Every finding on record at Arav Healthcare

A Chow/Recertification survey was conducted on 06/13/2024 with a follow-up for survey dated 06/25/2021. Licensed and Certified census was 48. The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A CHOW/Recertification survey was conducted on 06/13/2024 with a follow-up for survey dated 06/25/2021. Licensed and Certified census was 48. Abbreviations/Acronyms: Adm-Administrator DON-Director of Nursing ADON - Alternate Registered Nurse (RN) Licensed Vocational Nurse (LVN) Physical Therapist (PT) hha-Home Health Aide POC-Plan of Care SOC- Start of Care SN-Skilled Nursing EHR-Electronic Health Record Moo90-Date OASIS Assessment is completed. OASIS- outcome and assessment information set. CMS-- Center for Medicare and Medicaid Services NOMNC-Notice of Medicare Non-Coverage PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement IQIES – Internet Quality Improvement & Evaluation System HMO-Health Management Organization Quality Improvement Organization (QIO) OMB-Office of Management and Budget

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to encode and electronically transmit each completed (OASIS) assessment to the (CMS) system regarding each beneficiary, within 30 days of completing the OASIS assessment of the beneficiaries (Patients # 1, 2, 4, 6, 7, and 12 through 40), in that; For report period 05/11/2023 to 05/11/2024 (49 of 153) of OASIS assessments had submission dates that were more than 30 days after the M0090 date (date OASIS assessment completed). The failure prevented the patients’ data from being available to CMS for timely analysis to identify agency performance levels in the provision of patient care and treatment. Findings included: Review of iQIES (Internet Quality Improvement & Evaluation System) on 06/12/2024 revealed the Agency's OASIS error summary report for review period of (05/11/2023 to 05/11/2024). Review of the report revealed the following: error description “Record Submitted Late: The submission date was more than 30 days after the M0090 date on this new record…) Review of the agency’s “OASIS Agency Final Validation” reports for the months of May, June, July, August, October, November, December of 2023 and for the months of January, February, March, April, and May of 2024 revealed the following: that the agency submitted (49 of 153) OASIS assessments late (more than 30 days after the M0090 date); and the late assessments included the following: A discharge OASIS assessment for Client # 12 was submitted on 05/13/2023 with a Moo90 date of 04/04/2023. A resumption of care OASIS assessment for Client # 6 was submitted on 06/22/2023 with a Moo90 date of 04/28/2023. A start of care OASIS assessment for Client # 13 was submitted on 06/23/2023 with a Moo90 date of 05/22/2023. A recertification OASIS assessment for Client # 14 was submitted on 07/13/2023 with a Moo90 date of 06/13/2022. A resumption of care OASIS assessment for Client # 6 was submitted on 07/19/2023 with a Moo90 date of 06/03/2023. A transfer to inpatient OASIS assessment for Client # 6 was submitted on 07/21/2023 with a Moo90 date of 05/26/2023. A start of care OASIS assessment for Client # 7 was submitted on 08/07/2023 with a Moo90 date of 07/06/2023. A start of care OASIS assessment for Client # 2 was submitted on 10/09/2023 with a Moo90 date of 09/06/2023. A start of care OASIS assessment for Client # 15 was submitted on 10/25/2023 with a Moo90 date of 09/22/2023. A start of care OASIS assessment for Client # 16 was submitted on 10/25/2023 with a Moo90 date of 09/19/2023. A start of care OASIS assessment for Client # 17 was submitted on 11/20/2023 with a Moo90 date of 07/06/2023. A start of care OASIS assessment for Client # 18 was submitted on 12/20/2023 with a Moo90 date of 11/04/2023. A start of care OASIS assessment for Client # 19 was submitted on 01/24/2024 with a Moo90 date of 12/20/2023. A start of care OASIS assessment for Client # 4 was submitted on 01/24/2024 with a Moo90 date of 12/20/2023. A start of care OASIS assessment for Client # 20 was submitted on 01/26/2024 with a Moo90 date of 12/20/2023. A discharge OASIS assessment for Client # 21 was submitted on 02/01/2024 with a Moo90 date of 01/01/2024. A transfer to inpatient OASIS assessment for Client # 22 was submitted on 02/01/2024 with a Moo90 date of 12/21/2023. A transfer to inpatient OASIS assessment for Client # 6 was submitted on 02/01/2024 with a Moo90 date of 12/27/2023. A transfer to inpatient with discharge OASIS assessment for Client # 6 was submitted on 02/01/2024 with a Moo90 date of 12/31/2023. A transfer to inpatient OASIS assessment for Client # 1 was submitted on 02/01/2024 with a Moo90 date of 12/20/2023. A resumption of care OASIS