Every finding on record at Amberkare Home Health, Inc

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION Surveys. The survey team entered the home health agency on 4/16/25 at 1227 hours. The home health agency identified the census as 34. The survey sample size was 8. GLOSSARY AND DEFINITIONS: DPCS: Director of Patients Care Services HHA: Home Health Agency P&P: Policy and Procedure

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include a process for collaboration with the regional and tribal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 4/23/26 at 1615 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This failure created the potential risk of not being to facilitate patients evacuation and transportation at an emergency event. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include policies and procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. On 4/23/26 at 1618 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. This failure created the potential risk of not providing continuity of necessary care and services to the patients during emergency events. Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include procedures to inform State and local officials of any on-duty staff or patients that they are unable to contact. On 4/23/26 at 1620 hours, an interview and concurrent facility document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness P&P included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This failure created the potential risk of not protecting the patient's confidential information during an emergency event. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. On 4/23/26 at 1623 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the potential risk of not providing immediate necessary care and services to the patients during emergency events. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 4/23/26 at 1625 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included a communication plan that showed the contact information for tribal and regional emergency preparedness staff. This failure created the potential risk of not getting possible immediate resources for necessary care and services to the patients during emergency events. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not include a communication plan that showed the contact information for tribal and regional emergency preparedness staff. On 4/23/26 at 1627 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness plan included method for sharing information and medical documentation for patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. This failure created the potential risk of not maintaining continuity of care and services to the patients during emergency events. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26, and showed the plan did not address method for sharing information and medical documentation for the patients under the agency's care, as necessary, with other health providers to maintain the continuity of care. On 4/23/26 at 1627 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency's 2026 emergency preparedness program documents was conducted on 4/23/26. However, the emergency preparedness communication plan did not include a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 4/23/26 at 1629 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS Surveys. The survey team entered the home health agency on 4/16/25 at 1227 hours. The home health agency identified the census as 34. The survey sample size was 8. GLOSSARY AND DEFINITIONS: ADL: Activity of Daily Living CHHA: Certified Home Health Aide CNA: Certified Nursing Assistant cm: centimeter(s) CMS: Centers for Medicare and Medicaid Services CNS: central nervours system coccyx: tailbone delirium: a mental state in which the person is confused, disoriented, and unable to think or remember clearly Dementia: group of symptoms affecting memory, thinking, and social abilities Diabetes mellitus: a disease of inadequate control of blood levels of glucose DME: Durable Medical Equipment DPCS: Director of Patient Care Services Dyspnea: shortness of breath EKG: electrocardiogram (noninvasive test that records the heart's electrical activity) ER: extended release French: unit of measurement used to measure the outer diameter of cylindrical medical instruments, most commonly catheters gm: gram(s) H: hour HHA: Home Health Agency HR: Human Resources Hyponatremia: a condition where the amount of sodium in the blood is too low Hypoxemia: low levels of oxygen in the blood Interferon Gamma Release Assays: crucial diagnostic tools used primarily for detecting Mycobacterium tuberculosis infection, which causes tuberculosis (TB). These blood tests measure the immune response to specific TB antigens, providing a reliable method for diagnosing TB infection, especially in populations where traditional skin tests may be less effective. lbs: pounds LVN: Licensed Vocational Nurse Mantoux test is a skin test used to detect exposure to Mycobacterium tuberculosis by measuring a delayed hypersensitivity reaction to purified protein derivative (PPD). Metabolic acidosis: a condition in which acids build up in the body mg: milligram(s) NP: Nurse Practitioner NSAID: nonsteroidal anti-inflammatory drugs Oxygen saturation: the percentage of oxygen in a person's blood OT: Occupational Therapy/Therapist PCG: Primary Caregiver PCP: Primary Care Physician pneumonia: infection of the lungs P&P: Policy and Procedure PPD: Purified Protein Derivative Test (skin test is a method used to diagnose silent tuberculosis infection. PO: By mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist Q: Every QAPI: Quality Assurance and Performance Improvement RN: Registered Nurse Sacrum: a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis SN: Skilled Nursing/Nurse SOB: shortness of breath SOC: Start of Care ST: Speech Thearapy/Therapist Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Tachycardia: an abnormal heart rhythm with a fast heart rate of more than 100 beats per minute at rest. TB: tuberculosis (a bacterial disease that usually attacks the lungs. But it can also attack other parts of the body, including the kidneys, spine, and brain) TID: three times a day W: Week

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 record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for one of eight sampled patients (Patient 3). This failure had the potential for not providing the necessary care and services timely to this patient. Findings: The agency's P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, on the start of care date ordered by the physician (or other authorized licensed independent practitioner), or at the patient/family request with the approval of the physician (or other authorized licensed independent practitioner). A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care. Review of Patient 3's clinical record was initiated on 4/17/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The clinical record showed the referral date was 1/9/26, and the patient's Comprehensive Start of Care was 1/14/26. However, further review of the clinical record showed no documented evidence of the reason why the SOC was 1/14/26, instead of the 48 hours of the referral date of 1/9/26. On 4/23/26 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding.

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 initial comprehensive assessments were completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the SOC date for one of eight sampled patients (Patient 3). This failure created the risk of not identifying and addressing the care needs timely for this patient. Findings: Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The Comprehensive Start of Care Assessment dated 1/14/26, showed the patient's primary diagnosis was other specified chronic obstructive pulmonary disease. The narrative notes showed the patient had asthma. Further review of the Comprehensive Start of Care Assessment included the section for respiratory. The assessment showed the patient was assessed to have dyspnea with ADL care. Breath sound was assessed to have wheezing on the anterior and posterior lung fields. However, there was no documented evidence the oxygen saturation level was assessed as the section was left blank. In addition, the section for home oxygen risk assessment and compliance checklist showed the sections for the flow rate setting and prescribe setting. However, those sections were left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were reviewed and updated to reflect the current medications and include specific indications and parameters for its use for two of eight sampled patients (Patients 3 and 4). These failures had the potential for the patients not to receive the appropriate care and necessary services and negatively affect the patients' well-being. Findings: 2. Review of Patient 4's clinical record was initiated on 4/20/26. The clinical record showed SOC was 2/20/26. The patient was certified for home health services during the certification periods from 2/20/26 to 4/20/26. The Medication Profile revised date 3/20/26 included fluticasone propionate/salmeterol aerosol inhaler, to inhale 1 puff by mouth three times a day. On 4/20/26 at 1333 hours, a home visit observation, interview and concurrent document review with RN 3 and medical technician for Patient 4 residing in an Assisted Living Facility. During the medication profile review, a medication, fluticasone propionate/salmeterol aerosol inhaler was not available. The medical technician was asked and informed the Patient 4 no longer used the medication. RN 3 was asked if it should have been followed up and updated in the medication profile. RN 3 acknowledged the medication profile should have been updated. 3. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. However, Patient 7's Medication Profile was not updated not include calcium alginate. On 4/23/26 at 0932 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the findings. On 4/23/26 at 1640 hours, an interview was conducted with the DPCS and Administrator. Both were informed and acknowledged the findings. Review of the hospice's P&P titled Medication Profile revised 4/2019 showed patients receiving the medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and or discontinued medications. 1. Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The Medication Profile revised date 2/18/26 showed the patient was on bisacodyl (laxative) 10 mg unwrap and insert one suppository rectally every other day as needed for constipation, ibuprofen (NSAID) 600 mg one tablet PO Q6H PRN for pain NTE 4 doses per 24H, Acetaminophen (NSAID) 325 mg one tablet POQ6H for severe pain, milk of magnesia (laxatives) 400 mg per 5 ml oral suspension take two tablespoon (30 ml) Q8H PRN for constipation and Fleet enema (laxative) 19 gm- 7gm/118ml insert one dose rectally every 24H PRN for constipation. A joint home visit with LVN 2 was conducted on 4/23/26 at 1300 hours, to the Assisted Living facility where Patient 3 resided. Review of the patients medication with the LVN 2 and the facilities medical technician was conducted. However, the above list of medications were discontinued on 3/16/26. On 4/17/26 at 1347 hours an interview and clinical record was conducted with the facility medical technician. The medical technician was asked as to the availability of the above medications. The medical technician checked the facility's medication orders and replied, those medications were discontinued on 3/16/26. On 4/17/26 at 1402 hours, the an interview and concurrent clinical record review was conducted with the LVN 2. LVN 2 was asked as to the frequency of medication check. LVN 2 replied every visit. LVN 2 was informed and acknowledged the findings. On 4/23/26 at 1318 hours, the findings were shared with the Administrator/DPCS. The Administrator/DPCS acknowledged the findings.

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 ensure the comprehensive assessment was updated within the last five days of every 60 days for one of eight sampled patients (Patients 6). This failure had the potential for not addressing the care needs for this patient. Findings: Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The Comprehensive Recertification dated 3/9/26, showed the patient's vital signs were checked. However, there was no documented evidence the patient's oxygen saturation level was checked as part of the comprehensive assessment. On 4/23/26 at 1411 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

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 agency failed to 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 to ensure the safe and effective transition of care for one of eight sampled patients (Patient 2). This failure had a potential risk of not providing continuity of necessary care and services to the patient. Review of the agency's P&P titled Transfer Summary revised 4/2019 showed the completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization, along with a copy of the clinical records, within two business days of a planned transfer or within two days of becoming an unplanned transfer and will file the original in the clinical record. Review of Patient 2's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health services during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. The patient was discharged on 2/24/26. Review of Patient 2's Comprehensive Transfer Without Discharge dated 2/24/26, showed the patient was taken to the general acute care hospital due to the NP's recommendations for acute medical decline characterized by worsening hypoxemia, productive cough with suspected aspiration pneumonia, significant dehydration with metabolic acidosis, persistent hyponatremia increasing seizure and delirium risk, acute altered mental status beyond her usual dementia baseline, tachycardia on EKG consistent with systemic illness, and severe malnutrition. The Comprehensive Transfer Without Discharge showed the plan of care was provided to the physician and to another facility. However, the facility name to which the plan of care was provided was not the same as the hospital name to where the patient was transferred. On 4/23/26 at 1614 hours, an interview and document review was conducted with the DPCS and Intake Coordinator. The DPCS was asked where Patient 2 was transferred. The DPCS stated Patient 2 was sent to the hospital. The DPCS was asked if a copy of a transfer summary was sent to the hospital. The DPCS stated the Intake Coordinator usually sent the copy. The Intake Coordinator was informed and verified she sent to another facility but not to the hospital where the patient was transferred. On 4/23/26 at 1640 hours, the DPCS and Administrator were informed and acknowledged the findings.

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 the SN and the CHHA missed visits were rescheduled for two of eight sampled patients (Patients 2 and 7). This failure had a potential risk to provide necessary care and services to the patients. Review of the agency's P&P titled Missed Visits showed if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 1. Review of Patient 2's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health services during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. The patient was discharged on 3/6/26. Review of the POC dated 1/7/26, showed SN visits 2W2 (two times a week for two weeks), and 1W7; and CHHA visits 2W9. Review of Patient 2's calendar visits showed the following documentation of the missed visits: -On 1/13 and 2/3/26, the physician was informed of the CHHA missed visit and reason. However, there was no documentation of a rescheduled CHHA visit. On 4/23/26 at 0936 hours, an interview and clinical record review was conducted with the DPCS. The DPCS verified the findings. 2. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of the POC dated 2/27/26, for the certification period from 2/27/26 to 4/27/26, showed SN visits 1W1, 3W, 2W7, and 1W1; and CHHA visits 0W1, 2W8, and 1W1. Review of Patient 7's calendar visits showed the following documentation of the missed visits: -On 3/30/26, the physician was informed of the missed visit and reason. However, there was no documentation of the reschedule of CHHA visit. On 4/23/26 at 1022 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the missed visit should have been rescheduled.

