Every finding on record at All Med Home Health Srvs

The following reflects the findings of the California Department of Public Health during a Re-Licensing emergency preparedness survey. Representing the Department of Public Health: Surveyor ID # 43979-RN-HFEN Surveyor ID # 43929 -RN-HFEN Census: 12 Sample Size: 7 Home visits: 3 Unduplicated census: 37 No deficiencies were issued.

The following reflects the findings of the Department of Public Health during Recertification survey. Representing the California Department of Public Health: Surveyor #25046, Health Facilities Evaluator Nurse Surveyor #44186, Health Facilities Evaluator Nurse On 5/12/2022, at 9:30 a.m., a survey team attempted a recertification survey at the agency's address on record, 16661 Ventura Blvd Suite 503, Encino CA 91436. The agency door was locked, knocked several times at the door and nobody came to open the door. Called the telephone number on record and a recording was heard, "due to some unforeseen events, the office is now closed". Left a voicemail requesting to call the Department about the status of the agency. An email was also sent to the email address on record, but there was no reply.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the encoded OASIS information was transmitted to Centers for Medicare Services (CMS) within 30 days of completing the assessment for three of seven sampled patients (Patients 6, 7, and 3). This deficient practice resulted in delayed patient information to CMS. Findings: Patient’s 6’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnoses including unspecified atrial fibrillation (abnormal beating of the heart). Patient 7’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/12/22-7/10/22, indicated a start of care date of 5/12/22, with diagnoses including nausea. A review of Home Health Agency (HHA) “Outcome and Assessment Information Set (OASIS) Agency Final Validation” indicated Patient 3's, Patient 6's, and Patient 7’s Start of Care (SOC) OASIS “record was submitted late: The submission date is more than 30 days…” During an interview on 6/27/22, at 11:05 a.m., the Registered Nurse (RN) stated the HHA was supposed to review the Outcome and Assessment Information Set (OASIS) for accuracy and send it to CMS within 5 days of being completed. The RN stated the OASIS was submitted late due to user error. A review of facility’s policy titled, “Date Entry/Transmission of Outcome and Assessment Information Set (OASIS) Information” undated indicated, “OASIS information collected as start of care, resumption of care, follow-up, discharge and transfer to an inpatient facility will be encoded, edited and locked into the computer system within seven calendar days from the date the assessment is completed. The OASIS information will be sent electronically to the State and will match date in the clinical record… Agency personnel responsible for OASIS date entry will accurately encode data matching the date in the clinical record. The record must be locked within seven (7) days of completing an OASIS data set”.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the patients' folders contained the written information of the federal/state funded program information and the State toll free home health hot line telephone number for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice resulted in omission of information where patients can call to report concerns with their care. A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022, indicated Patient 1's diagnoses included diabetes mellitus II (DMII - High blood sugar), and rashes. Patient 1 was oriented to person, place, and time. A record review of Patient 1’s HHA folder indicated there was no federal/state funded program information inside the folder. The home health hotline number was also not indicated in the HHA folder. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022, indicated Patient 2 's diagnoses included chronic obstructive pulmonary disease (difficulty breathing) and essential primary hypertension (high blood pressure). Patient 2 was oriented to person, place, and time. A record review of Patient 2’s HHA folder indicated there is no federal/state funded program information inside the folder. The home health hotline number was also not indicated in the HHA folder. A concurrent interview and record review on 6/24/2022, at 2:30 p.m., with Registered Nurse 1 (RN1), of Home Health Agency (HHA)s Admission Folder indicated there was no contact information on Federal and State funded programs that included the home health hotline telephone number. RN1 stated will inform Staffing Coordinator (SC). A review of facility’s policy titled, “Patient Conduct, Responsibility and Rights” undated indicated, “Before the care is initiated, the agency must inform a patient orally and in writing of the following: 7. The nature and frequency of services to be delivered and the purpose of the service. As a patient you have the right to: 57. Be advised of the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that serve the area where the patient resides.”

