 27, 2023 b. May 2, 4, 9, 11, 18, 23, and 25, 2023 A review of Patient 8’s RN visit notes from April 1, 2023 to May 30, 2023, was conducted. There was no documented evidence to show an RN supervisory visit for the LVN had been conducted. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 19, 2023, at 2:14 PM, Patient 8’s LVN visit notes and RN visit notes for the certification period of April 1, 2023, to May 30, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. 1e. A review of Patient 10’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of June 6, 2023, with a certification period of June 6, 2023 to August 4, 2023. Patient 10 had diagnoses that included psoriasis vulgaris (a condition in which skin cells build up and form scales and itchy, dry patches). A review of Patient 10’s care plan addendum dated June 6, 2023 to August 4, 2023, indicated the skilled nurse (SN- a Registered Nurse-RN or a Licensed Vocational Nurse-LVN) was to make visits to Patient 10, one time a week for four weeks starting on week two. A review of Patient 10’s LVN visit notes indicated visits were made on: a. June 13, 20, and 27, 2023 b. July 4, and 18, 2023 A review of Patient 10’s RN visit notes from June 6, 2023 to August 4, 2023, was conducted. There was no documented evidence to show an RN supervisory visit for the LVN had been conducted. During a concurrent interview and record review with the Administrator (Admin) and Director of Patient Care Services (DPCS) on July 20, 2023, at 2:30 PM, Patient 10’s LVN visit notes and RN visit notes for the certification period of June 6, 2023, to August 4, 2023, were reviewed. The Admin and DPCS stated the LVN had not received a supervisory visit. The Admin and DPCS stated the agency was short staffed, so the LVN supervisory visit had not been conducted. During a review of the agency’s policy and procedure (P&P) titled, “4.24 Supervision and Evaluation of Staff”, dated 2016, the P&P indicated, “Supervisory Visits…2. Patients that are receiving LPN [LPN – Licensed Practical Nurse – also known as Licensed Vocational Nurse – LVN] visits are supervised at least every 30 days by a Registered Nurse. Supervision visits are conducted for each patient that is being services by the LPN…8. The supervisory visit will be documented, dated, signed and placed in the patient record…”