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 POCs included specific information related to medications, DME and blood sugar instructions for five of eight sampled patients (Patients 1, 3, 6, 7, and 8). This failure created the risk of not addressing the care needs for these patients. Findings: The agency P&P titled Care Planning Process revised 4/2019 showed the plan of care will include but not limited to all patient care orders from all physicians involved in the plan of care, specific services and treatments to be provided, equipment and supplies and all medications. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of Wound Pros Progress Notes dated 10/2/25 showed the treatment orders for the patients' stage 3 pressure injury to the center midline sacrococcyx. The treatment included cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed followed by collagen (clinician's supply) and oil emulsion gauze. Apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 (two times a week for two weeks), 1W7 (one time a week for seven weeks) to perform comprehensive observation and assessment and all the body systems. SN to assess and observe for signs and symptoms of wound infection/complication on sacral region, presence of pus, increase pain, swelling, redness, increase in wound size and fever. However, the POC did not include specific instructions to address the medications or treatment for the patients' stage 3 pressure injury to the sacrum. On 4/23/26 at 1427 hours an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed the SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC for the certification periods from 3/15/26 to 5/13/26 on the section of DME showed cane and incontinence supplies. The medication included oxygen at 2 liters via nasal cannula as needed for SOB. On 4/17/26 at 1300 hours, an joint visit was conducted with the LVN 2 to the patients home. The patient was observed to have an oxygen via nasal cannula connected to the oxygen concentrator. However, there was no documented evidence of the oxygen concentrator was listed in the POC on the section of DME. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding. 3. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 1/31/26 to 3/31/26 cited 0W1, 2W1, 1W8. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 2/2, 2/5, 2/10, 2/20, 2/26, 3/4, 3/12 and 3/25/26 showed the SN had performed the patients blood sugar check as ordered in the POC. However, the POC failed to include specific instructions as to who will check/ monitor the patients' blood sugar level during non - SN visit days. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26 cited SN 1W9. The POC included SN to instruct medication and pain management. The POC showed the list of the following pain medications. -Excedrin Extra Strength (analgesic, NSAID, CNS stimulant) APAP 250 mg/ASA 250 mg/caffeine 65 mg) two tablets PRN for pain, -Meloxicam (NSAID) 7.5 mg one tablet PO PRN for arthritis pain, -hydrocodone bitartrate (narcotic) 5 mg /acetaminophen 325 mg oral tablet one tablet PO TID PRN for pain. However, the POC failed to include specific instructions as to the level of pain when to give the PRN medications. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if they needed to include the level of pain for the PRN pain medications. The Administrator/DPCS replied, there should be a pain level. The Administrator/DPCS was informed and acknowledged the findings. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show individualized plan of care for the all wound sites that included wound care interventions and the additional wound care consult recommendations. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked to show individualized plan of care documentation on all the wound sites, treatment and recommendations as instructed by the wound care consult. The DPCS acknowledged specific individualized plan of care should have been done as instructed by the wound care consult. On 4/23/26 at 1701 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings. The agency's P&P titled Care Planning Process revised 4/2019 showed the plan of care will include but not limited to all patient care orders from all physicians involved in the plan of care, specific services and treatments to be provided, equipment and supplies and all medications. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the Wound Pros Progress Notes dated 10/2/25, showed the treatment orders for the patient's Stage 3 pressure injury to the center midline sacrococcyx. The treatment was to cleanse the wound with cleanser and pat dry with gauze, apply Tetracyte to the wound bed followed by collagen (clinician's supply) and oil emulsion gauze, apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation, and use a bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment and all the body systems. The POC also cited SN to assess and observe for signs and symptoms of wound infection/complication on sacral region, presence of pus, increase pain, swelling, redness, increase in wound size, and fever. However, the POC did not include specific instructions to address the medications or treatment for the patient's Stage 3 pressure injury to the sacrum. On 4/23/26 at 1427 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed the SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC, for the certification periods from 3/15/26 to 5/13/26, showed cane and incontinence supplies. The medication included oxygen at 2 liters via nasal cannula as needed for SOB. On 4/17/26 at 1300 hours, an joint visit was conducted with LVN 2 to the patient's home. The patient was observed to have an oxygen via nasal cannula connected to the oxygen concentrator. However, there was no documented evidence of the oxygen concentrator listed in the POC on the section of DME. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the finding. 3. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 1/31/26 to 3/31/26 cited 0W1, 2W1, 1W8. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 2/2, 2/5, 2/10, 2/20, 2/26, 3/4, 3/12 and 3/25/26 showed the SN had performed the patients blood sugar check as ordered in the POC. However, the POC failed to include specific instructions as to who will check/ monitor the patients' blood sugar level during non - SN visit days. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26 cited SN 1W9. The POC included SN to instruct medication and pain management. The POC showed the list of the following pain medications. -Excedrin Extra Strength (analgesic, NSAID, CNS stimulant) APAP 250 mg/ASA 250 mg/caffeine 65 mg) two tablets PRN for pain, -Meloxicam (NSAID) 7.5 mg one tablet PO PRN for arthritis pain, -hydrocodone bitartrate (narcotic) 5 mg /acetaminophen 325 mg oral tablet one tablet PO TID PRN for pain. However, the POC failed to include specific instructions as to the level of pain when to give the PRN medications. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if they needed to include the level of pain for the PRN pain medications. The Administrator/DPCS replied, there should be a pain level. The Administrator/DPCS was informed and acknowledged the findings. 5. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show individualized plan of care for the all wound sites that included wound care interventions and the additional wound care consult recommendations. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked to show individualized plan of care documentation on all the wound sites, treatment and recommendations as instructed by the wound care consult. The DPCS acknowledged specific individualized plan of care should have been done as instructed by the wound care consult. On 4/23/26 at 1701 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings.

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 the treatment was provided only as ordered by the physician for three of eight sampled patients (Patients 1, 7, and 8). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: XX. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and wound #4 located at left lateral lower leg sacral region, all with wound care consult treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult showed the following further recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning; -Frequent diaper checks and changes; -No sitting beyond 2 hours -Dietary recommendations for wound healing Review of Patient 7's SOC dated 2/27/26 showed RN 1 performed wound assessments and treatment for sacral, left hip, right buttocks, right lateral foot, left leg site #1, left leg site #2, right leg, right medial knee, and right lateral knee. RN 1 cleansed all wounds with NS, applied Manuka honey and covered with non woven sponge gauze 4x4. However, RN 1's wound treatment to all wound sites did not include application of calcium alginate, use of bordered foam dressing and recommendations as ordered from the wound care consult. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was asked if the wound care consult treatment and recommendations dated 2/24/26 should have been followed by RN 1 during her SOC dated 2/27/26. The DPCS verified the RN should have followed the wound care consult treatment orders and recommendations. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. The Administrator and DPCS acknowledged the findings. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the Comprehensive Recertification dated 10/5/25, showed the RN 1 performed comprehensive assessment. The assessment showed RN 1 had performed wound assessment and treatment to the patients' stage 3 pressure injury to the sacrum. The treatment showed cleansed with wound care spray, pat dry, applied with Medihoney and wet to dry dressing, wrapped with foam dressing daily and as needed if soiled. In addition, review of the Comprehensive Discharge dated 12/4/24, showed the RN 2 had performed comprehensive assessment. The assessment showed RN 2 had performed wound assessment and treatment to the patients stage 3 pressure injury to the sacrum. The treatment showed cleansed with wound care spray, pat dry, applied with Medihoney and wet to dry dressing, wrapped with foam dressing daily and as needed if soiled. However, review of the closed clinical record failed to show documented evidenced of the physicians' order of the treatment provided for the patients' stage 3 pressure injury to the sacrum. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if there was order for the above treatment. The Administrator/DPCS reviewed the closed clinical record and replied no. The Administrator/DPCS was also asked if they can provide treatment without a physicians' order. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1 and 1W7. Review of the clinical record showed the SN had visited the patient on Weeks 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted on Week 3 (4/12/26 to 4/18/26) as ordered in the POC. On 4/23/256 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked if there was a visit conducted on Week 3. The Administrator /DPCS reviewed the clinical record and replied, there was a visit on 4/16/26 but there was no notes submitted. The Administrator/DPCS was also asked as to the timeline of clinical notes submission. The Administrator/DPCS replied within 24 hours from the visit date. The Administrator/DPCS as informed and acknowledged the findings.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to revise and update the POC for one of eight sampled patients (Patient 1). This failure created the risk for not providing the necessary care and services to this patient. Findings: Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the wound care company's progress notes dated 10/2/25, showed the treatment orders for the patients' Stage 3 pressure injury to the center midline sacrococcyx. The treatment was to cleanse the wound with cleanser, pat dry with a gauze, apply Tetracyte to the wound bed followed by collagen (clinician's supply) and oil emulsion gauze, apply a foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation, and use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the wound care company's clinician and two times a week by the nurse and PRN. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7 to perform comprehensive observation and assessment and all the body systems. However, the POC was not revised to address the changes of the SN visit frequency for wound care. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the wound care, PT, and OT services were coordinated for five of eight sampled patients (Patients 1, 3, 6, 7, and 8). This failure created the risk of not providing the necessary care and services to these patients. Findings: The agency's P&P titled Care Coordination revised 4/2019 showed to ensure coordination of services for each patients. Each patient will be assigned a Case Manager upon admission by the Clinical Director or Clinical Supervisor. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group, will be appropriate to the needs and abilities of the patient, and will be relevant to the care provided. Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient's clinical records. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC for the certification periods from 10/5/25 and 10/6/25 to 12/4/25 cited SN 2W2 (two times a week for two weeks) 1W7 (one time a week for seven weeks) for skilled nursing assessment, observation and evaluation of all body system. Review of the closed clinical record from Week 3 (10/19/25 to 10/25/25) to Week 8 (11/23/25 to 11/29/25) showed the SN visit frequency was one time a week. Review of Wound Pros Progress Notes dated 10/14, 10/23, 10/30, 11/6, 11/13, 11/20, 11/25 and 12/2/25 showed the treatment orders for the patients' stage 3 pressure injury to the center midline sacrococcyx. The treatment included cleanse the wound with cleanser and pat dry with gauze. Apply Tetracyte to the wound bed followed by collagen (clinician's supply) and oil emulsion gauze. Apply foam dressing three times weekly and PRN for soiled or loose dressing and as needed for soilage /saturation. Use bordered gauze between scheduled dressing changes and PRN for soiled or loose dressing. The dressing frequency showed one time a week by the Wound Pros clinician and two times a week by the nurse and PRN. However, there was no documented evidence of the changes in the visit frequency to two times a week was coordinated as ordered by the Wound Care NP. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS replied, no. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. a. The Comprehensive Recertification dated 3/14/26 on the section of referrals showed a check mark for PT. However, there was no documented evidence of the RN had coordinated the referral for PT as identified on the comprehensive recertification assessment. b. Review of the Physical Therapy Clinical Notes dated 1/30/26 on the narrative showed patient was discharge from skilled therapy services. However, there was no documented evidence of the physician was notified of the PT discharge as the section for care coordination for MD was left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. 3. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The Comprehensive Recertification dated 1/30/26 on the section of referrals showed a check mark for PT and OT. However, there was no documented evidence of the RN had coordinated the referral for PT and OT as identified on the comprehensive recertification assessment. On 4/23/256 at 1411hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The Comprehensive Recertification dated 3/9/26 on the section of referrals showed a check mark for PT. However, there was no documented evidence of the RN had coordinated the referral for PT as identified on the comprehensive recertification assessment. On 4/23/26 at 1417 hours an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. XX. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Wound Care Consult dated 2/24/26 showed for wound #1 located at sacrum, sacral region, wound #2 located at right buttock, wound #3 located at left hip and #4 located at left lateral lower leg sacral region, all with wound treatment order to cleanse with normal saline, pat dry, apply medihoney and calcium alginate then cover with border foam dressing, SN to follow up two times per week and wound care specialist one time per week. The wound care consult with further following recommendations: -Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. Please remove all products with fragrance, including body washes and lotions. -To order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading, recommend: Every 2 hours turning, -Frequent diaper checks and changes, -No sitting beyond 2 hours, -Dietary recommendations for wound healing. Review of the POC dated 2/27/26 for the certification period from 2/27/26 to 4/27/26 showed SN frequency of visits of 1wk1 (one time a week) , 3wk1 ( three time a week for one week), 2wk7 ( two times a week for seven weeks) and 1wk1 (one time a week) to continue to monitor and record vital signs, and perform skilled nursing assessment, observation and evaluation of all body systems with emphasis on integumentary, cardiovascular, gastrointestinal, endocrine and genitourinary systems. SN to assess and observe for signs and symptoms of wound infection/complication on pressure ulcer of sacral region, stage 4, presence of pus, increased pain, swelling, redness, increase in wound size and fever, to inform SN/physician immediately if observed, However, the POC did not show documented evidence of the wound care consult treatment orders, recommendations and visit frequency were included. Review of Patient 7's miscellaneous notes dated 3/20/26 NP's notes showed remove as per communication with NP regarding report that catheter was removed due to no urine output, minor bleeding during removal, with NP recommendation to follow up urinalysis result, are there any signs and symptoms of infection?. However, there was no documentation for clarifications on following up with with NP regarding her recommendation and as to FC removal as change of condition or to discontinue. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Administrator and DPCS. The Administrator and DPCS acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits 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 agency failed to provide a written instruction outlining the visit schedule for one of eight sampled patients (Patient 3). This failure had the potential for not providing the necessary information to this patient. Findings: Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. The POC, for the certification period from 3/15/26 to 5/13/26, cited SN visits 2W2 and 1W7 for assessment, observation, and evaluation of all body systems. A joint home visit with LVN 2 was conducted on 4/17/26 at 1300 hours, to Patient 3's home. Review of the patient’s home folder was conducted with LVN 2. The home folder showed the visit schedule showing SN for the month of January 2026. However, there was no documented evidence of the updated written instructions outlining the SN visit schedules after January 2026. On 4/17/26 at 1402 hours, an interview and concurrent document review was conducted with LVN 2. LVN 2 was asked if a visit schedule was available in the home folder. LVN 2 stated no. On 4/23/256 at 1318 hours, the finding was shared with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide care and services as per the written plan of care for two of eight sampled patients (Patients 1 and 7). This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25 included a diagnosis of hypertensive heart disease. The POC cited SN visits 1W9 for SN to perform skilled nursing assessment, observation and evaluation of all the body systems. SN to weight patient once a week and report to MD if weight gain greater than 5 lbs. in one week, swelling and plus 3 edema or greater. Review of the SN notes dated 10/8, 10/11, 10/14, 10/17, 10/24, 10/31, 11/6, 11/12, 11/21, 11/24 and 12/1/25 showed the SN had performed the body system assessment. However, there was no documented evidence the SN had performed genitourinary assessment as the section was left blank. In addition, there was no documented evidence of the SN had weight the patient weekly as the section was left blank. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Patient 7's Face to Face Encounter dated 2/14/26 showed medical necessary services for Skilled Nursing, Wound Care, Home Health Aide, Cardiac, Care, Diabetic Care and for other services needed as foley catheter care and change. Review of SOC dated 2/27/26 showed RN performed Urinary Catheter Assessment. The Urinary Catheter Assessment showed Patient 7 was with French 16 indwelling catheter inflated with 10 ml balloon. Review of SN notes showed the following: -dated 3/26/26, 4/2/26 with no genitourinary assessment On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. All acknowledged the findings.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the instructions or teachings on wound care as advised by wound care consults were provided to patients/caregiver for one of eight sampled patients (Patient 7). This failure posed a potential for the caregiver not knowing how to care for this patient. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of Patient 7's Wound Care Consult dated 2/24, 3/3, 3/10, 3/17, 3/24, 3/31, and 4/7/26, showed the following: -Additional Recommendations: Turn patient every two hours, keep the skin clean and dry, avoid massaging bony prominences, provide adequate intake of protein and calories, maintain the current level of activity, mobility, and range of motion, use of positioning devices to prevent prolonged pressure bony prominences, keep the head of the bed as low as possible to reduce risk of shearing, and keep sheets dry and wrinkle free. To remove all products with fragrance, including body washes and lotions. Family and patients were instructed to order diaper wipes without fragrance; ideally, the patient should use chemical-free, fragrance-free disposable washcloths -Aggressive offloading and recommend: every 2 hours turning, frequent diaper checks and changes, no sitting beyond 2 hours, and refer to the PCP recommendations for dietary recommendations for wound healing. However. the SN visit notes dated 3/5, 3/7, 3/12, 3/19, 3/24, 3/26, 3/28, 4/2, 4/4, and 4/9/26, did not show the patient/caregiver were provided education regarding the wound care consult's recommendations. On 4/23/26 at 1112 hours, an interview and document review was conducted with the DPCS. The DPCS was asked if she could show any documentation from the SN visits regarding education was provided to the patient/family/caregiver on the additional recommendations advised by wound care consult. The DPCS verified all recommendations should have been included as teaching or reminders to the patient/family/caregiver.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for four of eight sampled patients (Patients 1, 3, 7, and 8). This failure created the increased risk of substandard healthcare outcomes to these patients. Findings: 4. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification periods from 2/27/26 to 4/27/26. Review of Patient 7's Face to Face Encounter dated 2/14/26 showed medical necessary services for Skilled Nursing, Wound Care, Home Health Aide, Cardiac, Care, Diabetic Care and for other services needed as foley catheter care and change. Review of SOC dated 2/27/26 showed RN performed Urinary Catheter Assessment. The Urinary Catheter Assessment showed Patient 7 was with French 16 indwelling catheter inflated with 10 ml balloon. Review of SN notes showed the following: -dated 2/28, 3/5/26 genitourinary assessment showed Patient 7 was with 16 French catheter, incontinent with yellow urine output. However, there was no documentation of when the foley catheter was last changed. -dated 3/10/26 genitourinary assessment showed Patient 7 was with foley catheter, with no odor, clear, yellow urine output. However, there was no documentation on French size and date last changed. On 4/23/26 at 1107 hours, an interview and record review was conducted with the DPCS. The DPCS was informed and verified the above findings. On 4/23/26 at 1640 hours, an interview was conducted with the Intake Coordinator, Administrator and DPCS. The Administrator and DPCS acknowledged the findings. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25 and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. Review of the POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2, 1W7 (two times a week for two weeks) to perform comprehensive observation and assessment and all the body systems. SN to assess and observe for signs and symptoms of wound infection/complication on Sacral region, presence of pus, increase pain, swelling, redness, increase in wound size and fever. a. Review of the Wound Pros Progress Report dated10/14/25 showed the following measurement: Length = 1, Width = 1, and Depth = 0.3. Review of the SN visit Notes dated 10/14/25 showed the SN had performed wound assessment to the patients stage 3 pressure injury to the sacrum. The measurement in centimeters showed the following: Length = 2 , Width = 2, and Depth = 0.3. However, the length and width was inconsistent. *Review of the Wound Pros Progress Report dated11/6/25 showed the following measurement: Length = 0.6, Width = 0.4, and Depth = 0.3. Review of the SN visit Notes dated 11/6/25 showed the SN had performed wound assessment to the patients stage 3 pressure injury to the sacrum. The measurement in centimeters showed the following: Length = 2 , Width = 2, and Depth = 0.3. However, the length and width was inconsistent. b. Review of the SN visit Notes dated 10/8, 10/11, 10/14, 10/17,10/24, 10/31, 11/5, 11/12, 11/21, 11/24 and 12/1/25 showed the SN had performed wound assessment to the patients’ stage 3 pressure injury to the sacrum. The section for comment showed a check marked on other "see tx order". However, there was no documented evidence as to what the treatment order was. On 4/23/26 at 1427 hours an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to what the treatment order was. The Administrator/DPCS reviewed the clinical record and replied, it was from Wound Pros, it was not documented on the SN visit notes. The Administrator/DPCS was also asked if the wound measurement were accurate in relation to the wound pros assessment. The Administrator/DPCS replied no, it was inconsistent. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 3's clinical record was initiated on 4/17/26. The clinical record showed SOC was 1/14/26. The patient was certified for home health services during the certification periods from 1/14/26 to 3/14/26 and 3/15/26 to 5/13/26. a. Review of the Comprehensive Recertification dated 3/14/26 on the section of respiratory showed the patient was assessed to have dyspnea with ADL's. Breath sound was assessed to have wheezing on the anterior and posterior lung fields. However, there was no documented evidenced of oxygen saturation was assessed as the section was left blank. In addition, on the section of home oxygen risk assessment and compliance checklist showed a section for the documentation of the flow rate setting and prescribe setting. However, those sections were left blank. On 4/23/256 at 1318 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. b. The POC for the certification period from 1/14/26 to 3/14/26 cited SN 1w1, 2W1 and 1W7 to monitor and record vital signs, perform nursing assessment, observation and evaluation of all body systems. Review of the SN visit notes dated 1/20, 1/23, 1/29, 2/5, 2/13, 2/17, 2/23 and 3/4/26 showed the SN had performed vital signs and body system assessment. The vital signs included the oxygen saturation. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. Review of the SN visit notes dated 1/20, 2/5/26 showed the SN had performed vital signs and body system assessment. The vital signs included the oxygen saturation. On the section of respiratory showed the patients breath sound was assessed to have wheeze and with SOB on exertion, oxygen saturation was checked. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. Further review of the SN visit notes dated 1/23, 1/29,2/13, 2/17, 2/23 and 3/4/26 showed the patient was assessed to have clear breath sounds, with SOB on exertion. However, on the section for the continuous, intermittent and PRN use of oxygen was left blank. On 4/23/256 at 1343 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS reviewed the clinical record and acknowledged the findings. 3. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1, 1 W2. The POC included SN to perform proper blood sugar checking/recording. Review of the SN visit notes dated 4/2, 4/6, 4/11/26 showed documented evidenced of the patients' blood sugar level. However, the section where to indicate a check mark if it was done by SN and or done by patient/PCG was left blank. On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/ DPCS. The Administrator/DPCS was informed and acknowledged the findings.