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 registered nurse failed to conduct the patient's initial assessment timely after the patient was referred for admission to the home health agency for one of seven sampled patients (Patient 4). This deficient practice resulted in delay of care for the patient under the agency’s care. Patient 4’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/17/22-7/15/22, indicated a start of care date of 5/22/22, with diagnosis including Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes sugar). Further review indicated inconsistent information of the certification period start date on 5/17/22 instead of 5/22/22 the SOC date. Further inconsistent information revealed during an interview on 6/27/22, at 1:00 p.m., the Director of Patient Care Services (DPCS) stated Patient 4 was referred to the agency on 5/19/22 and should have been seen by 5/21/22. The DPCS stated Patient 4’s start of care visit was late, and the patient was seen on 5/22/22. The DPCS stated the HHA should have seen the patient within 24-48 hours from receiving the referral. The DPCS stated there was no documentation in the patient’s record to explain why the visit was late. A review of Patient’s 4 prescription document dated 5/19/21, indicated “Home Health evaluation and treatment”. A review of Patient 4’s record titled, “OASIS Start of Care”, dated 5/22/21, indicated “Start of Care Date 5/22/21.” A review of facility’s undated policy titled, “Initial Nursing Assessment/Evaluation” indicated, “Whenever possible, clients will be initially assessed within 24-48 hours of receipt of referral or discharge from 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 HHA failed to ensure an occupational therapy evaluation was performed within 5 days of the start of care for one of seven (Patient 6). This deficient practice has the potential to result in the delay to provide care and services to the patient. Patient’s 6’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnosis including unspecified atrial fibrillation (abnormal beating of the heart). A review of Patient 6’s record titled, “OASIS Start of Care”, dated 5/11/22, indicated “orders for discipline and treatments…OT evaluation and treatment”. A review of Patient 6’s record titled, “Occupational Therapy Evaluation & Care Plan”, dated 5/20/22, indicated a visit by OT was made. During an interview on 6/27/22, at 1:00 p.m., the Director of Patient Care Services (DPCS) stated when Occupational Therapy (OT) is ordered by the doctor, the OT therapists needs to conduct the evaluation within 5 days of the start of care date. The DPCS stated the time frame for the initial evaluation was important to prevent adverse outcomes (undesired) and to follow the doctor’s orders. During an interview on 6/27/22, at 1:30 p.m., the DPCS stated Patient 6’s initial OT evaluation was not done within 5 days of start of care and there was no explanation or reason documented in the medical record. The DPCS stated Patient 6 was considered a fall risk and OT therapy could have helped the patient take better care of herself. A review of facility’s undated policy titled, “Comprehensive Assessment of Patients (Outcome and Assessment Information Set - OASIS)” indicated, “The SOC OASIS comprehensive assessment should be completed no later than five calendar days after the SOC date".

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the comprehensive assessment accurately reflected the current health status for two of seven sampled patients (Patient 3 and Patient 6). This deficient practice has the potential for the patients' care and needs will not be identified that could result in the delay to develop and implement the plan of care. Patient 6’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnosis including unspecified atrial fibrillation (abnormal beating of the heart). During an interview on 6/27/22, at 1:30 p.m., the DPCS stated Patient 6’s allergies were not identified in the comprehensive assessment. The DPCS stated information on the patient’s allergies should be documented to make sure the patients are not allergic to the medications being prescribed, and to be aware for potential medication to medication interactions. A review of Patient 6’s record titled, “OASIS Start of Care”, dated 5/11/22, did not have any information to indicate if Patient 6 had allergies or not. A review of facility’s undated policy titled, “Comprehensive Assessment of Patients (Outcome and Assessment Information Set - OASIS)”indicated, “The OASIS date collected must accurately reflect the patient’s status at the time of the assessment…Components of a comprehensive assessment includes, but is not limited to: The physical health component: -head to toe assessment, vital signs, diagnosis(es), identification of additional health problems or pertinent health history including …allergies,…other needed information that could impact the level of services required to meet the patient and family need…”

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure information needed to be used to demonstrate the patient’s progress toward achievement of the goals identified, were included in the comprehensive assessment for six seven sampled patients (Patients 1, 2, 3, 4, 5, and 6). This deficient practice placed these patients at risk for health complication and no interventions by not gathering information regarding allergies and vital sign parameters (normal ranges for blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation). 4. Patient 4’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/17/22-7/15/22, indicated a start of care date of 5/22/22, with diagnoses including Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes sugar). A review of Patient 4’s record titled “OASIS Start of Care”, dated 5/22/21, indicated “Endocrine…interventions please see 485…goals…please see 485.” Further review of the record indicated “notify physician of…” no information was documented. 