Every finding on record at Around the Clock Home Care

The following reflects the findings of the California Department of Public Health during a Recertification survey conducted on 7/7/25 - 7/9/25. The agency was found in compliance with the emergency preparedness regulations.

The following reflects the findings of the California Department of Public Health during a Recertification survey conducted on 7/7/25 - 7/9/25. Number of Unduplicated Admissions: 4,421 Sample Size: 17 Home Visits: 7 Record Review without Home Visits: 5 Closed Record Review: 5

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure its policies and procedures on abuse prevention and patient complaints indicated the requirement to suspend staff accused of abuse while the complaint is being investigated. This failure had the potential to place patients at risk for retaliation and further abuse. Findings: During a concurrent interview and record review on 7/9/25 at 9 a.m. with Administrator, the agency's policies and procedures (P&Ps) titled “Abuse/Neglect Assessment and Reporting” dated November 2018 and “Complaint and Grievance Process – Customer” dated November 2018 were reviewed. Administrator stated the above policies were the agency’s P&Ps on abuse prevention and patient complaints. The P&Ps did not indicate staff accused of patient abuse will be suspended pending the investigation of the abuse allegation. Administrator stated suspending staff accused of abuse while the allegations are being investigated is important to protect patients from abuse and should be included in the P&Ps.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to provide education to one of seven sampled patients (Patient 1) regarding environmental factors regarding infection prevention according to the plan of care. This failure had the potential to result in Patient 1 having worsening wound and/or developing wound infections. Findings: During an observation on 7/7/25 at 10:45 a.m. in Patient 1's home, Patient 1 was sitting on her bed. Patient 1 had wound dressing on her bottom and abdominal area. There was a detached wound VAC (vacuum assisted closure, negative pressure wound therapy used to help wounds heal. It works by applying gentle suction to the wound through a special dressing, which helps to remove excess fluid, reduce swelling, and promote the growth of new tissue) on the bed. There were clutters everywhere, folded clothes, books, shelves filled with things, bed was filled with folded clothes and miscellaneous things. The walkways were very narrow filled with various things on the sides, the floors had debris and stains. The Licensed Vocational Nurse (LVN) 1 performed the home visit to Patient 1 but did not educate Patient 1 regarding environmental safety and cleanliness. During a review of Patient 1's "Orders and Treatments (OT)" dated 5/15/25, the OT indicated, "SN [Skilled Nurse] to instruct on maintaining a safe/sanitary home environment to ensure optimal health and healing." During an interview on 7/8/25 at 12:47 p.m. with LVN 1, LVN 1 stated she did not educate Patient 1 on maintaining a safe and sanitary home environment. LVN 1 stated, "I have not seen any progress [on maintaining safe and sanitary environment]. I did not tell her yesterday [7/7/25]." During a review of the agency's policy and procedure (P&P) on "Education-Patient/Family" dated 11/2018, the P&P indicated, "Educate of patient/family may include, but is not limited to medications, safety, infection control, treatments and procedures and discharge planning. Continue to reinforce the new information or skills to reinstruct the patient/family as needed."

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to follow its policy and procedure (P&P) on "Competency Program" and "Performance Evaluation" for one of one sampled Social Worker (SW 1) when annual competencies and performance evaluations were not completed annually. This failure had the potential for compromised care to patients. Findings: During a concurrent interview and record review on 7/8/25 at 2:58 p.m. with Vice President of Operations (VPO), SW 1's employee file was reviewed. SW 1's "Initial competency assessment skills checklist - Medical Social worker" dated 6/19/20 was reviewed. VPO stated, SW 1 date of hire was 6/19/20, and SW 1's had an initial competency but no annual competency since 2020. VPO stated there were no performance evaluations in SW 1's employee file. VPO stated SW 1 should have had an annual competency and performance evaluation annually, and this had not been completed. During a review of the agency's P&P titled "Competency Program" revised November 2024, the P&P indicated, "Purpose: To ensure that the competence of clinical organization personnel is assessed, maintained, and improved on a continuing bases. Procedure: The organization will establish and annually re-evaluate its job specific "Competency Based Orientation Checklist" which reflects duties commonly required in the performance of patient contact positions. 2. The organization will establish and annually evaluate a group of specific "Competency Based Orientation Checklist" which reflects duties commonly required in the performance of patient contact positions." During a review of the agency's P&P titled "Performance Evaluations" revised November 2024, the P&P indicated, "Purpose To provide consistent and regular performance evaluations to promote improvement. Procedure: 1. Performance evaluations will be completed (and dated) on all personnel as follows: A. During the probationary period. B. Annually, based on personnel's annual evaluation date."