assessment for Client # 21 was submitted on 02/05/2024 with a Moo90 date of 12/02/2023. A start of care OASIS assessment for Client # 21 was submitted on 02/05/2024 with a Moo90 date of 01/02/2024. A recertification OASIS assessment for Client # 23 was submitted on 02/19/2024 with a Moo90 date of 10/01/2023. A recertification OASIS assessment for Client # 24 was submitted on 02/19/2024 with a Moo90 date of 12/07/2023. A recertification OASIS assessment for Client # 17 was submitted on 02/20/2024 with a Moo90 date of 08/30/2023. A start of care OASIS assessment for Client # 21 was submitted on 02/20/2024 with a Moo90 date of 09/14/2023. A recertification OASIS assessment for Client # 7 was submitted on 02/20/2024 with a Moo90 date of 08/30/2023. A start of care OASIS assessment for Client # 25 was submitted on 02/20/2024 with a Moo90 date of 08/08/2023. A recertification OASIS assessment for Client # 6 was submitted on 02/20/2024 with a Moo90 date of 08/29/2023. A recertification OASIS assessment for Client # 26 was submitted on 02/20/2024 with a Moo90 date of 08/29/2023. A start of care OASIS assessment for Client # 27 was submitted on 02/21/2024 with a Moo90 date of 09/30/2022. A start of care OASIS assessment for Client # 28 was submitted on 02/21/2024 with a Moo90 date of 09/09/2022. A start of care OASIS assessment for Client # 24 was submitted on 03/06/2024 with a Moo90 date of 08/14/2023. A recertification OASIS assessment for Client # 29 was submitted on 03/20/2024 with a Moo90 date of 01/01/2024. A recertification OASIS assessment for Client # 30 was submitted on 03/22/2024 with a Moo90 date of 02/02/2024. A recertification OASIS assessment for Client # 31 was submitted on 03/22/2024 with a Moo90 date of 02/08/2024. A recertification OASIS assessment for Client # 32 was submitted on 03/22/2024 with a Moo90 date of 02/09/2024. A resumption of care OASIS assessment for Client # 1 was submitted on 03/22/2024 with a Moo90 date of 02/09/2024. A start of care OASIS assessment for Client # 33 was submitted on 04/11/2024 with a Moo90 date of 03/11/2024. A start of care OASIS assessment for Client # 34 was submitted on 04/11/2024 with a Moo90 date of 03/11/2024. A recertification OASIS assessment for Client # 19 was submitted on 04/14/2024 with a Moo90 date of 02/13/2024. A recertification OASIS assessment for Client # 4 was submitted on 04/14/2024 with a Moo90 date of 02/13/2024. A start of care OASIS assessment for Client # 35 was submitted on 04/14/2024 with a Moo90 date of 12/20/2023. A start of care OASIS assessment for Client # 36 was submitted on 04/14/2024 with a Moo90 date of 07/26/2023. A recertification OASIS assessment for Client # 24 was submitted on 04/14/2024 with a Moo90 date of 10/08/2023. A recertification OASIS assessment for Client # 24 was submitted on 04/14/2024 with a Moo90 date of 02/05/2024. A discharge OASIS assessment for Client # 37 was submitted on 04/23/2024 with a Moo90 date of 03/08/2024. A transfer to inpatient OASIS assessment for Client # 38 was submitted on 04/23/2024 with a Moo90 date of 03/23/2024. A discharge OASIS assessment for Client # 39 was submitted on 04/23/2024 with a Moo90 date of 03/08/2024. A start of care OASIS assessment for Client # 40 was submitted on 05/09/2024 with a Moo90 date of 04/05/2024. During an interview with the Adm/DON on 06/20/2024 at approximately 3:15 p.m., the surveyor asked who at the agency was responsible for encoding and submitting the agency’s OASIS assessments. The Adm/DON stated that the ADON was responsible for encoding/completing the OASIS assessments. The Adm/DON stated that [the Adm/DON] was responsible for submitting/transmitting the OASIS assessments. The surveyor asked why the OASIS submissions were late. The Adm/DON stated, “Well, documentation. Sometimes the documentation was not completed in a timely manner.” Review of agency policy titled, “Timelines IM.35” dated 05/02/24 read in part: “…II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…” Review of the Centers for Medicare and Medicaid Services (CMS) website at, https://www.cms.gov/medicare/quality/home-health/oasis, on 06/26/2024 revealed that, “…The Outcome and Assessment Information Set (OASIS) is a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services (CMS)…The M0090 date is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific responses was completed…”