5. Patient 5’s records were reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 6/7/22-8/5/22, indicated a start of care date of 8/21/21, with diagnoses including age related osteoporosis (a chronic condition causing brittle bones, prone to breaking). A review of Patient 5’d record titled “OASIS Start of Care”, dated 8/11/21, indicated Pain Scale…intensity of pain 5…interventions please see 485…goals…please see 485”. Further review of the record indicated “ Respiratory…When is the patient dyspneic or noticeably short of breath? With moderate exertion…notify physician of…O2 sat less than…” no information documented. During an interview on 6/27/22, at 1:00 p.m., the Director of Patient Care Services (DPCS), stated the comprehensive assessment needed to have interventions and goals documented to become more familiar with the patient’s needs. The DPCS stated the interventions and goals needed to be tailored to the patient’s needs. During an interview on 6/27/22, at 1:10 p.m., the DPCS stated there should be parameters for all vital signs, which included blood pressure, temperature, heart rate, respirations rate, pain, and oxygen saturation, written in the comprehensive assessment. The DPCS stated the HHA checked oxygen saturation levels on all the patients, and these readings require individualized parameters depending on the illness. 6. Patient 6’s records were reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnoses including unspecified atrial fibrillation (abnormal beating of the heart). During an interview on 6/27/22, at 1:30 p.m., the DPCS stated Patient 6’s allergies were not identified in the comprehensive assessment. The DPCS stated information on the patients allergies should be documented to make sure the patients are not allergic to the medications being prescribed, and to be aware for potential medication to medication interactions. A review of facility’s undated policy titled, “Initial Nursing Assessment/Evaluation” indicated, “Initial assessment/evaluation form is filed in the client’s clinical record within seven (7) days of performing the assessment… The care plan is developed. Goals are established and actions to attain those goals are identified… Client’s needs are re-assessed during each visit in order to determine the client’s response to care…” A review of facility’s undated policy titled, “Comprehensive Assessment of Patients (Outcome and Assessment Information Set - OASIS)”indicated, “The OASIS date collected must accurately reflect the patient’s status at the time of the assessment…Components of a comprehensive assessment includes, but is not limited to: The physical health component: -head to toe assessment, vital signs, diagnosis(es), identification of additional health problems or pertinent health history including …allergies,…other needed information that could impact the level of services required to meet the patient and family need…” Findings: 1. A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022 indicated Patient 1 is a 79-year-old male, oriented to person, place, and time with diagnoses including Diabetes Mellitus II (High blood sugar), and rashes. There are no parameters set under fasting blood sugar greater than or Random blood sugar greater than. There are no interventions or goals written under the Endocrine section. 2. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022, indicated Patient 2's diagnoses including Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). There are no parameters set under temperature, pulse, respiration, systolic blood pressure, diastolic blood pressure, or oxygen saturation. 3. A review of Patient 3’s “OASIS Start of Care” dated 5/19/2022 indicated Patient 3's diagnosis of Essential Primary Hypertension (high blood pressure). It also indicated Patient 3’s Medication Profile was left blank. There are no parameters set under temperature, pulse, respiration, systolic blood pressure, or diastolic blood pressure. An interview on 6/27/2022, at 1:10 p.m., with Director of Patient Care Services (DPCS), DPCS stated that nurses, “are following their own definition of parameters. We should have universal parameters to follow. There should be parameters for all vital signs and blood sugars.” An interview on 6/27/2022, at 1:45 p.m., with Director of Patient Care Services (DPCS), DPCS stated Patient 3’s admitting diagnosis was Essential primary hypertension and that there were no blood pressure parameters, interventions or goals documented on his Comprehensive Assessment. DPCS stated it was important to document that information, “So that we know that we are following/providing appropriate care. If we don’t have actual numbers then the follow up won’t know what we are looking for, not matching medications. At risk for an event like a hyper or hypotensive episodes. Even the caregivers won’t know when to hold the medication which is a risk for falls.” An interview on 6/27/2022, at 1:53 p.m., with Director of Patient Care Services (DPCS), DPCS stated Patient 2’s diagnoses are COPD and HTN and that there were no parameters for blood pressure or oxygen saturation. DPCS stated “she’s on oxygen so that really needs to have parameters. It would have been good to know what the parameters were, and why it went up. She started off with high BP and when we were there it was low. More validation of what the doctor wanted.” An interview on 6/27/2022, at 2 p.m., with Director of Patient Care Services (DPCS), DPCS stated Patient 1’s diagnoses are rash and DM II and that there were no parameters for blood sugar. DPCS stated “It’s important so that we are making sure we are following the plan of care correctly, what we are doing is appropriate. To make sure BS is under control for proper healing of skin problems”. A review of facility’s policy titled, “Vital Signs (T, HR, RR, BP)” undated indicated, “Vital signs will potentially reveal sudden changes in a patient’s condition and will also measure changes that occur progressively over time. It is the policy of the Home Health Agency (HHA), to take vital signs during visits and report abnormal findings, as a difference between patients’ normal baseline vital signs and their present vital signs may indicate the need for intervention. Temperature, normal (oral) = 96.5 to 99F. Report findings outside of these parameters unless otherwise ordered by Medical Doctor (MD)… Heart Rate, normal resting heart rate = 60 to 100 beats per minute. Report findings outside of these parameters unless otherwise ordered by MD… Respiratory rate, normal resting respiratory rate = 12 to 20 breaths per minute. Report findings outside of these parameters unless otherwise ordered by MD… Blood pressure (BP), the average BP for an adult is 120/80 mmHg, but variations are normal for various reasons. Establish parameters in coordination with MD and report outside of those parameters…”