The following reflects the findings of the California Department of Public Health during a Recertification survey. Representing the Department: 32234, HFEN The agency was found in compliance with the emergency preparedness regulations. No deficient practices were identified.

The following reflects the findings of the California Department of Public Health during a Recertification survey. Representing the Department: 32234, HFEN 31486, HFES 34510, HFEN 42610, HFEN Number of Unduplicated Admissions: 4083 Sample Size: 17 Home Visits: 7 Record Review without Home Visits: 5 Closed Record Review: 5

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 medication reconciliation was completed during licensed nurses' home visits for two of 17 sampled patients (Patient 7 and Patient 11). This failure had the potential for patients not receiving medications according to physician’s order and potential for adverse health outcomes. 1. During a home visit observation and interview on 7/11/22, at 3 PM, in Patient 7’s home, with Licensed Vocational Nurse (LVN) 2 and Patient 7. LVN 2 was discussing Patient 7’s medications with Caregiver 7. LVN 2 did not check on the medication list, did not look into Patient 7’s medication supply, did not ask Caregiver 7 what medications he was administering Patient 7. Patient 7 stated, she was having a headache and the runs (loose stool). Caregiver 7 stated, he was not giving the Norco (narcotic pain medication) for pain and asked LVN 2 if he could give Ibuprofen (medication for pain) or half a tablet of the Norco. During an interview on 7/11/22, at 3:55 PM, with LVN 2, LVN 2 stated she did not have to perform medication reconciliation. During a review of Patient 7’s List of Medications, dated 6/8/22, the List of Medications indicated: a.Docusate Sodium (medication for constipation) 250 mg (milligram-unit of measurement) capsule, take 1 capsule by PEG tube (percutaneous endoscopic gastrostomy-tube inserted through the wall of the abdomen directly into the stomach, used to give drugs and liquids, including liquid food, to the patient) route 2 times per day. Reason: constipation (hard stool) b.Melatonin (medication for sleep) take 3 mg by peg tube route at bedtime. c.Norco 5mg-325 mg tablet, take 1 tab by peg tube route every 4-6 hours as needed. Reason: pain d.Xanax (medication for anxiety) 1 mg tablet take 1 mg by oral route (by mouth) everyday as needed. Reason: anxiety During an interview on 7/11/22, at 3:58 PM with Caregiver 7, Caregiver 7 stated he is cutting the Xanax in half and given routinely at bedtime. Caregiver 7 stated, he was not giving the Docusate Sodium, Melatonin, and Norco. During a review of Patient’s "Home Health Certificate and Plan of Care (HHCPOC)", dated 8/6/22, the HHCPOC indicated, “SN [Skilled Nurse – LVN 2] to instruct in medication regimen and compliance. 2. During a home visit observation on 7/12/22, at 11:58 AM, in the Assisted Living Facility (ALF) where Patient 11 was residing, Registered Nurse (RN) 1 reviewed with Patient 11 from the electronic medical record the following medications as ordered by the physician: a. Amlodipine 2.5 mg (used to treat high blood pressure]) take 1 tablet by mouth every day. b. Levothyroxine 100 mcg (microgram – a unit of measurement [used to treat an underactive thyroid gland]) take 1 tablet by mouth every day. c. Bisoprolol 5 mg – hydrochlorothiazide 2.25 mg (used to treat high blood pressure) take one tablet by mouth every day. d. Aleve 220 mg (used to relieve pain) take 1 tablet by mouth every 12 hours. RN 1 was not observed checking the actual medications available which included both the prescribed medications by the physician and the over-the-counter (OTC-non-prescription medication) medications at the ALF that Patient 11 was taking. RN 1 proceeded to perform Patient 11’s wound dressing to the right gluteus maximus (muscles that make up the buttock area). During a concurrent observation and interview on 7/12/22, at 1:18 PM, with Patient 11, in the ALF where Patient 11 was residing, the following OTC medications were found in Patient 11’s drawer by the kitchen area. Patient 11 stated, "I forgot to tell [Name of RN 1] [about the new OTC medications]. I just started these medications." a. Turmeric Curcumin (supplement used to improve heart health). Patient 11 stated, she was taking the Turmeric Curcumin supplement three times a day. b. Vitamin D3 2000 IU (international units – a unit of measurement – [supplement that helps body absorb calcium]). Patient 11 stated, she was taking the Vitamin D3 2000 IU once a day. c. Move Free Ultra (supplement used for bone health). Patient 11 stated, she was taking the Move Free Ultra once a day. During a review of Patient 11's "Agency Medication Profile (AMP)," dated 7/13/22, the "AMP" indicated, there were no physician's order for Turmeric Curcumin, Vitamin D3, and Move Free Ultra. During an interview on 7/13/22, at 2:40 PM, with RN 1, RN 1 stated, she did not check Patient 11’s actual medications available as ordered by the physician including the OTC medications Patient 11 was taking at the ALF. During a review of agency’s policy and procedure (P&P) titled, “Medication, Regimen Review Comprehensive,” dated 11/2018, the P&P indicated, “4. The clinician will ask the patient to describe or confirm any prescription medications, over the counter medications, vitamins, herbs or other supplements. . . 8. Nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen. This will include, but not be limited to: gathering the patient’s own perceptions about side effects and, when appropriate perceived efficacy, and referring to information from the patient’s record.”

