Every finding on record at Ams A Medical Service Inc

Nurses That Care Initial Comments Purpose of Visit - To Conduct a Recertification Survey Entrance Date/Time - 11/29/21 at 11:43 a.m. Census: 57 Licensed and Certified: 57 The Agency was in compliance with 42 CFR Part 484.22 Condition of Participation: Emergency Preparedness for Home Health Agencies. An exit conference was conducted on 12/02/2021 at 10:35 a.m. with the Administrator, Director of Nursing and the Alternate Director of Nursing. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator - Adm Alternate Administrator – AA Director of Nursing - DON Alternate Director of Nursing - ADON Registered Nurse - RN Licensed Vocational Nurse - LVN HHA- Home Health Aide

Nurses That Care Initial Comments Purpose of Visit - To Conduct a Recertification Survey Entrance Date/Time - 11/29/21 at 11:43 a.m. Census: 57 Licensed and Certified: 57 An exit conference was conducted on 12/02/2021 at 10:35 a.m. with the Administrator, Director of Nursing and the Alternate Director of Nursing. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator - Adm Alternate Administrator – AA Director of Nursing - DON Alternate Director of Nursing - ADON Registered Nurse - RN Licensed Vocational Nurse - LVN HHA- Home Health Aide POC - Plan of Care SN - Skilled Nursing MV - Missed Visit

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 clinical record review and interview, the Supervising Nurse failed to ensure the patients plans of care were followed as written for 3 of 7 agency clients (#2, #3 and # 4) whose records were reviewed. 1. LVN A did not instruct Patient #2 and/or caregiver as ordered on the Plan of Care (POC). 2. LVN A did not instruct Patient #3 and/or caregiver as ordered on the POC. 3. LVN B did not instruct Patient #4 and/or caregiver as ordered on the POC. Failure of the agency's skilled nurses to follow the plan of care placed the Agency's 57 active Licensed and Certified patients at risk of receiving inadequate care and services and could have placed the patients at risk of negative outcomes. The Findings Included: 1. Review of active Patient # 2's electronic clinical record included a form titled "Home Health Certification and Plan of Care (POC)" for the period of 06/12/21 thru 08/10/21 with diagnoses of Orthopedic Aftercare, Spinal Stenosis and Chronic Pain. The POC included a skilled nurse (SN) visit frequency of 1 time a week for 9 weeks. The POC included orders for the SN to perform a total of 9 skilled nursing visits and orders for teaching/instruction on Medications and side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. Further review of the POC revealed that there was two Misses Visits (MV) dated 07/01/21 and 07/21/21, coordination of care documentation was completed for both MV's. The SN visits signed by LVN A were dated 06/12/21, 06/17/21, 06/24/21, 07/05/21, 07/16/21 and 07/30/21. Review of the all 6 SN Visit Notes failed to contain documentation that LVN A instructed Patient #2 and/or the caregiver Medications and side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 09:51 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #2’s clinical record the DON agreed with the following: -LVN A did not follow the POC. There was no documentation to show that LVN A taught on Medication side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician for Patient #2. 2. Review of active Patient # 3's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 08/13/21 thru 10/11/21 with diagnoses of Urinary Device and Urinary Retention. The POC included a skilled nurse (SN) visit frequency of 2 time a month for one month and then 3 times a month for one month. The POC included orders for the SN to perform a total of 5 skilled nursing visits and orders for teaching/instruction on Medications and side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. The SN visits signed by LVN A were dated 08/19/21, 09/01/21, 09/16/21, 09/28/21 and 09/30/21. Review of the all 5 SN Visit Notes failed to contain documentation that LVN A instructed Patient #3 and/or the caregiver on Medications and side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 09:58 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #3’s clinical record the DON agreed with the following: -LVN A did not follow the POC. There was no documentation to show that LVN A taught Medication side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. 