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 HHA failed to review and document all the medications the patient is currently using for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice placed patients at risk of drug-to- drug interaction and harm by not knowing which medications the patients were taking. A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022 indicated Patient 1 was oriented to person, place, and time with diagnoses including Diabetes Mellitus II (High blood sugar), and rashes. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022 indicated Patient 2 was oriented to person, place and time with diagnoses including Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). A concurrent interview and record review on 6/24/2022 at 9 a.m. with Director of Patient Care Services (DPCS) of Patient 2’s HHA folder indicated there was no medication profile/list inside folder. DPCS stated it should be in folder so that the nurse can reconciliate the medications. DPCS stated that medications are reconciliated at SOC, recertification, and when there is a change in medications. DPCS stated medications should be reconciliated at every visit. DPCS stated, “We only see patient once a week, a lot of them have multiple meds”. A concurrent observation, interview and record review on 6/24/2022 at 9:40 a.m. with Director of Patient Care Services (DPCS) of Patient 2’s medication profile/list indicated Patient 2’ medication bottle read: Estroven Nightime Oral 4 milligrams (mg) 1 cap daily and Medication profile read: Estroven Nightime Oral 3 milligrams (mg) 1 cap daily. It also indicated Patient 2 was taking: Vitamin D3 2000 units 1 cap daily, but it was not listed on the Medication Profile. An interview on 6/24/2022 at 10:30 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated that there is no medication profile for Patient 1 in his Home Health folder. LVN1 stated, “It’s important to have it in there so we know what the patient is taking. It’s important to have a current medication list so that we may know when it needs to be updated and if we are giving the right medication.” LVN1 stated that the medication profile should be checked at every nurse visit, to make sure there are no changes. A concurrent interview and observation on 6/24/2022 at 11:10 a.m. with LVN1 of Patient 1’s medications indicated Patient 1 was being treated with Diflorasone 0.05% ointment apply topically to affected area twice daily, filled 2/14/22. LVN1 stated, “this is the medication they are using not the Triamcinolone or Calmoseptin that is printed on the med list”. A review of Patient 1’s “Admission Order” dated 3/16/2022 indicated to “Discontinue medication: Diflorasone Diacetate External 0.05% apply to affected area 2x daily. Medication causes skin reaction to patient. New Medication: Triamcinolone Acetonide External 0.1% apply topically daily to rashes area.” A review of Patient 1’s “Medication Profile” dated 6/5/2022 to 8/3/2022 Triamcinolone Acetonide External 0.1% apply topically daily to rashes areas. A review of Patient 1’s “Admission Order” dated 6/1/2022 indicated Registered Nurse (RN) to reconcile patient’s medication… An interview on 6/24/2022 at 12:50 p.m. with Registered Nurse 1 (RN1), RN1 stated that it is important to reconcile patients medications, “to ensure there is no interactions, unnecessary medications, or reviewed with MD. Continuation and discontinuation of medications”. RN1 stated medications should be reconcile at Start of care (SOC), recertification, resumptions of care, change of condition, new or changed order for medication. RN1 stated, “If there are multiple doctors, we need to make sure they are not taking medications for same thing”. An interview on 6/27/2022 at 2 p.m. with Director of Patient Care Services (DPCS), DPCS stated that it is important to reconcile patient medications, “In case there are changes in the medication, we need to know right away to check for interactions, blood pressure really high. So that it could give us a better view of what is going on with the patient. Also, so that the doctor knows what is going on with the patient. Education is wise for both patient and caregivers, for them to know and give them parameters”. A review of facility’s policy titled, “Medication Profile” undated indicated “It is the responsibility of the admitting therapist/nurse to record all medications that the patient is currently taking on a routine or PRN basis. Documentation will include upon admission, the medication, route, amount and frequency… The medication profile will be updated at least every 60 days or more often as needed. Medication profile will be updated when the patient’s medications change. A change is any/or all of the following related to routine and as needed medications: deletion/discontinuance of medication”. A review of facility’s policy titled, “Meds profile Form” undated indicated, “It is the policy of Home Health Agency (HHA), to ensure correct documentation of medications in the medication profile… The meds profile will be updated as frequently for changes in meds”.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to send all necessary medical information to the receiving health care practitioner of the patient’s transfer to another service for two of seven patients (Patient 6 and Patient 7). This deficient practice has the potential to affect the continuity of care that could affect their health status and well being. Patient 6’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnoses including unspecified atrial fibrillation (abnormal beating of the heart). Patient 7’s records were reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/12/22-7/10/22, indicated a start of care date of 5/12/22, with diagnoses including nausea. During an interview on 6/27/22, at 1:35 p.m., the Director of Patient Care Services (DPCS) stated Patient 6 and Patient 7 had been discharged from the HHA to Hospice services (care of those patients who have a terminal illness) and did not know the name of the agency where the patients were transferred to because it was not documented. The DPCS stated the HHA did not send any summary records to the new agency/service taking care of them. The DPCS stated it was important to send the information to the new agency/service, so they were aware of the care that was given to them. A review of facility’s undated policy titled, “Discharge of Clients” indicated, “…If the client is transferred or referred to another agency for services, the date and the agency’s name is recorded. The primary nurse will then give report regarding the client’s condition to the Registered Nurse (RN) supervisor of the other agency”.