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 observation, interview, and record review, the agency failed to follow its policy and procedure to develop an individualized plan of care for one of 17 sampled patients (Patient 6) when there were no plan of care addressing Patient 6’s environmental issues and non-compliance with care. This failure had the potential for further exposure of Patient 6 to infection, delay in wound healing, and environmental hazards. During an observation on 7/11/22, at 12:15 PM, in Patient 6’s home. Patient 6 was sitting on a wheelchair, her left foot had a wound dressing with dark colored stains, and the left foot was on the floor without a footwear. There were clutters and dusts on the floor and furniture, a bed with stained sheets, multiple flies flying around, roaches crawling on the floor, a bag of trash was hanging on the oven with flies, strong smoke and foul odor, and a box of clean wound dressing supplies uncovered with flies landing. During an interview on 7/11/22, at 12:45 PM, with Patient 6, Patient 6 stated she was not taking her medication because it makes her go to the bathroom more frequently. Patient 6 stated, she previously had maggots (larva/baby flies) on her left foot. Patient 6 stated, she smokes cigarette six times a day. During an interview on 7/13/22, at 3 PM, with LVN 1, LVN 1 reviewed the clinical record and stated, there was no plan of care specifically addressing the environmental issues and non-compliance with medications. LVN 1 stated, it was her first time to visit Patient 6. LVN 1 verified Patient 6’s home was unkempt and should have been addressed by educating Patient 6 and Caregiver 6. During a review of agency’s policy and procedure (P&P) titled, “Ongoing Assessment,” undated, the P&P indicated, “1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: J. Safety/home environment. M. Compliance with treatment and/or medications.”