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of the agency terminating on-going care in four (Patients # 8, 9, 10, and 11) of six discharged patient records reviewed. The agency failed to provide the patients with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC).” The failure could affect the patient’s health and safety and result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. Findings include: Discharged Clinical Record # 8: Record review of the electronic clinical record for Patient # 8 revealed a POC for the certification period of 03/03/2024 to 05/01/2024. Review of the POC revealed a start of care date of 11/04/2023 with a primary diagnosis of bilateral primary osteoarthritis of knee. The POC was dated 02/27/2024 and digitally signed by RN A. The POC revealed an order for skilled nursing visits for one time per for nine weeks and two as needed visits. Continued review of the record revealed a discharge order dated 03/05/2024 and signed by the Adm/DON. Review of the discharge order revealed a reason for discharge as “Insurance change from Medicare to HMO.” Further review of the record revealed a discharge summary that read in part: “…D/C (discharged) Date: 03/05/2024…” Further review of Patient # 8’s record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 03/05/2024. The record did not include a written NOMNC. Discharged Clinical Record # 9: Record review of the electronic clinical record for Patient # 9 revealed a POC for the certification period of 06/14/2023 to 08/12/2023. Review of the POC revealed a start of care date of 06/14/2023 with a primary diagnosis of primary generalized (osteo)arthritis. The POC was dated 06/14/2023 and digitally signed by the Adm/DON. The POC revealed an order for skilled nursing visits for two times per week for one week and one time per for eight weeks and two as needed visits. Continued review of the record revealed a discharge order dated 06/30/2023 and signed by the Adm/DON. Review of the discharge order revealed a reason for discharge as “Insurance change from Medicare to HMO.” Further review of the record revealed a discharge OASIS that revealed a discharge date of 06/30/2023” Further review of Patient # 9’s record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 06/30/2023. The record did not include a written NOMNC. Discharged Clinical Record # 10: Record review of the electronic clinical record for Patient # 10 revealed a POC for the certification period of 07/03/2023 to 08/31/2023. Review of the POC revealed a start of care date of 07/03/2023 with a primary diagnosis of rheumatoid arthritis, multiple sites. The POC was dated 07/03/2023 and digitally signed by RN B. The POC revealed an order for skilled nursing visits for two times per week for one week and one time per for eight weeks and two as needed visits. Continued review of the record revealed a discharge order dated 08/08/2023 and signed RN B. Review of the discharge order revealed a reason for discharge as “Insurance change from Medicare to HMO.” Further review of the record revealed a discharge summary that read in part: “…D/C (discharged) Date: 08/08/2023…” Further review of Patient # 10’s record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 03/05/2024. The record did not include a written NOMNC. Discharged Clinical Record # 11: Record review of the electronic clinical record for Patient # 11 revealed a POC for the certification period of 05/10/2024 to 07/08/2024. Review of the POC revealed a start of care date of 03/11/2024 with a primary diagnosis of arthritis, right hip. The POC was dated 05/05/2024 and digitally signed by RN A. The POC revealed an order for skilled nursing visits for one time per for nine weeks and two as needed visits. Continued review of the record revealed a discharge order dated 06/17/2024 and signed by the Office Nurse. Review of the discharge order revealed a reason for discharge as “Goals met.” Further review of the record revealed an incomplete discharge OASIS dated 05/31/2024…” The OASIS included the Adm/DON’s name as the “assessor” but did not include the assessor’s signature or date of signature. Further review of Patient # 11’s record did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 05/31/2024. The record did not include a written NOMNC. During an interview on 06/20/2024 at approximately 2:57 p.m. with the Adm/DON, the surveyor asked the Adm/DON to describe the agency’s discharge/transfer process. The Adm/DON stated that: it depended on the reason for discharge; when a patient was transferred or discharged an OASIS would be completed; and if goals were met the two-day notice for Medicare would be given. The surveyor asked who at the agency was responsible for providing the discharge notices to patients. The Adm/DON stated that the agency nurses or any clinician, and that the notices could also be mailed to the patients. The surveyor reviewed the findings and asked why the agency had not provided written notice of the intent to discharge with the NOMNC no later than two days in advance of terminating on-going care for Patients # 8, 9, 10, and 11. The Adm/DON replied, “I would say it was an oversight." The surveyor asked how the failure could adversely affect the patients’ health and safety. The Adm/DON stated that the failure would affect their ability to appeal the discharge and have a review of their Medicare coverage. Review of agency policy titled "Patient/Client Transfer and Discharge Notices" last reviewed 05/02/2024 read in part: " ...Purpose [:] To provide guidance on completion of the required discharge notices. Policy [:] I. Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client or the patient’s/client's parent, family, spouse, significant other, or legal representative, and will notify the patient’s/client's attending physician and/or non-physician practitioner or practitioner if involved in the Agency's care of the patient/client…Notification will be provided in accordance with state and federal regulations. II. The Agency will provide notice to eligible patients/clients of the right to expedited determinations when the period of covered care ends. III. The Agency will deliver the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) to the patient/client, or representative, at least two (2) calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily. IV. The Agency will deliver a Detailed Explanation of Non-Coverage (an OMB-approved Medicare form) to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client requests an expedited review by the QIO of the decision that coverage for items and/or services should end…Procedure [:] I. Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client, or representative (if any), when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end or the second to last day of service if care is not provided daily, the Agency representative will provide the NOMNC to the patient/client, or representative (if any) when providing notice of discharge. C, If the Agency fails to give valid notice, patient/client coverage continues for at least two (2) days after the notice is received. D. If an option for non-covered services exists, the Agency will also provide the patient/client with an Advance Beneficiary Notice (ABN). E. The notice may not be routinely delivered at the time services begin…”

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 failed to conduct and document PIP(s) for the calendar years 2021, 2022, and 2023 that reflected the scope, complexity and past performance of the agency's services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings included: During the entrance conference on 06/13/2024 at approximately 10:45 a.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s QAPI and business profile binders did not reveal any current QAPI records. At approximately 12:45 p.m. the surveyor requested the agency ‘s QAPI records. The Adm/DON stated that the records were online and that the Office Nurse was printing out infection control reports and the QAPI records would be provided. At approximately 2:30 p.m. the surveyor requested online access to the agency’s QAPI records. The Adm/DON provided access to the QAPI records, on the agency’s computer. At approximately 2:54 p.m. review of the records revealed the following: PIP folders for 2021, 2022, and 2023 that read in part: “This folder is empty.” QAPI Quarterly report[s] for 2nd and 4th quarter 2023 dated 07/05/2023 and 01/03/2024. The author of the reports did not sign the reports. QAPI Quarterly report[s] for 2nd and 4th quarter 2022 dated 07/06/2022 and 01/04/2023. The author of the reports did not sign the reports. Review of the reports revealed the following: a column titled, “Indicator.” Under the indicator column “Performance Improvement Project Status” was listed. The reports included a second column titled, “Findings/Recommendations/Actions to Prevent Reoccurrence.” Under the second column adjacent to Performance Improvement Project Status no findings/recommendations/actions were documented (the areas were blank on the reports). Continued review of the agency’s QAPI records did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for each calendar year of 2021, 2022, and 2023. During an interview on 06/13/2024 at 3:25 p.m. with the Adm/DON, the surveyor asked why the agency’s QAPI records and program was not implemented per agency policy and regulations. The Adm/DON stated, “I fell behind because of some circumstances.” The Adm/DON stated that the agency had booked a consultant and was waiting for the consultant; “I was waiting on an outside entity.” The surveyor asked what the agency’s processes were for the QAPI program. The Adm/DON stated that the agency had a process, “You can see we have a system. My process now is to make sure it is updated