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 facility failed to ensure each patient received treatment or services in accordance with the written plan of care for two of seven sampled patients (Patient 2 and Patient 3). This deficient practice had the potential to result in not meeting the patient's care needs identified in the plan of care. Findings: a. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022 indicated Patient 2's diagnoses of Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). Orders for discipline and treatments include Skilled Nurse (SN) to visit once a week for 1 week, twice a week for 4 weeks, once a week for 4 weeks. A review of Patient 2’s “Home Health Certification and Plan of Care” dated 4/23/2022 to 6/21/2022 indicated Patient 2 was ordered to have Skilled Nurse (SN) to visit once a week for 1 week, twice a week for 4 weeks, once a week for 4 weeks. SN was to evaluate/instruct patient on the following: any changes in medication. During an interview on 6/28/2022, at 11:30 a.m., with Director of Patient Care Services (DPCS), DPCS stated Patient 2 had four missed visits, one per week. DPCS stated, “The doctor was notified but it is not written, if it’s not documented it did not occur. We are supposed to enter the missed visit as soon as we can. When the nurse puts it in the system, we speak with the doctor then we speak with the patient to schedule a different time. We have to reformulate the POC if there is significant change”. b. A review of Patient 3’s “OASIS Start of Care” dated 5/19/2022, indicated Patient 3's admitting diagnosis included Essential Primary Hypertension (high blood pressure). Orders for discipline and treatments included Skilled Nurse (SN) to visit twice a week for 3 weeks, then once a week for 2 weeks. A review of Patient 3’s “Home Health Certification and Plan of Care” dated 5/19/2022 to 7/17/2022 indicated Patient 3 was ordered to have Skilled Nurse (SN) to visit twice a week for 4 weeks, then once a week for 2 weeks. A concurrent interview and record review on 6/24/2022 at 12:50 p.m. with Registered Nurse 1 (RN1) of Patient 3’s electronic medical record. RN1 stated a nurse was scheduled to conduct a visit on 6/15/2022, and 6/19/2022, but was unable to find their visit documentation. RN1 stated, “there are no notes, I tried calling the nurse but there was no answer.” RN1 stated that nurse visit notes should be documented within 72 hours in the event there is another nurse visit or something that needs to be reported. An interview on 6/27/2022 at 2 p.m. with Director of Patient Care Services (DPCS), DPCS stated if there were any missed visits nurses should, “They should record it in the system. It would have been plotted, so they have to change it to a missed visit. Then we have to tell the doctor why it was missed. Then discussed when we can see them or is it possible to make up the visit next week. If the doctor says its fine to continue without the visit”. A review of facility’s policy titled, “Charting/Documentation” undated indicated, “Each care provided will be in accordance with the patient’s plan of care and nursing care plan and shall be documented by the appropriate care provider onto the clinical note in a timely manner, and be entered as part of the patient’s clinical record. Each staff member shall document the appropriate services provided to clients on the same day”.