3. Review of active Patient # 4's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 08/04/21 thru 10/02/21 with diagnoses of High Blood Pressure and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of 2 times a week for 5 weeks and 1 time per week for 4 weeks. The POC included orders for the SN to perform a total of 14 skilled nursing visits and orders for teaching/instruction on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. Further review of the POC revealed that there were three Misses Visits (MV) dated 08/12/21, 08/16/21 and 08/19/21, coordination of care documentation was completed for the three MV's. The SN visits signed by LVN B were dated 08/04/21, 08/06/21, 08/09/21, 08/23/21, 08/26/21, 08/30/21, 09/02/21, 09/07/21, 09/14/21, 09/21/21 and 09/30/21. Review of the all 11 SN Visit Notes failed to contain documentation that LVN B instructed Patient #4 and/or the caregiver on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 10:00 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #4’s clinical record the DON agreed with the following: -LVN B did not follow the POC. There was no documentation to show that LVN A taught on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Review of the Agency's Policy and Procedure manual revealed a policy titled "Qualifications and Responsibilities of the Supervising Nurse/Director of Home Health Services". It was LD.6 and had a revision date of 07/01/21. It read in part: "6. Ensures that a patient’s Plan of Care is executed as written." Continued review of the Agency’s Policy and Procedure manual revealed a policy titled “Orders for Care”, it was numbered TX.5 and had a revision date of 01/01/21. It read in part: “A. Agency will obtain orders an provide care in accordance with physician’s orders which are established on a patient POC.”

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 record review and interview, the agency failed to ensure the plan of care was reviewed by a physician and returned to the agency within the same 60-day episode for 2 of 7 active patients (# 1 and # 7) whose records were reviewed. This failure could place the agency's 87 active Licensed Home Health and Licensed and Certified clients at risk of receiving inadequate care that can result in negative outcomes due to the physician not reviewing the Plan of Care, ensuring that specific treatments and/or disciplines are ordered to meet the patients on going needs. The Findings Included: 1. Patient # 1's electronic clinical record included a Home Health Certification and Plan of Care (POC) for the certification period of 07/24/21 to 09/21/21 that listed the diagnosis of Low Back Pain. The POC also included a skilled nurse (SN) visit frequency of 1 time a month for 2 months and HHA frequency of 4 times per week for 8 weeks. Further review of Patient # 1's electronic and paper record failed to contain evidence the physician reviewed and signed the POC within 60 days of the certification period. During an interview and concurrent on 12/02/21 at 09:49 a.m. with the Alternate Administrator (AA) and Director of Nurses (DON), the surveyor presented the above findings and the DON agreed with the following findings: -For the certification period of 07/24/21 to 09/21/21 the POC had not been reviewed and signed by the physician within the 60-day certification period. 2. Patient # 7's electronic record included a POC for the certification period of 01/18/20 to 03/17/20 that listed the following diagnoses: Traumatic Amputation of Lower Right Leg and Surgical Aftercare. The POC also included a SN visit frequency of 1 time a week for 1 week and 5 times a week for 1 week and then 1 time per week for seven weeks. Further review of Patient # 7's electronic and paper record failed to contain evidence the physician reviewed and signed the POC within 60 days of the certification period. During an interview and concurrent on 12/02/21 at 10:07 a.m. with the AA and DON, the surveyor presented the above findings and the DON agreed with the following findings: -For the certification period of 01/18/20 to 03/17/20 the POC had not been reviewed and signed by the physician within the 60-day certification period. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Orders for Care", it was numbered TX.5 and had a revision date of 01/01/21. It read in part: "E. The Medical orders for the Plan of Care will be approved and signed by the physician within sixty (60) calendar days."