biannually.” During a follow-up interview on 06/20/2024 at 1:37 p.m. with the Adm/DON, the surveyor reviewed the findings and asked why the agency had not conducted PIP(s) per agency policy and federal regulatory requirements for the years 2021, 2022, and 2023. The Adm/DON stated, “Unfortunately, we have not put it together.” The surveyor asked how not following agency policy and regulations could adversely affect the agency’s patients. The Adm/DON stated, “If policy and procedures are not followed completely it can impact the quality of patient care.” Review of agency policies titled, "Performance Improvement Process: Improvement Activities QAPI.25” last reviewed 05/01/2024 read in part: “Purpose [:] To establish a standard for achieving and sustaining improved performance. Policy…II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually…IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved…”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, observation, and interview the agency failed to ensure that all entries in the patients’ clinical records were completed and appropriately authenticated, dated, and timed with a primary author’s signature and title, who had reviewed and approved the entry, in four (Patients # 1, 2, 4, and 5) of five active patient records reviewed for authentication; and one (Patient # 11) of three discharged patient, who was discharged in 2024, whose records were reviewed for authentication. The failure placed the patients at risk of harm if care and treatment were not reviewed, approved, and authenticated by the primary author. Findings included: Clinical Record # 1: Review of Patient # 1’s record revealed a POC for the certification period of 06/12/2024 to 08/10/2024 with a SOC date of 06/18/2023. The POC included a primary diagnosis of encounter for change or removal of non-surgical wound dressing. The POC included an order for SN visits two times per week for one week and three times per week for eight weeks and two as needed visits. The POC was not signed, dated, timed, or titled by the primary author (RN A). During home visit with Patient # 1 on 06/17/2024 at approximately 10:15 a.m., the surveyor reviewed the agency’s written information that was provided to the patient. During the review, the surveyor observed a copy of the POC for certification period of 06/12/2024 to 08/10/2024 was included with the information. The POC was not signed, dated, timed, or titled by the primary author (RN A). Clinical Record # 2: Review of Patient # 2’s record revealed a POC for the certification period of 05/04/2024 to 07/02/2024 with a SOC date of 11/06/2023. The POC included a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (polyneuropathy is a complication of diabetes that affects the nerves in the arms, legs, hands, and feet). The POC included an order for SN visits one times per week for nine weeks and two as needed visits. Continued review of the record revealed a home health aide (hha) care plan dated 05/08/2024 and signed by the Adm/DON. Review of the care plan reveal a frequency of hha visits for three times per week. Further review of the record revealed home health aide notes for the following dates: May 08, 09, 10, 15, 16, 17, 22, 23, 24, 29, 30, 31, 2024 and June 05, 06, 07, 2024. The hha notes (15 of 15) were not signed, dated, timed, or titled by the primary author (the hha had not authenticated the hha visits in Patient # 2’s record). Continued review of the record reveal PT missed visit reports dated 05/31/2024 and 06/06/2024 completed by Biller A. The record also revealed a communication note for the missed PT visits dated 06/11/2024 and signed by the Office Nurse. During home visit with Patient # 2 and hha A on 06/17/2024 at approximately 10:50 a.m., the surveyor asked hha A how [hha A] recorded [hha A’s] visits with Patient # 2. The hha A stated that [hha A] wrote down the time; Patient # 2 signed it; and [hha A] emailed it to them (the agency). The hha A stated that [hha A] did not document anything online (on the computer). Clinical Record # 4: Review of Patient # 4’s record revealed a POC for the certification period of 04/18/2024 to 06/16/2024 with a SOC date of 12/20/2023. The POC included a primary diagnosis of Lumbago with sciatica, right side (lower back pain with pain that radiates from the sciatic nerve through the buttock and leg on the right side of the body). The POC included an order for SN visits one time per week for nine weeks and two as needed visits. Continued review of the record revealed nine SN visit notes. Review of the visit notes revealed that five (visit notes dated: 04/20/2024; 05/05/2024; 05/26/2024; 06/04/2024; and 06/09/2024) of nine SN visit notes were not signed, dated, timed, or titled