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 the HHA’s RN provided supervision to the LVN to ensure quality of care and services were provided for two of eight sampled patients (Patients 1 and 6). This failure had the potential for substandard health outcomes to these patients. Findings: The agency's P&P titled Supervisory Visits (LVN) undated showed all LVNs must be supervised by a Registered Nurse (RN) in accordance with CMS regulations to ensure safe and effective patient care. The procedure includes RN responsibilities to review LVN documentation, provide clinical oversight and adherence to the plan of care. The RN must still perform supervisory visit every 30 days. 1. Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25, cited SN visits 2W2 and 1W7. Review of the clinical record for Patient 1 showed the LVN did not provide services in accordance with the POC for this patient. Cross reference to G710, example #1. Review of the Supervisory Visit dated 11/6/25, showed the Administrator/DPCS had conducted a supervisory visit for LVN 2. However, the Administrator/DPCS failed to identify LVN 2 did not provide services in accordance with the POC. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 2. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The POC, for the certification periods from 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26, showed the supervisory visit was conducted for LVN 5 on 2/4, 2/24, and 4/7/26. However, there was no documented evidence the RN had conducted a supervisory visit for LVN 5 for the month of March as per the agency's P&P. On 4/23/25 at 1417 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency's RN provided the onsite supervision for the CHHA no less frequently than every 14 days to ensure quality of care and services provided for one of eight sampled patients (Patient 1). This failure had the potential for substandard health outcomes to this patient. Findings: The agency's P&P titled Supervisory Visits undated showed to ensure quality of care and compliance with supervision requirements for Certified Home Health Aides (CHHAs). All CHHA s must be supervised by a Registered Nurse (RN) in accordance with CMS regulations to ensure safe and effective patient care. RN must performed supervisory visits at least every14 days ( while aide services are provided). Review of Patient 1's closed clinical record was initiated on 4/16/26. The clinical record showed the SOC was 4/9/25. The patient was certified for home health services during the certification periods from 4/9/25 to 6/7/25, 6/8/25 to 8/6/25, 8/7/25 to 10/5/25, and 10/6/25 to 12/4/25. The patient was discharged from the agency on 12/4/25. The POC, for the certification period from 10/6/25 to 12/4/25, cited CHHA/CNA visits 2W9. The CHHA notes showed the CHHA visits were conducted during Week 1 (10/6/25 to 10/11/25), Week 3 (10/19/25 to 10/25/25) and Week 7 (11/16/25 to 11/22725). However, review of the Supervisory Visit showed the Administrator/DPCS performed the supervisory visit on 11/6/25, during Week 5 for CHHA 1. There was no documented evidence the RN completed a supervisory visit to conduct the assessment of CHHA services provided no less frequently than every 14 days during the above time period. On 4/23/25 at 1427 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked about the frequency for the CHHA supervisory visit. The Administrator/DPCS replied every 14 days. The Administrator/DPCS was informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency's Administrator failed to be responsible for the day-to-day operations related to the following: -The written agreements with Contractors 1, 2, 3, 4, 5, and 6 did not include the roles, rights and responsibilities. -The PT/OT evaluation was not conducted timely for five of eight sampled patients (Patients 2, 4, 5, 6, and 8) as per the agency's P&P. -The SN visit notes were not submitted/completed timely for one of eight sampled patients (Patient 8) as per the agency's P&P. -The personnel P&Ps were not followed. These failures created the risk of not providing quality of care and services to the patients receiving services from the HHA. Findings: Review of the HHA's Administrator Job Description Summary revised 4/2019 showed Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. The essential job functions/ responsibilities included the following: -planning, and directing operations to ensure the provision of adequate and appropriate care and services. -recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. -ensuring ongoing oversight of the agency's quality management system. -evaluating services and programs. -ensuring personnel development including orientation, in service education and continuing education. -ensuring that appropriate service policies are developed and implemented. -directing personnel in performance of their duties including admission, discharge and provision of service to patients. Review of agency's P&P titled Start of Care Referral (undated) showed scope that applies to Intake/Referral Coordinators, Registered Nurses, Clinical Supervisors and Therapy Staff as Physical Therapy/ Occupational Therapy/ Speech Therapy. SOC (Start of care must be initiated within 48 hours of referral. Review of agency's P&P titled Physical Therapy Evaluation (undated) showed scheduling of evaluation included PT (Physical Therapy) evaluation must be completed within 48 hours of referral or as ordered by the physician or based on patient needs, coordinate visit with patient/caregiver. Review of the agency's P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either with 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician (or other authorized license independent practitioner), or at the patient/family request with the approval of the physician( or other authorized licensed independent practitioner). 1.Review of Patient 2's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health service during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. Patient 2 was discharged on 3/6/26. Review of Patient 2's POC dated 1/14/26 showed Skilled Nursing Frequency Visit and duration of 2wk2 (two times a week for two weeks), 1wk7 ( one time a week for seven weeks), CHHA Certified Home Health Aide Visit Frequency and duration was 2wk9 (two times a week for nine weeks), Physical Therapy evaluation and treatment. Review of Patient 2's Recertification Order dated 1/5/26 showed Patient 2 was for Physical Therapy evaluation and treatment. Review of Patient 2's Physical Therapy Evaluation and Plan of Care dated 11/11/25 showed PT 3 assessed for functional status as bed mobility, gait, ADL ( activities of daily living), stretch and range of motion, posture, endurance, palpitation, sitting balance, standing balance plan of care, frequency an duration of treatment. However, PT 3's date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 0945H hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. 2. Review of Patient 4's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/20/26 The patient was certified for home health service during the certification periods from 2/20/26 to 3/21/26 and 3/22/26- 4/20/26. Review of Patient 4's POC dated 2/27/26 showed Patient 4 was for Physical Therapy evaluation and treatment. Review of Patient 4's SOC dated 2/20/26 showed Patient 4 was for Physical Therapy Evaluation and Treatment. Review of Patient 4's Physical Therapy Evaluation and POC showed PT 1 conducted assessments for functional status, balance, range of motion exercises, strength, frequency and treatment. However, PT 1's date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 1054 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. 3. Review of Patient 5's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 3/28/26. The patient was certified for home health services during the certification periods from 3/28/26 to 5/26/26. Review of Patient 5's POC dated 3/29/26 showed physician's orders for discipline and treatments that included Skilled Nursing visit and Physical Therapy evaluation and treatment. Review of Patient 5's SOC dated 3/28/26 showed a physician admission orders for Physical Therapy evaluation and treatment. Review of Patient 5's Physical Therapy evaluation and POC dated 3/31/26 showed Patient 5 was visited by PT 1. PT 1 assessed Patient 5's functional status as bed mobility, gait,range of motion, sitting balance, standing balance, frequency and treatment. However, PT 1's date of visit was more than 48 hours from the SOC and showed no documentation explaining the reason PT evaluation was not conducted within 48 hours of referral. On 4/23/26 at 1132 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. The agency P&P titled Appointment of Executive Director/Administrator revised 4/2019 showed the Executive Director/Administrator will be responsible for the day - to-day operations of the organization. Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. 1a. Review of the written agreements between the agency and Contractor 1 was initiated on 4/23/26. The written agreement showed for wound care services. However, the written agreements with Contractor 1 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment, development, review and revision of the POT or POC, patient care conferences and discharge planning. Moreover, the written agreement failed to include the responsibility of the contractor to applicable agency policies, procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Furthermore, the written agreement failed to include the agreements shall be reviewed and revised as necessary. b. Review of the written agreements between the agency and Contractor 2 was initiated on 4/23/26. The written agreement showed for PT,OT and ST services. However, the written agreements with Contractor 2 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. c. Review of the written agreements between the agency and Contractor 3 was initiated on 4/23/26. The written agreement showed for DME services. However, the written agreements with Contractor 3 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the agreements shall be reviewed and revised as necessary. Further review of the written agreement showed the written agreement was signed on 4/7/23. However, the service agreement was entered on 12/30/25 which was inconsistent. d. Review of the written agreements between the agency and Contractor 4 was initiated on 4/23/26. The written agreement showed for DME services. The written agreement was effective on 1/8/26. However, on the section of term, showed the agreement shall be effective as of October 18, 2022 which inconsistent. In addition, the written agreements with Contractor 4 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. Moreover, the written agreement failed to include the responsibility of the contractor for the procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Further, the written agreement failed to include the agreements shall be reviewed and revised as necessary. e. Review of the written agreements between the agency and Contractor 5 was initiated on 4/23/26. The written agreement showed for PT, OT and ST services. However, the written agreements with Contractor 5 did not include the rights and responsibilities of the program and the contracted providers in the coordination and supervision of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment and discharge planning. On 4/23/26 at 1000 hours, an interview and concurrent document review was conducted with the President. The President was informed and acknowledged the findings. 2. The agency P&P titled Submission of SN/HHA/PT Notes and Documentation undated showed all Skilled Nursing (SN), Home Health Aide (HHA), and Physical Therapy (PT) staff must complete and submit clinical documentation in a timely, accurate, and compliant manner in accordance with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and agency standards. All visit notes must be completed on the same day of service whenever possible. Documentation must be submitted no later than 24 hours after the visit. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26. The patients principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. a. The POC for the certification period from 4/1/26 to 5/30/26 showed an order for PT evaluation and treatment. Review of the Physical Therapy Clinical Notes showed the PT had a visit on 4/9/26 which was more than 48 hours as ordered in the POC. b. The POC for the certification period from 4/1/26 to 5/30/26 cited SN 1W1, 2W1 and 1W7. Review of the clinical record showed the SN had visited the patient on Weeks 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted on Week 3 (4/12/26 to 4/18/26) as ordered in the POC. On 4/23/256 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked as to the timeline for the PT to performed the evaluation. The Administrator/DPCS replied within 48 hours from the physicians order. The Administrator/ DPCS was also asked if there was a missed visit on Week 3. The Administrator/DPCS reviewed the clinical record and replied, there was a visit on 4/16 but the notes were not submitted. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26 and 3/10/26 to 5/8/26. The POC for the certification period from 1/9/26 to 3/9/26 showed an order for PT evaluation. Review of the clinical record showed the PT 2 performed the evaluation on 1/27/26 which was more than 48 hours from the POC. Further review of the POC for the certification period from 1/9/26 to 3/9/26 showed an order for OT evaluation. Review of the clinical record showed the OT 1 performed the initial evaluation on 2/6/26 which was more than 48 hours from the POC. On 4/23/256 at 1448 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. Review of the HHA's Administrator Job Description Summary revised 4/2019 showed the Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. The essential job functions/ responsibilities included the following: -planning, and directing operations to ensure the provision of adequate and appropriate care and services. -recruiting, employing and retaining qualified personnel to maintain appropriate staffing levels. -ensuring ongoing oversight of the agency's quality management system. -evaluating services and programs. -ensuring personnel development including orientation, in service education and continuing education. -ensuring that appropriate service policies are developed and implemented. -directing personnel in performance of their duties including admission, discharge and provision of service to patients. 1.Title 22 Section 74719 (Services Arranged by Agreement), showed the following: (b) The agreement shall include at least the following: (1) The nature and scope of the services to be provided; (2) The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; (3) The role, if any, of the agency and the contracted individual or agency in: (A) The patient admission process, (B) Patient assessment, (C) The development, review, and revision of the plan of treatment or plan of care, (D) Patient care conferences, (E) The scheduling of visits or hours, (F) Discharge planning; (4) The submission to the agency of documentation of services provided; (5) The responsibility of the contracted individual or agency to adhere to applicable agency policies, including personnel qualifications; (6) The procedures for determining charges and reimbursement; and (7) The term of the agreement and the conditions for its renewal or termination. (c) Agreements shall be reviewed and revised as necessary. a. Review of the written agreements between the agency and Contractor 1 was initiated on 4/23/26. The written agreement was for wound care services. However, the written agreement with Contractor 1 did not include the rights and responsibilities of the agency and contracted provider in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in the patient admission process, patient assessment, development, review and revision of the POT or POC, patient care conferences, and discharge planning. The written agreement failed to include the responsibility of the contractor to applicable agency policies, procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. Furthermore, the written agreement failed to include the agreements shall be reviewed and revised as necessary. b. Review of the written agreements between the agency and Contractor 2 was initiated on 4/23/26. The written agreement was for PT,OT and ST services. However, the written agreement with Contractor 2 did not include the rights and responsibilities of the agency and contracted provider in the coordination, supervision and evaluation of care and services provided. c. Review of the written agreement between the agency and Contractor 3 was initiated on 4/23/26. The written agreement was for DME services. However, the written agreement with Contractor 3 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. In addition, the written agreement failed to include the agreements shall be reviewed and revised as necessary. Further review of the written agreement showed the written agreement was signed on 4/7/23. However, the service agreement was entered on 12/30/25 which was inconsistent. d. Review of the written agreement between the agency and Contractor 4 was initiated on 4/23/26. The written agreement was for DME services. The written agreement was effective on 1/8/26. However, the section for term showed the agreement shall be effective as of October 18, 2022, which inconsistent. In addition, the written agreement with Contractor 4 did not include the rights and responsibilities of the program and the contracted providers in the coordination, supervision and evaluation of care and services provided. The written agreement did not include the responsibility of the contractor for the procedures for determining charges and reimbursement and term of agreement and conditions for its renewal. The written agreement failed to include the agreements shall be reviewed and revised as necessary. e. Review of the written agreements between the agency and Contractor 5 was initiated on 4/23/26. The written agreement was for PT, OT and ST services. However, the written agreements with Contractor 5 did not include the rights and responsibilities of the program and the contracted providers in the coordination and supervision of care and services provided. In addition, the written agreement failed to include the role of the agency and contractor in patient admission process, patient assessment and discharge planning. On 4/23/26 at 1000 hours, an interview and concurrent document review was conducted with the President. The President was informed and acknowledged the findings. 2. The agency's P&P titled Submission of SN/HHA/PT Notes and Documentation undated showed all Skilled Nursing (SN), Home Health Aide (HHA), and Physical Therapy (PT) staff must complete and submit clinical documentation in a timely, accurate, and compliant manner in accordance with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and agency standards. All visit notes must be completed on the same day of service whenever possible. Documentation must be submitted no later than 24 hours after the visit. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26, and 4/1/26 to 5/30/26. The patient's principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC, for the certification period from 4/1/26 to 5/30/26, cited SN 1W1, 2W1, and 1W7. Review of the clinical record showed the SN had visited the patient during Week 1 (4/1/26 to 4/3/26) and Week 2 (4/12/26 to 4/18/26) as ordered in the POC. However, there was no documented evidenced of the SN visit was conducted during Week 3 (4/12/26 to 4/18/26). On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/ DPCS was asked if there was a missed SN visit during Week 3. The Administrator/DPCS reviewed the clinical record and stated there was a visit on 4/16 but the notes was not submitted. The Administrator/DPCS was informed and acknowledged the findings. 3. Review of the agency's P&P titled Start of Care Referral (undated) showed scope that applies to Intake/Referral Coordinators, Registered Nurses, Clinical Supervisors and Therapy Staff as Physical Therapy/Occupational Therapy/ Speech Therapy. Start of care must be initiated within 48 hours of referral. Review of the agency's P&P titled Physical Therapy Evaluation (undated) showed scheduling of evaluation included PT (Physical Therapy) evaluation must be completed within 48 hours of referral or as ordered by the physician or based on patient needs, coordinate visit with the patient/caregiver. Review of the agency's P&P titled Initial and Comprehensive Assessment revised 4/2019 showed an initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either with 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician (or other authorized license independent practitioner), or at the patient/family request with the approval of the physician( or other authorized licensed independent practitioner). a.Review of Patient 2's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 11/7/25. The patient was certified for home health service during the certification periods from 11/7/25 to 1/5/26 and 1/6/26 to 3/6/26. Patient 2 was discharged on 3/6/26. Review of Patient 2's POC dated 1/14/26 showed SN visits 2W2 and 1wk7, CHHA visit 2W9, and PT evaluation and treatment. Review of Patient 2's Recertification Order dated 1/5/26, showed Patient 2 was to receive PT evaluation and treatment. Review of Patient 2's Physical Therapy Evaluation and Plan of Care dated 11/11/25, showed PT 3 assessed for functional status as bed mobility, gait, ADL, stretch and range of motion, posture, endurance, palpitation, sitting balance, standing balance plan of care, frequency an duration of treatment. However, PT 3's date of visit was more than 48 hours from the SOC. There was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 0945 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. b. Review of Patient 4's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/20/26 The patient was certified for home health service during the certification periods from 2/20/26 to 3/21/26 and 3/22/26- 4/20/26. Review of Patient 4's POC dated 2/27/26 showed Patient 4 was to receive PT evaluation and treatment. Review of Patient 4's SOC dated 2/20/26 showed Patient 4 was to receive PT evaluation and treatment. Review of Patient 4's Physical Therapy Evaluation and POC showed PT 1 conducted the assessments for functional status, balance, range of motion exercises, strength, frequency and treatment. However, PT 1's date of visit was more than 48 hours from the SOC and there was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 1054 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. c. Review of Patient 5's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 3/28/26. The patient was certified for home health services during the certification periods from 3/28/26 to 5/26/26. Review of Patient 5's POC dated 3/29/26, showed the physician's orders for discipline and treatments that included Skilled Nursing visit and Physical Therapy evaluation and treatment. Review of Patient 5's SOC dated 3/28/26, showed the physician admission orders for Physical Therapy evaluation and treatment. Review of Patient 5's Physical Therapy evaluation and POC dated 3/31/26, showed Patient 5 was visited by PT 1. PT 1 assessed Patient 5's functional status as bed mobility, gait, range of motion, sitting balance, standing balance, frequency and treatment. However, PT 1's date of visit was more than 48 hours from the SOC and there was no documentation explaining the reason PT evaluation was not conducted within 48 hours of the order date. On 4/23/26 at 1132 hours, an interview and concurrent document review was conducted with the DPCS. The DPCS was informed and verified the above findings. d. Review of Patient 8's clinical record was initiated on 4/22/26. The clinical record showed the SOC was 12/2/26. The patient was certified for home health services during the certification periods from 12/2/26 to 1/30/26, 1/31/26 to 3/31/26, and 4/1/26 to 5/30/26. The patient's principal diagnosis was Type 2 Diabetes Mellitus with other specified complications. The POC, for the certification period from 4/1/26 to 5/30/26, showed an order for PT evaluation and treatment. Review of the Physical Therapy Clinical Notes showed the PT had a visit on 4/9/26, more than 48 hours from when it was ordered. On 4/23/26 at 1411 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was asked regarding the timeline for the PT to perform the evaluation. The Administrator/DPCS replied within 48 hours of the physicians order. e. Review of Patient 6's clinical record was initiated on 4/21/26. The clinical record showed the SOC was 9/11/25. The patient was certified for home health services during the certification periods from 9/11/25 to 11/9/25, 11/10/25 to 1/8/26, 1/9/26 to 3/9/26, and 3/10/26 to 5/8/26. The POC, for the certification period from 1/9/26 to 3/9/26, showed an order for PT evaluation. Review of the clinical record showed PT 2 performed the evaluation on 1/27/26, which was more than 48 hours from when it was ordered. Further review of the POC, for the certification period from 1/9/26 to 3/9/26, showed an order for OT evaluation. Review of the clinical record showed OT 1 performed the initial evaluation on 2/6/26, which was more than 48 hours from when it was ordered. On 4/23/26 at 1448 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings. 4. Review of the agency's P&P titled Selection/Hiring of Personnel revised 4/2019 showed the candidates are screened to ensure that the candidate meets the job requirements, competencies and qualifications. Valid license, certification or registration are required by law to practice a profession, the organization verifies these credentials with the primary source on hire and upon expiration. Review of the agency's P&P titled Physical Examination Policy and Procedure (undated) showed all employees and contracted personnel providing patient care must be physically capable of performing assigned duties and must complete a physical examination prior to hire and as required thereafter. The P&P included the pre-employment requirement as follows: -Physical examination must be completed prior to patient contact -Conducted by licensed practitioner Review of the agency's P&P titled Performance Evaluation Policy (undated) showed agency ensures that all employees and contracted personnel receive ongoing performance evaluations to assess competency, clinical quality, compliance with agency standards, and adherence to patient care requirements. The procedures included the following: -Frequency: initial evaluation at completion of orientation/probationary period (typically 90 days), annually performance evaluation thereafter, additional evaluations as needed. Review of the agency's P&P titled Contracted Personnel (On Hiring) undated, showed the agency ensures that all contracted personnel meet the same standards as employed staff regarding qualifications, competency, health screening, and compliance with regulatory requirements. The procedure included the following: -Precontract requirements as valid professional license/certification verification, background check, verification of education, and experience and professional references -Health requirements as physical examination clearance, TB screening compliance, immunization records. -Orientation as contracted personnel must complete orientation including agencies policies and procedures, infection control, emergency preparedness, patient rights and documentation standards. -Competency Validation as skills validation based on discipline and specialty competencies -Documentation as personnel file maintained for each contractor includes all credentials, health records, and evaluations. Review of the personnel files for the agency's employees was conducted with the Intake Coordinator on 4/22/26, and showed the following: 1. RN 3's personnel file did not show any documentation of the pre-employment physical examinations. 2. LVN 3's personnel file did no show documentation of the 90 days performance evaluation. 3. PT 1's personnel file showed PT 1 was the contracted staff. However, PT 1 's personnel file did not contain the current valid professional license, hiring orientation, performance evaluations, and skill competencies. The Intake Coordinator verified the above findings. On 4/22/26 at 1330 hours, an interview and concurrent document review were conducted with the Administrator and Intake Coordinator. The Administrator and the Intake Coordinator were informed and acknowledged the above findings

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to send a completed Transfer Summary to the receiving hospital within two business days for one of eight sampled patient (Patient 7). This failure had a potential risk of not providing continuity of care and services to the patient. Review of the agency's P&P titled Transfer Summary revised 4/2019 showed within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: A. The reason for transfer B. The physical and psychosocial status at the tie of transfer, including specific medical, psychosocial or other problems requiring interventions or follow up. C. Continuing symptom management needs D. Medication Profile E. A summary of care provided and the progress toward achieving goals F. Any instructions and referrals provided to the patient G. The existence of any Advance Directive known to the organization H. Date of face to face encounter, if during initial certification I. The date of transfer, which is the date of last visit made. 2. Completed summaries will be given to the clinical records clerk who will send a copy to the receiving organization, along with a copy of the clinical record, within two business days of a planned transfer or within two days of becoming aware of unplanned transfer and will file the original in the clinical record. 3. A copy of the transfer summary will be sent to the physician within 48 hours of transfer. Review of Patient 7's clinical record was initiated on 4/20/26. The clinical record showed the SOC was 2/27/26. The patient was certified for home health services during the certification period from 2/27/26 to 4/27/26. Review of Patient 7's Comprehensive Transfer Without Discharge dated 4/10/26, showed in the agency's electronic system as 13 days overdue. The Comprehensive Transfer Without Discharged record showed the patient tracking information, administrative information, health condition, medications, special treatment, procedures and programs, participation in assessment and goal setting were completed by the DPCS. However, the details of emergent care or hospitalization or transfer to the SNF/Nursing Home if known was not completed. On 4/23/26 at 1016 hours, an interview and a document review was conducted with the DPCS and Intake Coordinator. The DPCS verified it was 13 days overdue and acknowledged the electronic record showed no details of emergent care or hospitalization or transfer to SNF/Nursing Home if known. The Intake Coordinator was asked if a transfer summary copy was sent to the hospital. The Intake Coordinator verified none was sent because it was only few days ago that it was learned that patient was transferred to the hospital.

The following reflects the findings of the California Department of Public Health during the concurrent EMERGENCY PREPAREDNESS and PARTIAL EXTENDED RECERTIFICATION surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN and 31929, HFEN. The survey team entered the HHA on 4/17/23 at 0900 hours. The survey team reviewed five active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITION: COVID-19: Coronavirus disease 2019 (an infectious disease caused by the SARS-CoV-2 virus) DPCS: Director of Patients Care Services HHA: Home Health Agency P&P: Policy and Procedure

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan consistently included facility-based and community-based risk assessment and the strategies addressing the emergency events identified by the risk assessment, creating the potential risk of not providing the necessary care and services to the patients during the emergency events Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. One section of the emergency preparedness program documents showed the agency had identified the following potential emergencies that require immediate attention for additional planning and preparation. These were Pandemic Covid-19, public shooting, and earthquake. Another section of the emergency preparedness program documents showed the prioritized hazards included earthquake, wild fire, COVID-19, and public shooting. The Hazard Vulnerability Analysis form for the first quarter of 2023 showed the natural events. Documentation showed the events were evaluated according to vulnerability, probability, and preparedness. However, the Hazard Vulnerability Analysis form showed the priority level was left blank. In addition, the two sections which identified the potential emergencies/prioritized hazards were not consistent wherein one of the section had wild fire. There was no documented evidence the strategies to address other identified event like public shooting were developed. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above findings.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness plan included the process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This created the potential risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23, and showed the plan did not include a process for collaboration with the regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. On 4/27/23 at 1040 hours, an interview and concurrent facility document review was conducted with the DPCS. She was informed and acknowledged the above finding.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness P&P included procedures to inform the state and local officials of any on-duty staff or patients that they are unable to contact. This created the potential risk of not meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, the agency's emergency preparedness P&P did not include the procedures to inform the state and local officials of any on-duty staff or patients that they are unable to contact. On 4/24/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness P&P included a system of medical documentation that protected confidentiality of the patient information; and secured and maintained availability of records. This created the potential risk of not protecting the patient's confidential information during the emergency. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, the emergency preparedness program did not address a system of medical documentation that protected confidentiality of patient information; and secured and maintained availability of records. On 4/24/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness P&P included the use of volunteers in an emergency or other emergency staffing strategies including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This failure created the risk of not effectively utilizing the available personnel during an emergency. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, the emergency preparedness program did not address the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and document review and interview, the agency failed to develop the communication plan to include contact information for the staff, entities providing services under arrangement, and volunteers, creating the risk of not able to contact or request for assistance during emergency events. Finding: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, there was no documented evidence the communication plan included the contact information for some of the staff, entities providing services under arrangement, and volunteers. On 4/27/23 at 1040 hours, an interview and concurrent document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to develop the communication plan to include contact information for Federal, State, and regional preparedness staff, creating the risk of not able to contact or request for assistance during emergency events. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, there was no documented evidence the communication plan included the contact information for Federal, State, and regional preparedness staff. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness communication plan included a method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care. This failure created the risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, the emergency preparedness communication plan did not include a method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health providers to maintain the continuity of care. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above finding.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the emergency preparedness communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This failure created the risk of not providing the necessary care and services to the patients during emergency events. Findings: Review of the agency's 2023 emergency preparedness program documents was conducted on 4/20/23. However, the emergency preparedness communication plan did not include a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above finding.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure the trainings in the emergency preparedness program was provided to all staff, creating the risk of the HHA's staff not knowing what to do in case of emergency. Findings: Review of the agency's 2020 emergency preparedness program documents was conducted on 4/20/23. The following was identified: a. An agency Memo dated 3/6/20, showed an in-service on COVID-19 will be conducted on 3/3/20 via video conference. The Attendance Roster form and In-Service Sign-In Sheet dated 3/23/20, showed a list of the HHA staff. However, the documentation showed only the Administrator had signed the document. b. An agency Memo dated 9/7/20, showed an in-service on flash flood will be conducted via video conference on 9/21/20. The Attendance Roster form and In-Service Sign-In Sheet dated 9/21/20, showed a list of the HHA staff. However, the documentation showed only the Administrator had signed the document. On 4/27/23 at 1040 hours, an interview and concurrent agency document review was conducted with the DPCS. She was informed and acknowledged the above findings.