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 follow infection control practices during the licensed nurse home visit for one of 17 sampled patients (Patient 9) when the biohazardous waste (infectious waste such as blood and body fluids) was not disposed in a safe and appropriate manner. This failure had the potential to spread infection to the patient, family, staff, and visit During a review of Patient 9's "Home Health Certification And Plan Of Care" (HHCPOC), dated 6/22/22, the "HHCPOC" indicated, "SN [Skilled Nurse] to perform blood draw for CBC (Complete Blood Count). . . CMP [Comprehensive Metabolic Panel]. . . Frequency: Weekly. . . " During a concurrent home visit observation and interview on 7/11/22, at 1:35 PM, with Registered Nurse (RN) 2, in Patient 9’s home, RN 2 was drawing blood from Patient 9’s PICC (peripherally inserted central catheter [a thin and flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart]) line for blood specimen. RN 2 had drawn approximately 10 ml (milliliter-a unit of measurement) of blood from the PICC line using the first 10 ml syringe to be wasted. RN 2 proceeded to put the 10 ml syringe with the blood specimen in the regular plastic trash bag container mixed with the other trashes (used dirty wound dressing, paper trash, and used empty syringes) and discarded them in Patient 9’s trash bin container at home. RN 2 was not observed throwing the wasted blood specimen in the 10 ml syringe into a hazardous waste container or a red bag trash container. During an interview on 7/14/22, at 8:40 AM, with RN 2, RN 2 stated, “I forgot to use the red bag for the blood specimen drawn from the PICC line that was to be wasted [for Patient 9].” RN 2 stated, the 10 ml syringe with the blood specimen drawn from the PICC line of Patient 9 to be wasted should have been placed inside a red bag. During a review of the agency's policy and procedure (P&P) titled, "Infection Control Program," dated 11/18, the P&P indicated, "[Name of the Agency] will follow accepted standards of practice. . . blood and body fluid precautions should be consistently used for all patients. This approach, recommended by CDC, and referred to as "Standard Blood and Body Fluid Precautions" or "Standard Precautions", should be used in the care of all patients. . . 10. . . b. Ensure appropriate handling and disposal of waste products as stated in Policy Hazardous Materials, Regulated and Home Generated Waste Related to Home Care Service." During a review of the agency's P&P titled, "Hazardous Materials, Regulated and Home Generated Waste Related to Home Care Service," dated 11/18, the P&P indicated, ". . . 2. Blood Specimens a. All collected specimens shall be placed in a container which prevents leakage and secondary container on which the hazardous waste symbol shall be displayed for transportation to lab." During a review of the agency's P&P titled, "Exposure Control Plan," dated 11/18, the P&P indicated, "3. [Name of the Agency] will maintain and provide . . . red bags as required by the standard. . . Labels 1. Warning labels or red bags are to be used for regulated waste. .

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure rehabilitation services (Physical Therapy [PT] and Occupational Therapy [OT]) were provided in a timely manner after the start of care (SOC) as indicated in the authorization notification form for one of 17 sampled patients (Patient 10). This failure had the potential for a decline in Patient 10's physical functioning. During a review of Patient 10's "Plan of Treatment" (POT), dated 6/22/22, the "POT" indicated, "Hemiplegia [paralysis of one side of the body] and Hemiparesis [inability to move on one side of the body] following Cerebral Infarction [stroke as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it] Affecting Right Dominant Side." During a review of Patient 10's "[Name of Insurance] Outpatient Notification Form,"," dated 6/15/22, the [Name of Insurance] Outpatient Notification Form" indicated, "Approve [Insurance authorization]. . . 6 PT, 6 OT visits 6/15 - 7/15/22 with [Agency Name] HH [Home Health]." During a review of the Patient 10's "Home Health Certification and Plan of Care" (HHCPOC), the "HHCPOC" indicated, "Start of Care [SOC] Date 062222 [6/22/2022]." During an interview on 7/11/22, at 4:02 PM, with Family Member (FM)1, FM 1 stated, Patient 10 did not received the PT and OT services from the home health agency after eight days when Patient 10 returned back home from the hospital. FM 1 stated, My main concern was the length of time for PT and OT to get here [provide home visit services for Patient 10]. During an interview on 7/13/22, at 3:50 PM, with Director of Rehabilitation (DOR), DOR stated, Patient 10 was evaluated by PT and OT on 6/27/22 [six days after the SOC on 6/22/22]. DOR stated, "Nobody [from PT and OT] was able to see the patient as soon as possible." During a concurrent interview and record review on 7/14/22, at 10:25 AM, with Administrator, Patient 10's Home Visits Schedule dated 6/22 and 7/22 were reviewed. The Home Visits Schedule indicated, "PT Eval [Evaluation] Visit. . . OT Eval Visit" was done on 6/27/22. The first "OT Routine Visit. . . PT Routine Visit" was done on 7/1/22 [10 days after the SOC]. Administrator stated, there were no available PT and OT to see the patient timely. During a review of the agency's policy and procedure (P&P) titled, "Admission Criteria And Process," dated 9/19, the P&P indicated, "A. The Initial visit will be performed either within 48 hours of a completed referral. . . within 48 hours of the patient's return home, or on the start of the care date ordered by the physician. . . or requested by the patient/PCG [patient caregiver]. B The patient's most critical needs for home health services must be identified during the initial assessment, and met in a timely fashion."