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. This failure could place the agency's patients at risk of receiving inadequate care and services due to the agency not being able to trend patterns. The Findings Included: Review of the QAPI manual revealed 12 agency forms titled "QAPI Report and Meeting Minutes." They were dated as follows: - 01/07/19, 04/08/19, 07/08/19 and 10/10/19. - 01/10/20, 04/01/20, 08/03/21 and 11/30/20. - 01/11/21, 04/04/21, 07/06/21 and 10/4/21. These forms listed the indicators and reported on the Agency's findings and status. However, there was no documentation to support the indicator findings for 2019, 2020 or 2021 or that indicators had been used to identified problems to be solved in an orderly and constructive manner and to provide for measures to address identified opportunities for improvement. Continued review of the QAPI manual failed to have documentation that focused on client outcomes that were measurable, and have a written plan of implementation for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative client care outcomes for 2019, 2020 and 2021. Still further review of the QAPI manual revealed that there was no documentation or information on the determination that services had been performed as outlined on the Individual Service Plan / POC for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation of a review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff or a review of infection control activities or effectiveness and safety of all services provided, including the competency of the agency's attendant staff and licensed nurses, the promptness of service delivery and the appropriateness of the agency's responses to client complaints and incidents for 2019, 2020 and 2021. In an interview conducted on 11/30/21 at 10:50 a.m. with the DON, the Surveyor presented the above findings, and after review of the QAPI manual and the 12 QAPI Report and Meeting Minutes, the DON agreed with the following: - That there was no documentation to support the indicator findings for 2019, 2020 or 2021 or that indicators had been used to identified problems to be solved in an orderly and constructive manner and to provide for measures to address identified opportunities for improvement. - That there was no documentation that focused on client outcomes that were measurable, and have a written plan of implementation for 2019, 2020 and 2021. - That the Agency did not have a Quality Assessment Performance Improvement (QAPI) program that addressed key indicators for 2019, 2020 and 2021. Review of the Agency's policy and procedure manual revealed a policy titled "Quality Assessment and Performance Improvement (QAPI)" it was numbered QAPI.1 and had a revision date of 10/03/18. It read in part: "Develop implement, evaluate and maintain an effective, ongoing Agency wide data driven Quality Assessment Performance Improvement Program, which captures significant outcomes essential to safe and quality care. Continued review of the QAPI policy read in part: "2. Focuses on indications related to improve outcomes..." Further review of the QAPI policy read in part: "Maintains documentary evidence of its QAPI program and activities..." Continued review of the Agency's policy and procedure manual revealed a policy titled "Performance Improvement Process: Data Collection" , it was numbered QAPI.2 and had a revision date of 04/17/19. It read in part: "Data is collected to monitor the effectiveness and safety of services and quality of care and to identify opportunities for improvement. To identify needed changes that will lead to improvement and sustain improvement over time..."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's 1 of 1 Quality Assessment Performance Improvement (QAPI) program failed to implement a policy that required the Agency to develop Performance Improvement Projects that were based on the QAPI program activities and data, which would measures analyze and tract quality indicators to assess which projects are indicated and the priority of the projects for 2019, 2020 and 2021. This failure could place the agency's active clients at risk of receiving inadequate care and of not having their needs met and problems corrected. The Findings Included: Review of the QAPI manual revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative patient care outcomes for 2019, 2020 and 2021. Continued review of the QAPI manual revealed that there was no documentation or information on the determination that services had been performed as outlined on the Individual Service Plan / Plan of Care for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation of a review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff or a review of infection control activities or effectiveness and safety of all services provided, including the competency of the agency's attendant staff and licensed nurses, the promptness of service delivery and the appropriateness of the agency's responses to patient complaints and incidents for 2019, 2020 and 2021. Still further review of the QAPI manual revealed that there was no documentation of Performance Improvement Projects based on the ongoing QAPI program activities and data for 2019, 2020 and 2021. During an interview on 11/30/21 at 10:50 a.m., with the DON the above findings were presented, and the QAPI manual was reviewed. After reviewing the DON agreed with the following: - That the Agency’s QAPI program activities failed to collect data that would measures analyze and tract quality indicators for 2019, 2020 and 2021. - That the Agency had failed to implement and document Performance Improvement Projects for 2019, 2020 and 2021. Review of the Agency's policy and procedure manual revealed a policy titled "Quality Assessment and Performance Improvement (QAPI)" it was numbered QAPI.1 and had a revision date of 01/13/18. It read in part: "K. Performance Improvement Projects will be conducted..." Continued review of the QAPI policy revealed in part: "The Agency will systematically collect data to measure various aspects of quality of care, the frequency and detail of data collection, how the data will be collected and analyzed and that the data collected is used to assess quality and stimulate Performance Improvement Projects."