The following reflects the findings of the California Department of Public Health during the concurrent PARTIAL EXTENDED RECERTIFICATION and EMERGENCY PREPAREDNESS surveys. Representing the California Department of Public Health: Surveyors 39539, HFEN and 31929, HFEN. The survey team entered the HHA on 4/17/23 at 0900 hours. The survey team reviewed five active and two closed clinical records. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL: activities of daily living ALF: Assisted Living Facility Asthma: a chronic (long-term) condition that affects the airways in the lungs ADL: Activities of Daily Living BID: twice a day BS: Blood sugar CDC: Centers for Disease Control and Prevention cm: centimeter(s) CNS: central nervous system conjunctivitis: inflammation of the transparent membrane that lines the eyelid and eyeball COVID 19: an infectious disease caused by the SARS-CoV-2 virus DPCS: Director of Patient Care Services EENT: Eyes, Ears, Nose, and Throat gm: gram(s) HAI: Healthcare-Associated Infection (infections that occur in patients while the patients are receiving healthcare) HHA: Home Health Agency HS: at bedtime Lateral malleolus: the prominence on the outer side of the ankle, formed by the lower end of the fibula (calf bone). LVN: Licensed Vocational Nurse MAR: Medication Administration Record mg: milligram(s) ml: milliliter(s) MSW: Medical Social Worker NMS: neuroleptic malignant syndrome (a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs) OT: Occupational Therapy/Therapist PCG: Patient Care Giver Oxygen saturation: a measure of how much hemoglobin is currently bound to oxygen compared to how much hemoglobin remains unbound P&P: policy and procedure PCG: Patient Caregiver PO: by mouth POC: Plan of Care PRN: As needed PT: Physical Therapy/Therapist Pulse oximeter: an electronic device that measures the saturation of oxygen carried in your red blood cells. Q: Every QAPI: Quality Assurance and Performance Improvement QD: Every day QSO: Quality and Safety Oversight RN: Registered Nurse Sacrum: a triangular bone at the inferior portion of the spine that supports the weight of the spine superior to it. SC: subcutaneous SN: Skilled Nurse SOC: Start of Care ST: Skilled Therapy/Therapist Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. TID: three times a day U: unit(s) UTI: Urinary Tract Infection W: week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the medication profiles were updated to reflect the current medications, including specific indications and parameters for their use; all side effects, actual or potential drug interactions; and duplicate drug therapy for five of seven sampled patients (Patients 2, 3, 5, 6, and 7). This failure created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. #. Review of Patient 3’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 2/27/23. The patient was certified for home health services during the certification period from 2/27/23 to 4/27/23. A joint home visit with LVN 3 was conducted on 4/18/23 at 1200 hours, to Patient 3's home. Review of the patient’s medications showed the patient was on atenolol (antihypertension) 20 mg one tablet PO QD and as per the medication profile. The patient stated she was on atenolol 25 mg one tablet PO BID for two to three years already. * However, the medication was not updated in the patient’s medication profile. On 4/24/23 at 955 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 4/18/23. The clinical record showed the SOC was 12/14/22. The patient was certified for home health services during the certification periods from 2/12/23 to 4/12/23 and 4/13/23 to 6/11/23. The patient resided in a ALF. A joint home visit with PT 1 was conducted on 4/19/23 at 1200 hours, to Patient 5’s ALF. Review of the patient medication profile from certification period 4/13/23 to 6/11/23, showed the patient was on Lidoderm (local anesthetic) 5% to lower and upper back in the morning and remove per schedule, trazadone hydrochloride (antidepressant) 100 mg one tablet PO QHS PRN for inability to sleep, Robaxin (muscle relaxant) 500 mg one tablet PO Q eight hours PRN, Tums (antacid) 500 mg one tablet PO Q two hours PRN for indigestion, calazime cream (skin protectant) topically BID, nystatin (antifungal) 1000 u/gm topically daily, melatonin (supplement) 3 mg one tablet PO QHS PRN, diclofenac sodium (nonsteroidal anti-inflammatory agent) apply two grams topically to the affected are up to four times a day PRN; however, these medications were not listed in the ALF’s April 2023 MAR. In addition, the medication profile showed the patient was on Abilify (antipsychotic) 5 mg BID and 10 mg BID and Ativan (antianxiety) one mg one tablet PO BID. The ALF’s April 2023 MAR showed the patient’s medications included amiodarone hcl (antiarrhythmic) 200 mg one tablet PO BID, Abilify 20 mg PO BID, and Ativan one mg PO TID PRN. However, amiodarone hcl was not listed in the patient’s medication profile and the dosage of Ativan and Abilify was not consisted with the ALF’s MAR and HHA’s medication profile. The medication profile, for the 2/12/23 to 4/12/23 and 4/13/23 to 6/11/23, showed the patient’s medication included Eliquis (anticoagulant) 5 mg one tablet PO BID. According to Lexi-Comp's pharmacology website, the significant adverse reaction for Eliquis include major bleeding. However, there was no documented evidence the agency had identified the significant adverse reaction for this medication. On 4/24/23 at 0959 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. #. Review of Patient 7’s closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 6/6/22. The patient was certified for home health services during the certification period from 6/6/22 to 8/4/22. The patient was transferred to the hospital on 7/12/22 and was discharged from the HHA on 7/29/22. According to Lexi-Comp's pharmacology website, the US Boxed Warning for hydrocodone/APAP included concomitant use of opioids with benzodiazepines or other CNS depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. Further review of the Medication Profile showed the patient’s medication included baclofen (muscle relaxant) 10 mg one tablet PO BID and hydrocodone/APAP (opioid analgesic) 5-325 mg one tablet PO Q six hours PRN. * However, there was no documented evidence the agency had identified the potential drug interactions between baclofen and hydrocodone/APAP. On 4/24/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. Review of the agency’s P&P titled Medication Profile dated April 2019, showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of admission when updates to the comprehensive assessments are performed, and when care is resumed after a patient has been placed on hold. The review will identify drug/food interactions. Potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy omissions and unclear information. 1. Review of Patient 2's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 12/8/22. The patient was certified for home health services during the certification periods from 4/7/23 to 6/5/23 and 2/6/23 to 4/6/23. The Medication Profile, for both certification periods, showed the patient’s medications included lorazepam (antianxiety) one mg PO QD PRN. However, there was no documented evidence in the medication profile showing the specific indications for the PRN medications. On 4/24/23 at 0931 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2. Review of Patient 6's closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 8/24/22. The patient was certified for home health services during the certification periods from 10/23/22 to 12/21/22 and 8/24/22 to 10/22/22. The Medication Profile for both certification periods, showed the patient’s medications included olanzapine (antipsychotic) 10 mg supralingual QD PRN. However, there was no documented evidence in the medication profile showing the specific indications for the PRN medications. In addition, review of the Medication Profile showed the patient was taking olanzapine (antipsychotic), risperidone (antipsychotic) and fluoxetine (antidepressant). According to Lexi-Comp’s pharmacology website, the concurrent use of these medications may enhance the adverse/toxic effects of the antipsychotic medications which could increase the patient’s risk for NMS. Further review of the Medication Profile showed a drug regimen review was conducted and potential adverse effect/drug reactions were identified. However, there was no documented evidence showing the specific drug interactions that were identified. On 4/24/23 at 0952 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate the care to meet the patients' care needs for four of seven sampled patients (Patients 1, 2, 3, and 5). This failure created the risk of not providing the necessary care and services to these patients. #. Review of Patient 1’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 1/25/23. The patient was certified for home health services during the certification periods from 1/25/23 to 3/25/23 and 3/26/23 to 5/24/23. a. The Comprehensive Start of Care dated 1/25/23, showed the patient had Stage 3 pressure injuries on the right lateral malleolus ankle, left lateral heel foot, and sacrum. The POC, for the certification period from 1/25/23 to 3/25/23, showed SN visits 2W8 and 1W1 for SN to perform and teach wound care on the following: - apply calcium alginate (wound dressing) on the right lateral malleolus and the left lateral heel foot, cover with bordered gauze, change dressing Q two to three days PRN for soilage or loss of skin integrity - apply Xeroform (wound dressing) on the sacrum, cover with bordered gauze, change dressing Q two to three days PRN for soilage or loss of skin integrity The Progress Notes of the wound care providers dated 2/6/23, showed home visits were conducted. Documentation showed the recommendation for the right lateral malleolus and left lateral heel pressure injuries was the following: - apply calcium alginate silver to the wound bed, cover with bordered gauze, and change daily on the * However, there was no documented evidence the SN coordinated with the HHA’s physician of the recommendation of the wound care provider related to the frequency and the wound dressing on the right lateral malleolus and left lateral heel foot pressure injuries. Cross reference G710 example ### The Progress Notes of the wound care providers dated 2/6, 2/13, 2/20, 2/27, 3/6, 3/13/23, showed home visits were conducted. Documentation showed the recommendation for the sacrum pressure injury was the following: - apply Xeroform to the wound bed, cover with bordered gauze, and change Q two to three days. The Progress Notes of the wound care providers dated 3/20, and 3/27/23, showed home visits were conducted. Documentation showed the recommendation for the sacrum pressure injury was the following: - apply xeroform to the wound bed, cover with bordered gauze, and change daily. * However, there was no documented evidence the SN coordinated with the HHA’s physician of the recommendation of the wound care provider related to the frequency of the treatment for the sacrum pressure injury. The Progress Notes of the wound care providers dated 2/13, 2/20, 2/27, 3/6, 3/13, 3/20, and 3/27/23, showed home visits were conducted. Documentation showed the patient had a Stage 3 right heel pressure injury and the recommendation was to apply calcium alginate silver to the wound bed, cover with bordered gauze, and change daily. * However, there was no documented evidence the SN coordinated with the HHA’s physician the recommendation of the wound care provider related to the wound care on the right heel. Cross reference G 710 example ### b. The POC, for the certification period from 3/26/23 to 5/24/23, showed SN visits 2W2 and 1W7. The POC included SN to teach and perform wound care. Documentation showed to apply Xeroform on the sacrum, cover with bordered gauze, secure with tape, change dressing once daily or PRN for soilage or loss of skin integrity. The POC showed the PCG to perform wound care for non skilled nursing days. The Progress Note of the wound care providers dated 4/3/23, showed sacrum pressure injury was close. The SN note dated 4/4/23, showed wound care was performed “on the sacro area 0.8 cm x 0.5 cmx 0.1 cm.” The SN note dated 4/7/23, showed wound care was performed “on the sacro area 0.5 cm x 0.5 cmx 0.1 cm.”. * However, there was no documented evidence the SN coordinated with the HHA’s physician and the wound care provider of the status of the sacrum pressure injury after the home visit conducted by the wound care provider on 4/3/23, when the sacrum pressure injury was close. On 4/24/23 at 0948 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. #. Review of Patient 3’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 2/27/23. The patient was certified for home health services during the certification period from 2/27/23 to 4/27/23. Review of the Patient Referral and Orders of Company 1 dated 2/17/23, showed refer to PT for balance and body strengthening. Further review of the clinical record showed no documented evidence of the PT referral was coordinated by the HHA. On 4/24/23 at 0955 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS and Office Manager. She stated Company 1 was the provider that conducts face to face encounter. The Office Manager stated the patient refused PT. However, there was no documented evidence of the patient’s PT refusal. They were informed and acknowledged the findings. #. Review of Patient 5’s clinical record was initiated on 4/18/23. The clinical record showed the SOC was 12/14/22. The patient was certified for home health services during the certification periods from 2/12/23 to 4/12/23 and 4/13/23 to 6/11/23. The patient resided in a ALF. Review of the Patient Referral and Orders of Company 1 dated 2/16/23, showed refer to PT for balance and body strengthening. The POC, for the certification period from 4/13/23 to 6/11/23, showed PT evaluation/follow-up to assess home safety, ADLs, and safety fall injury risk. A joint home visit with PT 1 was conducted on 4/19/23 at 1200 hours, to Patient 5's ALF. Further review of the clinical record showed no documented evidence of the PT referral was coordinated by the HHA, until the certification period from 4/13/23 to 6/11/23, more than a month from the PT referral dated 2/16/23. On 4/24/23 at 0959 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS and Office Manager. She stated Company 1 was the provider that conducts face to face encounter. The Office Manager stated the patient refused PT at that time. However, there was no documented evidence of the patient’s PT refusal. They were informed and acknowledged the findings Review of the agency’s P&P titled Update on Care Coordination (undated) showed written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient’s clinical records. 