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure an environmental cleanliness/hazard education was performed during a home visit for one of 17 sampled patients (Patient 6). This failure had the potential for spreading infection and diseases. During an observation on 7/11/22, at 12:15 PM, in Patient 6’s home. Patient 6 was sitting on a wheelchair, her left foot had a wound dressing with dark colored stains, and was touching the floor without a footwear. There were clutters and dusts on the floor and furniture, a bed with stained sheets, multiple flies flying around, roaches crawling on the floor, a bag of trash was hanging on the oven with flies, strong smoke and foul odor, and a box of clean wound dressing supplies was uncovered with flies around. LVN 1 did not educate Caregiver 6 and Patient 6 regarding environmental cleanliness and infection control. During an interview on 7/11/22, at 12:30 PM, with Patient 6, Patient 6 stated her left foot wound had maggots (larva/baby flies) and was infected. Patient 6 stated she smokes six times a day. During an interview on 7/12/22, at 3 PM, with LVN 1, LVN 1 stated, she did not educate Caregiver 6 and Patient 6 regarding environmental infection control. LVN 1 stated, she only documented the home was unkempt and stated, she should have provided education to Patient 6 and Caregiver 6 regarding environmental cleanliness. During a review of Patient 6’s "Home Health Certificate and Plan of Care (HHCPOC)," dated 5/19/22, the HHCPOC indicated, "SN [skilled nurse-LVN 1] to instruct in universal precautions and infection control measure in patient's daily care, disease process, signs and symptoms to report and actions to take. SN to skillfully observe patient's safety in the home environment." During a review of the agency’s policy and procedure (P&P) titled, “Education-Patient/Family”, dated 11/2018, the P&P indicated, “g. Continue to reinforce the new information or skills and reinstruct the patient/family as needed."