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the Administrator failed to organize and direct the agency's ongoing functions as follows:1. The Administrator failed to implement a policy that required the Agency to measure, analyze and track quality indicators to assess care services and operations. The agency failed to maintain 1 of 1 Quality Assessment Performance Improvement (QAPI) program that addressed the significant measures as outlined in the agency's QAPI policy to ensure optimal client care outcomes for 2019, 2020 and in 2021. 2. The Administrator failed to implement in the Agency's 1 of 1 QAPI program policy that required the Agency to develop Performance Improvement Projects that were based on the QAPI program activities and data, which would measures analyze and tract quality indicators to assess which projects are indicated and the priority of the projects for 2019, 2020 and 2021.This failure resulted in the Agency failing to carry out, organize and supervise ongoing work under the Agency's policies, and could have put the Agency's active clients at risk of receiving substandard care and services. The Findings Included: 1. Review of the QAPI manual revealed 12 agency forms titled "QAPI Report and Meeting Minutes." They were dated as follows: - 01/07/19, 04/08/19, 07/08/19 and 10/10/19. - 01/10/20, 04/01/20, 08/03/21 and 11/30/20. - 01/11/21, 04/04/21, 07/06/21 and 10/4/21. These forms listed the indicators and reported on the Agency's findings and status. However, there was no documentation to support the indicator findings for 2019, 2020 or 2021 or that indicators had been used to identified problems to be solved in an orderly and constructive manner and to provide for measures to address identified opportunities for improvement. Continued review of the QAPI manual failed to have documentation that focused on client outcomes that were measurable, and have a written plan of implementation for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative client care outcomes for 2019, 2020 and 2021. Still further review of the QAPI manual revealed that there was no documentation or information on the determination that services had been performed as outlined on the Individual Service Plan / Plan of Care for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation of a review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff or a review of infection control activities or effectiveness and safety of all services provided, including the competency of the agency's attendant staff and licensed nurses, the promptness of service delivery and the appropriateness of the agency's responses to client complaints and incidents for 2019, 2020 and 2021. In an interview conducted on 11/30/21 at 10:50 a.m. with the DON, the Surveyor presented the above findings, and after review of the QAPI manual and the 12 QAPI Report and Meeting Minutes, the DON agreed with the following: - That there was no documentation to support the indicator findings for 2019, 2020 or 2021 or that indicators had been used to identified problems to be solved in an orderly and constructive manner and to provide for measures to address identified opportunities for improvement. - That there was no documentation that focused on client outcomes that were measurable, and have a written plan of implementation for 2019, 2020 and 2021. - That the Agency did not have a Quality Assessment Performance Improvement (QAPI) program that addressed key indicators for 2019, 2020 and 2021. Review of the Agency's policy and procedure manual revealed a policy titled "Quality Assessment and Performance Improvement (QAPI)" it was numbered QAPI.1 and had a revision date of 10/03/18. It read in part: "Develop implement, evaluate and maintain an effective, ongoing Agency wide data driven Quality Assessment Performance Improvement Program, which captures significant outcomes essential to safe and quality care. Continued review of the QAPI policy read in part: "2. Focuses on indications related to improve outcomes..." Further review of the QAPI policy read in part: "Maintains documentary evidence of its QAPI program and activities..." Continued review of the Agency's policy and procedure manual revealed a policy titled "Performance Improvement Process: Data Collection" , it was numbered QAPI.2 and had a revision date of 04/17/19. It read in part: "Data is collected to monitor the effectiveness and safety of services and quality of care and to identify opportunities for improvement. To identify needed changes that will lead to improvement and sustain improvement over time..." 2. Review of the QAPI manual revealed that there was no documentation the agency conducted a review of a representative sample of services furnished, conducted an analysis of its services and reviewed negative patient care outcomes for 2019, 2020 and 2021. Continued review of the QAPI manual revealed that there was no documentation or information on the determination that services had been performed as outlined on the Individual