1. Review of Patient 2's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 12/8/22. The patient was certified for home health services during the certification period from 4/7/23 to 6/5/23. The POC, for the certification period from 4/7/23 to 6/5/23, showed an order for medical social services evaluation and intervention. The POC was electronically signed by the physician on 4/17/23. Further review of the clinical record showed no documented evidence the patient was evaluated by the MSW. On 4/24/23 at 0931 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was asked if the patient was evaluated by the MSW as cited in the POC. RN 1 stated no because the patient had refused MSW services from the previous certification period. RN 1 stated the order may have been entered in error as there was no indication showing why the patient needed MSW services.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the SN provided education to the patient/PCG related to the patient’s disease process for one of seven sampled patients (Patient 3), creating the risk of not providing the necessary care and services to this patient. Findings: Review of Patient 3’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 2/27/23. The patient was certified for home health services during the certification period from 2/27/23 to 4/27/23. The POC, for the certification period from 2/27/23 to 4/27/23, showed the primary diagnosis of the patient was mild intermittent asthma with acute exacerbation. The POC included SN visits 2W2 and 1W7, to instruct the patient and PCG about asthma which is a disease that affects the lungs; it causes repeated episode of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing; and asthma can be controlled by taking medicine and avoiding the triggers that can cause an attack. * However, review of the clinical record showed no documented evidence the SN instructed the patient about asthma as per the POC. On 4/24/23 at 955 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the finding.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits 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 agency failed to provide the written instructions outlining the visit schedules for two of seven sampled patients (Patients 4 and 5). This failure created the risk of not providing the necessary information to these patients. #. Review of Patient 5’s clinical record was initiated on 4/18/23. The clinical record showed the SOC was 12/14/22. The patient was certified for home health services during the certification periods from 2/12/23 to 4/12/23 and 4/13/23 to 6/11/23. The patient resided in a ALF. The POC. For the certification period from 4/13/23 to 6/11/23, showed SN visits 1w1, 2w1, and 1W7. A joint home visit with PT 1 was conducted on 4/19/23 at 1200 hours, to Patient 5's ALF. Review of the patient's home folder provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 4/24/23 at 0959 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 1. Review of Patient 4's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 3/13/213. The patient was certified for home health services during the certification period from 3/13/23 to 5/11/23. The POC, for the certification period from 3/13/23 to 5/11/23, cited SN visits 2W2 and 1W7. On 4/18/23 at 1000 hours, a joint home visit was conducted with LVN 1 to Patient 4’s home. LVN 1 was asked to show the written instructions outlining the SN visit schedule. LVN 1 showed the calendar; however, it was blank. Further review of the patient’s admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedules. On 4/18/23 at 1025 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to analyze the quality indicators to assess the processes of care as part of the QAPI program. This failure created the risk of not identifying areas for performance improvement to improve care and services provided to the patients. Findings: Review of the agency’s P&P titled Sample Quality Assessment and Performance Improvement Plan dated April 2019 showed one of the objectives is to measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, home health services, and operations. Review of the agency’s QAPI program for 2019 to 2023 was initiated on 4/20/23. The QAPI program showed the agency had developed and maintained an ongoing data driven QAPI program. The agency had collected, tracked, and trended the data identified as part of the performance improvement projects. However, there was no documented evidence the QAPI committee had analyzed the data collected. In addition, there was no documented evidence the infection control data was discussed and analyzed as part of the QAPI program. Cross reference to G684. On 4/24/23 at 1046 hours, an interview and concurrent document review was conducted with the Administrator/DPCS. The Administrator/DPCS was informed and acknowledged the findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to implement infection control practices related to the use of a medical equipment for one of seven sampled patients (Patient 4). This failure had the potential to spread infection. Findings: Review of the agency’s P&P titled Bag Technique dated April 2019 showed when the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag. Blood pressure cuff will be cleaned in accordance with the manufacturer’s guidelines such as with soap and water at a frequency recommended by the cuff manufacturer and when the cuff has been soiled with blood, other body fluids, or spills. Review of Patient 4's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 3/13/213. The patient was certified for home health services during the certification period from 3/13/23 to 5/11/23. On 4/18/23 at 1000 hours, a joint home visit was conducted with LVN 1 to Patient 4’s home. LVN 1 was observed performing proper hand hygiene and donning and doffing of gloves during the assessment. When assessing the patient’s blood pressure, LVN 1 used the blood pressure cuff and placed it on the patient’s right arm. After taking the blood pressure, LVN 1 set the blood pressure cuff on top of the table. LVN 1 then continued to perform assessments on the patient. After all the services were provided, LVN 1 cleaned the thermometer, stethoscope, and pulse oximeter, then placed them in her bag. However, LVN 1 took the blood pressure cuff and placed it in her bag without cleaning it. On 4/18/23 at 1025 hours, an interview was conducted with LVN 1. LVN 1 was informed and acknowledged the finding.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to implement and maintain the infection control program which included surveillance, identification, prevention, and control, creating the risk of spread of infections. Findings: Review of the agency's P&P titled Evaluating and Maintaining Records of Infections Among Patients dated 4/19 showed in part: - All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery. If trends are discovered, target surveillance or problem-oriented surveillance may be initiated for specific high-risk patient populations if high volume, problem-prone areas are identified. - The Infection Identification-Patient Report Form is completed when any of the following occur: a. A new, actual, or suspected infection is clinically observed by home health personnel b. Culture is ordered and performed, and the results are positive c. A new antibiotic is ordered d. A patient is admitted to a hospital due to an actual or suspected infection e. An unanticipated death due to an actual or suspected infection f. A major permanent loss of function associated with an actual or suspected infection g. A reportable, communicable infection is identified h. Patient has temperatures greater than 101 degrees F i. Patient has conjunctivitis - The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection. - Each section of the report should be completed in its entirety. - If patient was admitted to home care from a hospital and a new infection was identified by the clinician within the first 48 hours of service, the source of the suspected infection may be nosocomial. - After completion, the original form will be sent to the Performance Improvement Coordinator, and a copy will be submitted to the appropriate personnel for follow-up. - The Performance Improvement Coordinator summarizes, trends, and analyzes the reports. The break down and summary may include, but will not be limited to: a. Number of infection types b. Sources of infection c. Diagnoses d. Age/sex of patients e. Family/caregiver f. Pathogens, if identified g. Follow-up taken - The Performance Improvement Coordinator, in conjunction with the Clinical Supervisor, will investigate possible causal factors and recommend appropriate action to contain the transmission of the infection. Actions may include implementing target or problem surveillance to aid in identifying causal factors and appropriate recommendations. - A report on infections will be given at each Performance Improvement Committee meeting. A summary will be forwarded to the appropriate Governing Body committee. - Information from the summary, analysis, and discussion will be used as part of the organization’s risk analysis and annual evaluation of the organization’s infection prevention and control activities. 1. Review of the agency's Infection Control and QAPI documents from January to December 2020 was conducted on 4/20/23, and showed the following information: The Infection Control Report form from January to December 2020 showed one patient was reported with infection. However, the January to December 2020 infection control graph showed 13 cases of pneumonia infection and 16 cases of UTI for the year. * The information on the number of cases of infections in the Infection Control Report form and the 2020 infection control graph were not consistent. In addition, there was no documented evidence an individual Patient Report Form was completed. There was no documented evidence of the summary on the types of infections identified. 2. Review of the agency's Infection Control and QAPI documents from January to December 2021 was conducted on 4/20/23. a. Some of the patient's Infection Log failed to identify the location of the infection. For example: The individual Infection Log of Patient A dated 9/12/21, showed the patient had a nosocomial infection and was treated with doxycycline (antibiotic) 100 mg one capsule PO BID for 14 days. The location of the infection section showed, “hyponatremia,” which was not a location of an infection. According to MedlinePlus (online health information resource), doxycycline is used to treat a variety of infections caused by certain types of bacteria; also used to treat or prevent anthrax (a serious infection that may be spread on purpose as part of a bioterror attack); and also used to prevent malaria. b. The agency failed to track and trend the types of infection, analyze the infection control data, and implement specific action plan. For example: The infection control and QAPI documents for the first quarter of 2021 showed there were two infections reported which were an ear infection and cellulitis. The infections were treated and resolved, and the physician was updated. Documentation showed the SN had educated on medication and prevention. The infection control and QAPI documents for the second quarter of 2021 showed there was one infection noted during the quarter which was an infected toe. Documentation showed the physician was aware. The infection control and QAPI documents for the third quarter of 2021 showed there were nine infection cases reported (one case of sepsis in July; three ear infection cases and one boil on the left thigh in August; and two UTI, one with “ileus” and one with toenail infection in September). Documentation showed the infections were treated and resolved, and the physician was updated. The infection control and QAPI documents for the fourth quarter of 2021 showed there were nine infection cases reported (no infection case in October; one infection on the left lower leg in November; and one case of cellulitis, one case of conjunctivitis, one case of UTI, one case of sore throat, and one case of GI bleeding secondary to infection). Documentation showed the infections were treated and resolved, and the physician was updated. The graphs on all four quarters for 2021 showed the collected data was whether the infections were resolved/unresolved, not the types of infection. There was no documented evidence the agency had analyzed the data based on the type of infections and implemented specific actions to minimize infection. 3. Review of the agency's Infection Control and QAPI documents from January to December 2022 was conducted on 4/20/23. For example: a. The agency failed to track and trend the types of infection, analyze the infection control data, and implemented specific action plan. For example: Review of the first quarter 2022 individual Infection Log showed five cases of UTI, two cases of upper respiratory infection, and two cases of cough. There was no documented evidence of a wound infection case. Documentation showed the UTI was reported, the patient was treated with antibiotic, and the infection was resolved. The infection control graph for the first quarter of 2022 showed the infection cases included UTI, wound infection, and others. However, the data in the graph was not complete and not accurate as there was no case of wound infection as per the individual infection Log for the first quarter of 2022; and the upper respiratory/cough cases were not included. In addition, the number of UTI cases were not consistent with the infection control graph. There was no documented evidence the agency had analyzed the data and implemented specific actions to minimize infection. b. The individual Infection Log was not completed. For example: - The individual Patient Log for Patient B dated 10/1/22, showed the patient had UTI and was treated with nitrofurantoin (antibiotic) 100 mg one tablet PO QD for seven days. However, the information if the infection was HAI or non-HAI was not completed. - The individual Patient Log for Patient C dated 11/14/22, showed the patient had integumentary infection and was treated with doxycycline (antibiotic) 100 mg one tablet PO BID for seven days. However, the information if the infection was HAI or non-HAI was not completed. On 4/24/23 at 1030 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She stated when identified a case of infection, the nurse would call the physician and office. She stated whoever in the office would log the infection case. She stated the DPCS would summarize and analyze the infection data every three months and report to QAPI. She was informed and acknowledged the findings.