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 Home Health Agency (HHA) failed to ensure the plan of care included parameters to vital signs (normal ranges for blood pressure, heart rate, respiratory rate, body temperature) and oxygen saturation (the amount of oxygen traveling to the body with the red blood cells), and blood sugar levels, for six of seven sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice has the potential in the delay to coordinate with the physician regarding the significant changes of the patient's condition for further intervention and treatment. 4. A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022, indicated Patient 1 was oriented to person, place, and time with diagnoses including Diabetes Mellitus II (DMII - High blood sugar), and rashes. There are no parameters set under fasting blood sugar greater than or Random blood sugar greater than. There are no interventions or goals written under the Endocrine section. An interview on 6/27/2022 at 2 p.m. with Director of Patient Care Services (DPCS), DPCS stated Patient 1’s had diagnoses of skin rash and DMII. DPCS stated that there were no blood sugar parameters in Patient 1’s comprehensive assessment. 5. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022 indicated Patient 2 is a 75-year-old female, with diagnoses including Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). There are no parameters set under temperature, pulse, respiration, systolic blood pressure, diastolic blood pressure, or oxygen saturation. An interview on 6/27/2022 at 1:53 p.m. with Director of Patient Care Services (DPCS), DPCS stated Patient 2’s had diagnoses of COPD and HTN and that there were no parameters for blood pressure or oxygen saturation. DPCS stated “she’s on oxygen so that really needs to have parameters. It would have been good to know what the parameters were, and why it went up. She started off with high BP and when we were there it was low. More validation of what the doctor wanted.” 6. A review of Patient 3’s “OASIS Start of Care” dated 5/19/2022 indicated Patient 3 is a 92-year-old male, with admitting diagnosis of Essential Primary Hypertension (high blood pressure). There are no parameters set under temperature, pulse, respiration, systolic blood pressure, or diastolic blood pressure. An interview on 6/27/2022 at 1:10 p.m. with Director of Patient Care Services (DPCS), DPCS stated that nurses, “are following their own definition of parameters. We should have universal parameters to follow. There should be parameters for all vital signs and blood sugars.” An interview on 6/27/2022 at 1:45 p.m. with Director of Patient Care Services (DPCS), DPCS stated Patient 3’s admitting diagnosis was Essential primary hypertension and that there were no blood pressure parameters, interventions or goals documented on his Comprehensive Assessment. DPCS stated it was important to document that information, “So that we know that we are following/providing appropriate care. If we don’t have actual numbers then the follow up won’t know what we are looking for, not matching medications. At risk for an event like a hyper or hypotensive episodes. Even the caregivers won’t know when to hold the medication which is a risk for falls.” Findings: 1. Patient 4’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/17/22-7/15/22, indicated a start of care date of 5/22/22, with diagnoses including Type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes sugar). During an interview on 6/27/22, at 1:00 p.m., the Director of Patient Care Services (DPCS), stated Patient 4 was supposed to have blood sugar parameters (normal ranges) written in the plan of care to be aware of when the blood sugar levels are too high or too low, so the doctor was notified and updated the plan of care. The DPCS stated the HHA should have called the doctor for blood sugar parameters. A review of Patient 4’s record titled “Home Health Certification and Plan of Care”, for certification period 5/17/22-7/15/22, indicated “SN (skilled nursing) to perform:…4) BS (blood sugar) checking.” Further review of the record did not include parameters for Patient 4’s blood sugar readings. 2. Patient 5’s clinical record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 6/7/22-8/5/22, indicated a start of care date of 8/21/21, with diagnoses including age related osteoporosis (a chronic condition causing brittle bones, prone to breaking). A review of Patient 5’s clinical record titled “Home Health Certification and Plan of Care”, for certification period 6/7/22-8/5/22, indicated “SN to perform:…3) oxygen saturation as needed for shortness of breath/respiratory distress.” Further review of the record did not include parameters for oxygen saturation. 3. Patient 6’s record was reviewed. Form titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated a start of care date of 5/11/22, with diagnoses including unspecified atrial fibrillation (abnormal beating of the heart). A review of patient 6’s clinical record titled “Home Health Certification and Plan of Care”, for certification period 5/11/22-7/9/22, indicated “SN to perform: 1) vital signs…3) oxygen saturation as needed for shortness of breath/respiratory distress.” Further review of the record did not include parameters for vital signs and oxygen saturation. During an interview on 6/27/22, at 1:10 p.m., the DPCS stated there should be parameters for all vital signs, which included blood pressure, temperature, heart rate, respirations rate, pain, and oxygen saturation, written in the plan of care. The DPCS stated the HHA checks oxygen saturation levels on all the patients, and these readings require individualized parameters depending on the disease. A review of facility’s undated policy titled, “Vital Signs (T, HR, RR, BP)” indicated, “Vital signs will potentially reveal sudden changes in a patient’s condition and will also measure changes that occur progressively over time. It is the policy of the Home Health Agency (HHA), to take vital signs during visits and report abnormal findings, as a difference between