Service Plan / Plan of Care for 2019, 2020 and 2021. Further review of the QAPI manual revealed that there was no documentation of a review of complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff or a review of infection control activities or effectiveness and safety of all services provided, including the competency of the agency's attendant staff and licensed nurses, the promptness of service delivery and the appropriateness of the agency's responses to patient complaints and incidents for 2019, 2020 and 2021. Still further review of the QAPI manual revealed that there was no documentation of Performance Improvement Projects based on the ongoing QAPI program activities and data for 2019, 2020 and 2021. During an interview on 11/30/21 at 10:50 a.m., with the DON the above findings were presented, and the QAPI manual was reviewed. After reviewing the DON agreed with the following: - That the Agency’s QAPI program activities failed to collect data that would measures analyze and tract quality indicators for 2019, 2020 and 2021. - That the Agency had failed to implement and document Performance Improvement Projects for 2019, 2020 and 2021. Review of the Agency's policy and procedure manual revealed a policy titled "Quality Assessment and Performance Improvement (QAPI)" it was numbered QAPI.1 and had a revision date of 01/13/18. It read in part: "K. Performance Improvement Projects will be conducted..." Continued review of the QAPI policy revealed in part: "The Agency will systematically collect data to measure various aspects of quality of care, the frequency and detail of data collection, how the data will be collected and analyzed and that the data collected is used to assess quality and stimulate Performance Improvement Projects." Review of the Agency's Policy and Procedure Manual reveled a policy titled "Qualifications and Responsibilities of the Administrator", it was numbered LD.5 and had a revision date of 10/20/21. It read in part: "An Administrator will be responsible for 2. Organize and Direct the Agency's ongoing functions."

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 record review and interview, the Administrator failed to manage the daily operations of the agency in that: 1. The Administrator failed to ensure the patients plans of care were followed as written for 3 of 7 agency clients (#2, #3 and # 4) whose records were reviewed. - Licensed Vocational Nurse (LVN) A did not instruct Patient #2 and/or caregiver as ordered on the Plan of Care (POC). - LVN A did not instruct Patient #3 and/or caregiver as ordered on the POC. - LVN B did not instruct Patient #4 and/or caregiver as ordered on the POC. 2. The Administrator failed to ensure the plan of care was reviewed by a physician and returned to the agency within the same 60-day episode for 2 of 7 active clients (# 1 and # 7) whose records were reviewed. These failures could place the agency's active clients at risk of receiving substandard care, inadequate or incomplete care/treatment, and lack of coordination of services that could result in negative outcomes. The Findings Included: 1. Review of active Patient # 2's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 06/12/21 thru 08/10/21 with diagnoses of Orthopedic Aftercare, Spinal Stenosis and Chronic Pain. The POC included a skilled nurse (SN) visit frequency of 1 time a week for 9 weeks. The POC included orders for the SN to perform a total of 9 skilled nursing visits and orders for teaching/instruction on Medications and side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. Further review of the POC revealed that there was two Misses Visits (MV) dated 07/01/21 and 07/21/21, coordination of care documentation was completed for both MV's. The SN visits signed by LVN A were dated 06/12/21, 06/17/21, 06/24/21, 07/05/21, 07/16/21 and 07/30/21. Review of the all 6 SN Visit Notes failed to contain documentation that LVN A instructed Patient #2 and/or the caregiver Medications and side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 09:51 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #2’s clinical record the DON agreed with the following: -LVN A did not follow the POC. There was no documentation to show that LVN A taught on Medication side effects and Non-Pharmaceutical pain relief, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician for Patient #2. - Review of active Patient # 3's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 08/13/21 thru 10/11/21 with diagnoses of Urinary Device and Urinary Retention. The POC included a skilled nurse (SN) visit frequency of 2 time a month for one month and then 3 times a month for one month. The POC included orders for the SN to perform a total of 5 skilled nursing visits and orders for teaching/instruction on Medications and side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. The SN visits signed by LVN A were dated 08/19/21, 09/01/21, 09/16/21, 09/28/21 and 09/30/21. Review of the all 5 SN Visit Notes failed to contain documentation