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure their COVID-19 P&P included the process of ensuring all staff were fully vaccinated for COVID-19; and the process by which staff may request an exemption from the COVID-19 vaccination requirements. This failure created the risk of not meeting the health and safety needs of the patient population and staff. Findings: Review of the QSO-22-07 showed the HHA’s P&Ps must include, at a minimum, a process for ensuring all staff have received, at a minimum, a single dose COVID-19 vaccine or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; a process for ensuring that all staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; and a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on applicable Federal law. Review of the HHA’s P&P titled Pandemic COVID-19 Corona Virus Preparedness dated April 2020 showed the procedures on what to do if the staff was experiencing signs and symptoms of COVID-19 or was exposed to COVID-19 infection. However, the P&P did not include the process for ensuring all staff were fully vaccinated for COVID-19 and the process by which staff may request an exemption to the vaccination requirements. On 4/24/23 at 1000 hours, an interview and concurrent document review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care and services were provided in accordance with the POC for five of seven sampled patients (Patients 1, 2, 3, 6, and 7). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. #. Review of Patient 1’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 1/25/23. The patient was certified for home health services during the certification periods from 1/25/23 to 3/25/23 and 3/26/23 to 5/24/23. a. The POC, for the certification period from 1/25/23 to 3/25/23, showed SN visits 2W8 and 1W1 to continue evaluation and assessment of all body systems. The POC included for SN to perform and teach wound care on the right lateral malleolus (outer aspect of the ankle) and left lateral heel foot. Documentation showed to apply calcium alginate (wound dressing), cover with bordered gauze, change dressing Q two to three days PRN for soilage or loss of skin integrity. The POC showed the PCG to perform wound care for non skilled nursing visit days. * The SN notes dated 1/27, 1/31, 2/3, 2/10, 2/14, 2/17, 2/21, 2/24, 2/28, 3/3, 3/7, 3/10, 3/14, 3/17, and 3/21/23, showed no documented evidence the patient’s endocrine system, EENT, and mouth assessment were completed. The SN notes dated 2/3 and 2/10/23, showed the SN performed skin care to the left heel and right ankle by applying calcium alginate silver (wound dressing) on the wound bed and covering with wound dressing. * However, there was no documented evidence the POC included the use of silver. Cross reference G 608 example# The SN notes dated 2/14, 2/17, 2/21, 2/24, 2/28, 3/3, 3/7, 3/10, 3/14, 3/17, and 3/21/23, showed the SN performed wound care on the right heel by applying calcium alginate silver on the wound bed and covering with wound dressing. * However, there was no documented evidence of a physician’s order for the wound care on the right heel. Cross reference G 608 example # b. The POC, for the certification period from 3/26/23 to 5/24/23, showed SN visits 2W2 and 1W7 for comprehensive assessment, observation, and all body system. The SN notes dated 3/28, 3/31, 4/4, 4/7 and 4/11/23, showed no documented evidence the patient’s endocrine system, EENT, and mouth assessment were completed. On 4/24/23 at 0948 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. #. Review of Patient 3’s clinical record was initiated on 4/17/23. The clinical record showed the SOC was 2/27/23. The patient was certified for home health services during the certification period from 2/27/23 to 4/27/23. The POC, for the certification period from 2/27/23 to 4/27/23, showed SN visits 2W2 and 1W7 to continue evaluation and assessment of all body systems. * The SN note showed the SN conducted one visit on Week 2 (3/5/23 to 3/11/23), instead of two visits per week as per the POC. * The SN note dated 3/3/22, showed no documented evidence the patient’s neurological assessment was completed. On 4/24/23 at 0955 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. #. Review of Patient 7’s closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 6/6/22. The patient was certified for home health services during the certification period from 6/6/22 to 8/4/22. The patient was transferred to the hospital on 7/12/22 and was discharged from the HHA on 7/29/22. The Comprehensive Start of Care assessment dated 6/6/22, showed the patient was unable to take injectable medication unless administered by another person The POC, for the certification period 6/6/22 to 8/4/22, showed SN visits daily for 60 days to continue skilled nursing evaluation and assessment of all body systems. The POC showed the patient’s medication included Lantus (insulin) 100 u/ml solution, inject 18 u SC daily. The POC included SN to do BS check via finger stick Q visit or PRN; and to instruct patient and PCG on proper use of insulin. The SN notes for the certification period from 6/6/22 to 7/11/22, showed the SN prepared/administered Lantus 18 u SC. * However, the POC failed to show documented evidence for the SN to administer Lantus. On 4/24/23 at 1015 hours, an interview and concurrent clinical record review was conducted with the Administrator/DPCS. She was informed and acknowledged the findings. 1. Review of Patient 2's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 12/8/22. The patient was certified for home health services during the certification period from 4/7/23 to 6/5/23. The POC, for the certification period from 4/7/23 to 6/5/23, showed for the SN to check the patient’s oxygen saturation via pulse oximeter and monitor signs and symptoms of respiratory distress. Review of the Comprehensive Recertification dated 4/5/23, showed no documented evidence the patient’s oxygen saturation was assessed. On 4/24/23 at 0931 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2a. Review of Patient 6's closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 8/24/22. The patient was certified for home health services during the certification periods from 10/23/22 to 12/21/22 and 8/24/22 to 10/22/22. The POC, for the certification period from 10/23/22 to 12/21/22, showed for the SN to perform comprehensive assessments, observation, and evaluation of all body systems with an emphasis on genitourinary, musculoskeletal, respiratory, and cardiovascular systems. Review of the SN Clinical Notes dated 10/25, 10/27, 11/1, 11/4, and 11/8/22, showed no documented evidence the EENT, mouth, and integumentary systems were assessed. b. The POC, for the certification period from 8/24/22 to 10/22/22, showed for the SN to continue skilled nursing evaluation and assessment of all body systems, homebound status, and medical necessity with an emphasis on musculoskeletal, endocrine, cardiovascular, respiratory, gastrointestinal, integumentary, genitourinary, and neuro-mental status. Review of the SN Clinical Notes during the certification period, showed there were multiple dates where the SN did not consistently assess all body systems as cited in the POC. For example, on 8/29/22, there was no documented evidence showing the patient’s genitourinary, EENT, mouth, and integumentary systems were assessed. On 4/24/23 at 0952 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled professionals prepared accurate clinical notes for two of seven sampled patients (Patients 2 and 6). This failure created the increased risk of substandard healthcare outcomes to these patients. Findings: 1. Review of Patient 2's clinical record was initiated on 4/17/23. The clinical record showed the SOC was 12/8/22. The patient was certified for home health services during the certification period from 2/6/23 to 4/6/23. Review of the Comprehensive Recertification dated 2/5/23, showed the action/intervention/plan section showing a check mark was placed to indicate the patient’s referral to PT. However, further review of the same form, under the section for referrals, showed a check mark was placed indicating the PT referral was not necessary. The note showed the patient refused PT services which was inconsistent with what documented on the action/intervention/plan section. On 4/24/23 at 0931 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding. 2. Review of Patient 6's closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 8/24/22. The patient was certified for home health services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The POC, for the certification periods 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22, showed the patient’s nutritional requirements included no added salt, low sodium, low fat, and low cholesterol diet. However, further review of the clinical record showed no documented evidence the agency had clarified the patient’s diet with the physician to identify whether the patient should have a no added salt or low sodium diet. On 4/24/23 at 0952 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency's Administrator failed to ensure the responsibility for the day-to-day operations of the agency as follows: * The agency failed to ensure three of the five employee files reviewed (RNs 2, 3, and LVN 2) had their health assessments completed in a timely manner. * The agency failed to ensure the written agreements for five of the eight contractors (Contractors 1, 2, 3, 4, and 5) included the required elements as per the state regulations, Title 22. These failures had the potential to negatively impact the agency’s operational performance. Findings: Review of the agency’s P&P titled Governing Body dated April 2019 showed the Governing Body will appoint a qualified Executive Director/Administrator who will be responsible for the day-to-day management of the organization and will establish procedures for systematic executive communication. 1. According to Title 22 Section 74723 (b)(2), a written health assessment of each employee who has direct patient contact shall be performed within six months prior to employment or within 15 days of assuming employment with the agency. Review of the employee files conducted on 4/20/23, showed the following: - RN 2 was hired on 2/24/21. However, the employee’s health assessment was completed on 8/27/21, more than 15 days of assuming employment with the agency. - LVN 2 was hired on 4/1/21. However, the employee’s health assessment was completed on 10/20/21, more than 15 days of assuming employment with the agency. - RN 3 was hired on 3/1/22. However, the employee’s health assessment was completed on 6/11/22, more than 15 days of assuming employment with the agency. On 4/24/23 at 1005 hours, an interview and concurrent record review was conducted with RN 1. RN 1 was informed and acknowledged the findings. 2. According to Title 22 Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: the nature and scope of services to be provided; the rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of the care or services provided; and the role, if any, of the agency and the contracted individual or agency in the patient admission process, patient assessment, the development, review, and revision of the plan of treatment or plan of care, patient care conferences, the scheduling of visits or hours, discharge planning, the submission to the agency of documentation of services provided, and the responsibility of the contractor to applicable agency policies including personnel qualifications. a. Review of the written agreement between the agency and Contractor 2 providing PT services was initiated on 4/19/23. The written agreement showed the scope of services to be provided by the contractor included PT, OT, and ST services. On 4/23/23 at 1015 hours, an interview and concurrent document review was conducted with RN 1. RN 1 verified Contractor 2 only provided PT services and did not provide OT and ST services. b. Review of the written agreements between the agency and Contractors 1, 3, 4, and 5 was initiated on 4/19/23. The written agreements did not include the following requirements: - The rights and responsibilities of the agency or individual providing services and of the contracting agency in the coordination, supervision, and evaluation of care and services provided. - The role, if any, of the agency and the contractors in the patient admission process. - The role, if any, of the agency and the contractors in patient assessments. - The role, if any, of the agency and the contractors in the development, review, and revision of the plan of treatment or POC. - The role, if any, of the agency and the contractors in the patient care conferences. - The role, if any, of the agency and the contractors in the scheduling of visits or hours. - The role, if any, of the agency and the contractors in the discharge planning. c. Review of the written agreements between the agency and Contractors 4 and 5 was initiated on 4/19/23. The written agreements did not include the role, if any, of the agency and the contractors in the submission of documentation of services provided. d. Review of the written agreements between the agency and Contractors 3 and 4 was initiated on 4/19/23. The written agreements did not include the responsibility of the contractor to applicable agency policies, including personnel qualifications. On 4/24/23 at 1015 hours, an interview and concurrent document review was conducted with RN 1. RN 1 was informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the discharge summary was completed for one of the seven sampled patients (Patient 6). This failure created the risk of providing substandard care to these patients as their clinical information were not complete. Findings: Review of Patient 6's closed clinical record was initiated on 4/18/23. The clinical record showed the SOC was 8/24/22. The patient was certified for home health services during the certification periods from 8/24/22 to 10/22/22 and 10/23/22 to 12/21/22. The patient was discharged on 11/15/22. Review of the Discharge Summary dated 11/15/22, showed the summary of care provided. The notes showed the medication review was completed. However, there was no documented evidence the patient's medications at the time of discharge were listed. On 4/24/23 at 0952 hours, an interview and concurrent clinical record review was conducted with RN 1. RN 1 was informed and acknowledged the finding.