patients’ normal baseline vital signs and their present vital signs may indicate the need for intervention. Temperature, normal (oral) = 96.5 to 99F. Report findings outside of these parameters unless otherwise ordered by Medical Doctor (MD)… Heart Rate, normal resting heart rate = 60 to 100 beats per minute. Report findings outside of these parameters unless otherwise ordered by MD… Respiratory rate, normal resting respiratory rate = 12 to 20 breaths per minute. Report findings outside of these parameters unless otherwise ordered by MD… Blood pressure (BP), the average BP for an adult is 120/80 mmHg, but variations are normal for various reasons. Establish parameters in coordination with MD and report outside of those parameters…”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure written instructions/information regarding the patient’s care are provided to patient and caregiver for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice placed these patients at risk of not fully understanding what services to expect from the HHA, the purpose of each service and when to expect the services. A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022 indicated Patient 1 was oriented to person, place, and time, with diagnoses including Diabetes Mellitus II (High blood sugar), and rashes. A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022 indicated Patient 2 was oriented to person, place, and time, with diagnoses including Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). A concurrent interview and record review on 6/24/2022 at 9 a.m. with Director of Patient Care Services (DPCS) of Patient 2’s HHA folder indicated there was no written plan of instructions provided for the patient and caregiver inside the folder. DPCS stated she was not aware there should be a a written plan in the patients folder. DPCS stated that it would be a good idea, because if there is a new nurse that will assist the patient they will know what the plan of care is and will know what to do. A concurrent interview and record review on 6/24/2022 at 10:30 a.m. with License Vocational Nurse 1 (LVN1) of Patient 1’a HHA folder indicated there was no written plan instructions inside the folder. LVN1 stated that she was not aware there should be one in the folder. LVN1 stated, “Do we need to put one? We don’t usually put one in the folder, not really, as long as we have the medication profile. I’m not sure if we should have one, I’ll ask.” LVN1 stated that is important to have a POC in the folder, “so we know when the patient is recertified, and we can read what needs to be done and we can follow the POC”. An interview on 6/24/2022 at 12:50 p.m. with Registered Nurse 1 (RN1), RN1 stated that it is important to have a POC with patient. RN1 stated, “I can’t recall what the policy says, technically yes. If they are receiving certain treatment and medications, it should inform others of what the POC the patient has”. An interview on 6/27/2022, at 2 p.m., with Director of Patient Care Services (DPCS), DPCS stated that the POC should be with the patient, “So that they see why we are doing. So that whoever is taking care of them, they can assist us in helping the patient. There are more disciplines there to assist us in reaching our goals”. A review of facility’s policy titled “Coordination of Patient Care” undated indicated “All service providers involved in the care of a patient, including contracted health care professionals or another agency, will be engaged in an effective interchange reporting, and coordination of care regarding the patient. Upon admission, the patient will be assigned to an RN case manager for the purpose of care oversight and coordination of services. Coordination of care among the health care provides will support the objectives outlined in the plan of care. Staff shall communicate patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to the aforementioned to all other relevant staff members to endure quality care in a timely manner”. A review of facility’s policy titled, “Patient Conduct, Responsibility and Rights” undated indicated, “Before the care is initiated, the agency must inform a patient orally and in writing of the following: 7. The nature and frequency of services to be delivered and the purpose of the service. As a patient you have the right to: 13. Know when and how each service will be provided and coordinated, the agency ownership, name and functions of any person and affiliated agency personnel providing care and services. 37. The patient has the right to be informed about the individuals providing his or her care.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure written information regarding the patient’s medication regime was provided for three of seven sampled patients (Patient 1, Patient 2, and Patient 3). This deficient practice resulted in the patients missing information regarding the treatment plan the HHA was provided. Findings: A review of Patient 1’s “OASIS Start of Care” dated 6/1/2022 indicated Patient 1 was oriented to person, place, and time with diagnoses including Diabetes Mellitus II (High blood sugar), and rashes. A concurrent interview and record review on 6/24/2022 at 10:30 a.m. with License Vocational Nurse 1 (LVN1) of Patient 1’a HHA folder indicated there was no medication profile list inside folder. LVN1 stated, “No, I don’t see one. It’s important to have it in there so we know what the patient is taking. It’s important to have a current medication list so that we may know when it needs to be updated and if we are giving the right medication.” A review of Patient 2’s “OASIS Start of Care” dated 4/23/2022 indicated Patient 2 was oriented to person, place and time with diagnoses including Chronic Obstructive Pulmonary Disease (difficulty breathing) and Essential Primary Hypertension (high blood pressure). A concurrent interview and record review on 6/24/2022, at 9 a.m., with Director of Patient Care Services (DPCS) of Patient 2’s HHA folder indicated there was no medication profile/list inside folder. DPCS stated it should be in folder so