by the primary author (LVN A). Continued review of the record revealed a communication note related to a patient fall, dated 05/10/2024. The communication note was not signed, dated, timed, or titled by a primary author. Clinical Record # 5: Review of Patient # 5’s record revealed a POC for the certification period of 04/06/2024 to 06/04/2024 with a SOC date of 04/06/2024. The POC included a primary diagnosis of hypertensive heart disease (heart disease caused by long term high blood pressure). The POC included an order for SN visits one time per week for one week, two times per week for one week, one time per week for seven weeks, and two as needed visits. Continued review of the record revealed an infection control report dated 04/06/2024. Review of the report revealed that LVN A had not digitally signed, dated, and timed the report. Clinical Record # 11: Record review of Patient # 11’s record revealed a POC for the certification period of 05/10/2024 to 07/08/2024. Review of the POC revealed a start of care date of 03/11/2024 with a primary diagnosis of arthritis, right hip. The POC was dated 05/05/2024 and digitally signed by RN A. The POC revealed an order for skilled nursing visits for one time per for nine weeks and two as needed visits. Continued review of the record revealed a discharge order dated 06/17/2024 and signed by the Office Nurse. Review of the discharge order revealed a reason for discharge as “Goals met.” Further review of the record revealed an incomplete discharge OASIS dated 05/31/2024…” The OASIS included the Adm/DON’s name as the “assessor” but did not include the assessor’s signature, date, or time of signature. Continued review of the record reveal a discharge summary dated 05/31/2024. Review of the discharge summary revealed that it was incomplete and was not signed, titled, timed, or dated by a primary author. During follow-up interviews on 06/20/2024 with the Adm/DON the surveyor reviewed the findings and asked: At 1:49 p.m. for Patient # 1: why RN A had not authenticated the current POC in the patient record and patient information in the home. The Adm/DON stated, “I had to send her a message two days ago to sign her pending orders.” The surveyor requested to speak with RN A by phone. The surveyor asked why RN A had not authenticated the current POC in the patient record and patient information in the home. RN A replied, “It might have been an oversight.” At 2:07 p.m. for Patient # 2: what was the agency process for hha visit documentation. The Adm/DON stated that the hha conducted the visit and then completed the documentation online. The surveyor asked why the hha had not authenticated the hha visits in Patient # 2’s record. The Adm/DON replied, “It must not be completed. It only gets authenticated when it gets completed.” The surveyor reviewed hha A’s explanation of how [hha A] documented hha visits to Patient # 2. The Adm/DON replied, “That doesn’t sound right.” The surveyor asked why there was no PT order or PT evaluation in the record (there were missed visit notes for PT visits). The Adm/DON replied, “I will have to check on it.” During the exit conference at 3:45 p.m. the Adm/DON provided a PT order that read in part: “…on 05/29/2024 Home health to evaluate and treat patient for Physical Therapy.” The order had a stamped or electronic signature for physician (Identifier 200). The signature did not include a title, date, or time. At 2:40 p.m. for Patients # 4 and 5: the surveyor asked to speak with LVN A by telephone. The surveyor asked LVN A why the notes were not authenticated. LVN A replied, “I don’t know.” The Adm/DON asked, “Was it an oversight?” LVN A replied, “It could have been an oversight.” The surveyor asked how the failure could adversely affect the patients. LVN A replied, “it could cause them to not get the proper treatment that they need.” At 3:00 p.m. for Patient # 11: why were the discharge records not authenticated. The Adm/DON stated that the agency just became aware of the transfer on 06/17/2024. At 3:13 p.m. the surveyor asked how the failure could adversely affect the agency’s patients. The Adm/DON replied, “It could affect the validity of care provided.” Review of agency policy titled, “Authorization and Authentication of Medical Record Entries IM.30” last reviewed 05/01/24 read in part: “Purpose [:] To identify the authors of medical record entries…Policy [:] All medical record entries whether paper, electronic, or a combination format will be legible, clear, complete, made by appropriate staff, and authenticated as true and accurate by the author of the entry. Procedure…IV Each medical record entry will be dated, timed, and signed with the complete name and title of the person making the entry…”