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 clinical records of four of 17 sampled patients (Patient 6, Patient 8, Patient 13 and Patient 14) were accurate when the referral dates recorded were more than 48 hours before the start of care date. This failure had the potential for patients not receiving care within 48 hours from the referral date and had the potential for inaccurate medical records. 1. During a review of Patient 6’s Face Sheet, dated 4/28/22, the Face Sheet indicated a referral date of 4/22/22. Patient 6’s "Home Health Certificate and Plan of Care" (HHCPOC), dated 4/26/22, the "HHCPOC" indicated, the start of care date was 4/26/22 (4 days after the referral date). 2. During a review of Patient 8’s Face Sheet, dated 7/11/22, the Face Sheet indicated a referral date of 6/17/22. Patient 8’s "HHCPOC" dated 6/23/22, the "HHCPOC" indicated, the start of care date was 6/23/22 (6 days after the referral date). 3. During a review of Patient 13’s Face Sheet, dated 6/20/22, the Face Sheet indicated a referral date of 5/18/22. Patient 13’s "HHCPOC" dated 6/16/22, the "HHCPOC" indicated, the start of care date was 6/16/22 (28 days after the referral date). 4. During a review of Patient 14’s Face Sheet, dated 5/18/22, the Face Sheet indicated a referral date of 5/18/22. Patient 14’s "HHCPOC" dated 6/13/22, the "HHCPOC" indicated, the start of care date was 6/13/22 (26 days after the referral date). During an interview on 6/13/22, at 2:30 PM, with Quality Assurance Nurse (QAN), QAN verified the finding and stated, sometimes (name of insurance) refer to us early before the surgery so the start of care is more than 48 hours from the referral date and that date was recorded on the face sheet. During an interview on 6/13/22, at 3:13 PM, with Administrator, Administrator verified the finding. Administrator stated, “It’s [error in referral dates] the computer system, it does not allow us to change the date.” During a review of the agency’s policy and procedure (P&P) titled, “Admission Criteria and Process” dated 6/19, the P&P indicated, “The initial visit will be performed either within 48 hours of a completed referral, that meets agency requirements, within 48 hours of the patient’s return home, or on the start of the care date ordered by the physician (or authorized licensed independent practitioner) or requested by the patient/PCG.” During a review of the agency’s policy and procedure (P&P) titled, “EMR (Electronic Medical Record)”, undated, the P&P indicated, “A. It is the policy of [name of agency] to provide a medical record of the patient that is timely, meaningful, authentic, and legible description of the patient clinical condition. Ensure the documentation in the medical record meets generally accepted professional standards within the industry.”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure supervisory visit was conducted by a Registered Nurse (RN) every two (2) weeks to monitor the services of a Certified Home Health Aide (CHHA) for one of 17 sampled patients (Patient 5). This failure had the potential to result in problems going unidentified and not providing the appropriate care for Patient 5. During a review of Patient 5’s “Home Health Certification and Plan of Care” (HHC/POC), dated 6/4/22 to 8/2/22, the “HHC/POC “ indicated, “6/6/22 to 6/23/22 -Aide 2 week 3. CHHA TO ASSIST/PERFORM ADL’s (Activities of Daily Living) AND PERSONAL CARE BEGINNING WEEK OF 6/6/22 SN SUPERVISORY EVERY TWO WEEKS.” During a concurrent interview and record review, on 7/14/15, at 10:30 AM, with Administrator, Patient 5’s “HHC/POC,” and calendar dated 6/6/22 to 6/23/22 were reviewed. It was noted there was no documentation supervisory visit was conducted by an RN between 6/6/22 to 6/23/22. The administrator confirmed the finding and stated, “There was a miscommunication. The scheduler was not informed we had a missed visit on the 16th of June so she can reschedule the missed supervisory visit of the RN." During a review of the agency's policy and procedure (P&P) titled, "HOME HEALTH AIDE SUPERVISORY VISITS" dated April 2010, the P&P indicated, "PROCEDURE 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every two (2) weeks."

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to follow the written plan of care (POC) for one of 17 sampled patients (Patient 2). This failure had the potential to result in not reaching the patient's established goal. During a concurrent interview and record review on 6/11/22, at 2:55 PM, with Interim Director of Nursing (IDON), Patient 2's "Home Health Certification and Plan of Care (HHCPOC)," with certification period for 6/28/22 to 8/26/22 was reviewed. The HHCPOC indicated, Home Health Aide (HHA) to visit one time a week starting the week of 6/28/22 for one week and two times a week starting the week of 7/4/22 for two weeks to assist/perform ADL's (activities of daily living) and personal care. PT (Physical Therapy) evaluation beginning week of 6/28/22 for strength, endurance, balance, and increased safety and independence with mobility. There was no documentation the HHA conducted a routine home visit one time a week for one week starting the week of 6/28/22. There was also no documentation PT conducted an evaluation beginning week of 6/28/22 as written in the plan of care. There was no evidence the missed routine home visit was reschedule. IDON confirmed the findings and stated, "HHA and PT order need to be deleted. Intake department will put it open. It will start the following week, the actual frequency." During a concurrent interview and record review on 7/11/22, at 3:07 PM, with Administrator, Patient 2's HHCPOC with certification period for 6/28/22 to 8/26/22 was reviewed. The Administrator was asked about the missed visit of the HHA and the PT. The Administrator stated , "It's a mistake. There should be a new order. HHA services and PT evaluation orders starting the week of 6/28/22 should not be there (POC)." During a review of the agency’s policy and procedure (P&P) titled, “EMR (Electronic Medical Record)”, undated, the P&P indicated, “A. It is the policy of [name of agency] to provide a medical record of the patient that is timely, meaningful, authentic, and legible description of the patient clinical condition. Ensure the documentation in the medical record meets generally accepted professional standards within the industry.”