that the nurse can reconcile the medications. DPCS stated that medications are reconciled at SOC, recertification, and when there is a change in medications. DPCS stated medications should be reconciliated at every visit. DPCS stated, “We only see patient once a week, a lot of them have multiple meds”. A review of Patient 3’s “OASIS Start of Care” dated 5/19/2022 indicated Patient 3's admitting diagnosis included Essential Primary Hypertension (high blood pressure). It also indicated Patient 3’s Medication Profile was left blank. An interview on 6/24/2022 at 12:50 p.m. with Registered Nurse 1 (RN1), RN1 stated that it is important to have a medication list/profile with patient. RN1 stated, “There should be one in folder, it needs to reflect what the patient is taking. Also, if the patient should ask about their medications”. An interview on 6/27/2022 at 1:45 p.m. with Director of Patient Care Services (DPCS), DPCS stated Patient 3’s admitting diagnosis was Essential primary hypertension. DPCS stated it was important to document that information. An interview on 6/27/2022 at 2 p.m. with Director of Patient Care Services (DPCS), DPCS stated that the medication profile, “It should be with patient. It would help them be more compliant if they knew what and why they were on their medications. Which would help in reaching their goals of them being or getting better.” A review of facility’s policy titled, “Medication Profile” undated indicated “It is the responsibility of the admitting therapist/nurse to record all medications that the patient is currently taking on a routine or PRN basis. Documentation will include upon admission, the medication, route, amount and frequency. The medication profile will be updated at least every 60 days or more often as needed. Medication profile will be updated when the patient’s medications change. A change is any/or all of the following related to routine and as needed medications: deletion/discontinuance of medication”. A review of facility’s policy titled, “Meds profile Form” undated indicated, “It is the policy of Home Health Agency (HHA), to ensure correct documentation of medications in the medication profile… The meds profile will be updated as frequently for changes in meds”. A review of facility’s policy titled, “Patient Conduct, Responsibility and Rights” undated indicated, “Before the care is initiated, the agency must inform a patient orally and in writing of the following: 7. The nature and frequency of services to be delivered and the purpose of the service. As a patient you have the right to: 5. Receive treatment, care and services that are adequate, appropriate, and in compliance with relevant state, local, and federal laws and regulations.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA’s governing body failed to ensure an ongoing program for quality improvement and patient safety is defined, implemented, and maintained. This failure had the potential for the HHA’s inability to provide safety and quality of patient care and services. Findings: During an interview on 6/24/22, at 2:20 p.m., the Director of Patient Care Services (DPCS) stated the governing body met every year in February to discuss the Quality Assurance Performance Improvement project for the year. The DPCS stated quarterly meetings were scheduled for March and June. The DPCS stated the agency did not have evidence the governing body met on those dates. The DPCS stated there was no agenda, no meeting minutes, and/or no sign in sheet. A review of the Home Health Agency (HHA) “Annual Performance Evaluation Meeting Attendance” dated February 12, 2021, indicated that the Quality Assurance Performance Improvement (QAPI) met on this day. Further review of the record did not indicate additional meetings were held during 2021. A review of the Home Health Agency (HHA) “Annual Performance Evaluation Meeting Attendance” dated February 18, 2022, indicated that the QAPI met on this day. Further review of the record did not indicate additional meetings were held during 2022. A review of facility’s undated policy titled, “Quality Assurance and Performance Improvement (QAPI)” indicated, the Home Health Agency (HHA) will “develop a QAPI plan in accordance with Federal Guidelines… 1. The facility will develop, implement, and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life... 4. The facility presents evidence in the form of documentation to substantiate the ongoing implementation and QAPI program compliance with regulations to the State Survey Agency, Federal Surveyor or CMS if requested.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure supplies stored in the agency for patient use, were checked for expiration dates. This failure placed all patients at risk of an adverse outcome due to the use of expired items provided to the patients. On 6/24/22, at 11:00 a.m., an observation of the medical supplies was conducted at the agency. Multiple expired items were observed: 10 urethral catheters (tubing used to drain urine from the bladder) expired on 3/31/21, 5 surgical dressings expired on 1/1/2020, and 5 non-adhering dressings expired on 12/2016. During an interview on 6/24/22, at 11:00 a.m., the registered nurse (RN) stated “there is a lot of expired supplies here”. The RN stated the supplies at the agency were used as a stock pile and didn’t necessarily mean they were used on patients. The RN stated he could not provide evidence that supplies had been checked for expiration date by the staff taking the item. The RN stated the risk of using an expired item is patient can have a reaction or the supply my not be working as intended. During an interview on 6/24/22, at 11:45 a.m., the RN stated the agency policy did not direct staff to check for expiration dates on supplies. States policy should include the process because it is an important task to check for expiration dates on supplies used on patients. A review of the home health agency’s (HHA), undated policy and procedure titled “Medical Supplies”, did not indicate a process for checking expiration dates on medical supplies.