that LVN A instructed Patient #3 and/or the caregiver on Medications and side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 09:58 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #3’s clinical record the DON agreed with the following: -LVN A did not follow the POC. There was no documentation to show that LVN A taught Medication side effects, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. - Review of active Patient # 4's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 08/04/21 thru 10/02/21 with diagnoses of High Blood Pressure and Type 2 Diabetes Mellitus. The POC included a skilled nurse (SN) visit frequency of 2 times a week for 5 weeks and 1 time per week for 4 weeks. The POC included orders for the SN to perform a total of 14 skilled nursing visits and orders for teaching/instruction on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Continued review of the POC revealed that it was signed by the physician. Further review of the POC revealed that there were three Misses Visits (MV) dated 08/12/21, 08/16/21 and 08/19/21, coordination of care documentation was completed for the three MV's. The SN visits signed by LVN B were dated 08/04/21, 08/06/21, 08/09/21, 08/23/21, 08/26/21, 08/30/21, 09/02/21, 09/07/21, 09/14/21, 09/21/21 and 09/30/21. Review of the all 11 SN Visit Notes failed to contain documentation that LVN B instructed Patient #4 and/or the caregiver on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. In an interview and concurrent record review conducted on 12/02/21 at 10:00 a.m. with the AA and the DON, the Surveyor presented the above findings. After review of Patient #4’s clinical record the DON agreed with the following: -LVN B did not follow the POC. There was no documentation to show that LVN A taught on Medications and side effects and Non-Pharmaceutical pain relief, Diabetic Management, Heart Healthy Diet, Standard Precautions for Safety, Falls, Infection Control, Foley Care, Home Safety, Environmental changes to increase safety, Use of Adaptive Devices, When to call 911 and Signs and Symptoms to report to Physician. Review of the Agency's Policy and Procedure manual revealed a policy titled "Qualifications and Responsibilities of the Supervising Nurse/Director of Home Health Services". It was LD.6 and had a revision date of 07/01/21. It read in part: "6. Ensures that a patient’s Plan of Care is executed as written." Continued review of the Agency’s Policy and Procedure manual revealed a policy titled “Orders for Care”, it was numbered TX.5 and had a revision date of 01/01/21. It read in part: “A. Agency will obtain orders an provide care in accordance with physician’s orders which are established on a patient POC.” 2. Patient # 1's electronic clinical record included a Home Health Certification and Plan of Care (POC) for the certification period of 07/24/21 to 09/21/21 that listed the diagnosis of Low Back Pain. The POC also included a skilled nurse (SN) visit frequency of 1 time a month for 2 months and HHA frequency of 4 times per week for 8 weeks. Further review of Patient # 1's electronic and paper record failed to contain evidence the physician reviewed and signed the POC within 60 days of the certification period. During an interview and concurrent on 12/02/21 at 09:49 a.m. with the Alternate Administrator (AA) and Director of Nurses (DON), the surveyor presented the above findings and the DON agreed with the following findings: -For the certification period of 07/24/21 to 09/21/21 the POC had not been reviewed and signed by the physician within the 60-day certification period. - Patient # 7's electronic record included a POC for the certification period of 01/18/20 to 03/17/20 that listed the following diagnoses: Traumatic Amputation of Lower Right Leg and Surgical Aftercare. The POC also included a SN visit frequency of 1 time a week for 1 week and 5 times a week for 1 week and then 1 time per week for seven weeks. Further review of Patient # 7's electronic and paper record failed to contain evidence the physician reviewed and signed the POC within 60 days of the certification period. During an interview and concurrent on 12/02/21 at 10:07 a.m. with the AA and DON, the surveyor presented the above findings and the DON agreed with the following findings: -For the certification period of 01/18/20 to 03/17/20 the POC had not been reviewed and signed by the physician within the 60-day certification period. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Orders for Care", it was numbered TX.5 and had a revision date of 01/01/21. It read in part: "E. The Medical orders for the Plan of Care will be approved and signed by the physician within sixty (60) calendar days." Review of the Agency's policy and procedure manual revealed a policy titled "Qualifications and Responsibilities of the Administrator", it was numbered LD.5 and had a revision date of 10/20/21. It read in part: "An Administrator will be responsible for 1. Manage and be responsible for all day-to-day operations of the Agency."