Every finding on record at Asklepius Home Health, Inc.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey at the new agency address at 15643 Sherman Way, Van Nuys, CA 91406. Complaint Number: 109191 Old Address: 14039 Sherman Way, Suite #202, Van Nuys, CA 91405. Unapproved New Address: 15643 Sherman Way, Van Nuys, CA 91406. Census: 0 Unduplicated admissions: 488 Sample Size: 10 Home Visits: 3 Closed Record review: 10 On 8/22/2024, at 5:25 p.m., the Department called the first Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the HHA failure to ensure a licensed nurse (in general) authenticated the notes in the clinical records for Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10. The non-compliance resulted in unauthorized patient information entries that did not reflect Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s current medical condition and needs, which is likely to result in inappropriate treatment, delayed or incorrect diagnoses, and fatal medical errors that can lead to serious injury, harm, impairment, or death. These failures resulted in unauthorized patient information entries that did not reflect Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s current medical condition and needs, which is likely to result in inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:22 p.m., the Department called a second Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Administrator Designee (AD) related to the HHA failure to ensure clinical records for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) included their plan of care (POC), initial assessments, comprehensive assessment, clinical notes and physician admission and discharge orders that reflected the patients’ current health status, correct and updated assessments. The noncompliance had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. These failures had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:22 p.m., the Department called a third Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Administrator Designee (AD) related to the HHA’s failure to ensure a governing body assume responsibility for the operations of the HHA, has an organizational structure with clear lines of authority, and the HHA was operating within all legal bounds. The noncompliance had the potential to result in disruption of patient care and services and in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:22 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and will no longer be opened. The HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. The following Conditions of Participation (COP) not met: 484.50 Condition of Participation: Patient rights. 484.55 Condition of Participation: Comprehensive assessment of patients. 484.60 Condition of participation: Care planning, coordination of services, and quality of care. 484.75 Condition of participation: Skilled professional services. 484.105 Condition of Participation: Organization and administration of services. 484.110 Condition of Participation: Clinical Records

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Patient rights as follows: 1 Ensure two of ten sampled patients (Patient 2 and Patient 4) were informed they were discharged from the agency. This failure resulted in a violation of patient rights and lack of information of which agency was providing HHA services. (Refer to G464). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Patient rights to ensure home health care benefits are provided to patients.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure two of ten sampled patients (Patient 2 and Patient 4) were informed they were discharged from the agency. This failure resulted in violation of patient rights and lack of information of which agency was providing HHA services. 1. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s record titled, “OASIS E-Start of Care,” dated 6/14/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During an interview on 8/23/2024, at 9:30 a.m., Patient 2 stated the last time a nurse from the HHA visited him was in the month of July 2024. Patient 2 stated he had brain surgery about three and a half years ago and had not been well ever since. Patient 2 stated his speech was not good, he was unable to speak well, and he needed to receive speech therapy. Patient 2 stated the only services he was receiving was speech therapy (ST), which began two weeks ago. Patient 2 stated the ST did not come this week and the HHA told him the ST would be off next week. Patient 2 stated he had not received any notice that he was being discharged or transferred to another HHA. Patient 2 stated, “I’m not going anywhere, I need the speech therapist.” Patient 2 stated what he knows is, he is still a current patient of the HHA. During a review of Patient 2’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the ADM, the paper chart included Patient 2’s printed EMR record titled, “Discharge Summary,” dated 8/9/2024. The Discharge Summary indicated the patient was discharged for the reason of goals met. The Discharge Summary indicated the DPCS signed the document digitally, with a date of 8/9/2024. During a review of Patient 2’s EMR, on 8/23/2024, at 4:51 p.m., there were no ST notes. During a review of Patient 2’s EMR, on 8/23/2024, at 4:58 p.m., there was Physical Therapy visit dates (PT), dated 6/19/2024, 6/26/2024, 7/3/2024, 7/10/2024, 7/17/2024, 7/24/2024, 7/31/2024, and 8/7/2024. When selecting “PT Visit” for any date, there was no documentation. The “print view” (a function used to view and print the note) option was not available. During a review of Patient 2’s record titled, “Notice of Medicare Non-Coverage,” dated 8/9/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/9/2024.” The Notice of Medicare Non-Coverage had Patient 2’s signature. The form did not indicate Patient 2 was discharged from the HHA. During a review of Patient 2’s record titled, “OASIS-E Discharge,” dated 8/9/2024, the OASIS-E Discharge indicated the assessment was done for the reason of discharged from agency. During a review of Patient 2’s record titled, “Task Details Patient 2 OASIS-E Discharge,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the record on 8/20/24. The Task Details Patient 2 OASIS-E Discharge indicated, “S.LVN” reopened and updated tasks on 8/22/2024. The DD signed and completed the document on 8/22/2024. During a review of Patient 2’s records titled, “Task Details Patient 2 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 11:29 p.m. The Task Details Patient 2 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 11:54 p.m. 2. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s record titled, “OASIS E-Start of Care,” dated 6/20/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 4’s record titled, “Skilled Nursing Visit”, dated 6/24/2024, 7/2/2024, 7/12/2024, 7/17/2024, 7/25/2024, 7/29/2024, 8/8/2024, the Skilled Nursing Visit indicated visits were made to Patient 4. During an interview on 8/22/2024, at 3:40 p.m., OW 1 stated there was no discharge summary in Patient 4’s EMR. During an interview at Patient 4’s home on 8/23/2024, at 10:40 a.m., Patient 4 stated he was receiving nursing and physical therapy (PT) services. Patient 4 stated his last PT and nursing visit was two days ago (8/20/2024). During an interview, on 8/23/2024, at 10:51 a.m., Patient 4 stated he was not informed that HHA services were stopped or that he was discharged from the HHA. During a concurrent interview and record review on 8/23/2024, at 10:52 a.m., Patient 4 had a document titled, “Notice of Medicare Non-Coverage”, dated 8/13/2024. The Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/13/2024.” Patient 4 stated a nurse came two days ago and had him sign the papers (the Notice of Medicare Non-Coverage), but he did not know what they were for. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 4. The chart included Patient 4’s printed EMR record titled, “Discharge Summary,” dated 8/13/2024. The Discharge Summary indicated Patient 4 was discharged for the reason of goals met. The record indicated the DPCS signed the document digitally with a date of 8/13/2024. During a review of Patient 4’s record titled, “OASIS-E Discharge,” dated 8/13/2024. the OASIS-E Discharge indicated assessment done for reason of discharged of agency. During a review of Patient 4’s record titled, “Task Details Patient 4 OASIS-E Discharge”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the document on 8/19/2024. The Task Details Patient 2 OASIS-E Discharge indicated “S. LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s record titled, “Task Details Patient 4 Discharge Summary”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 Discharge Summary indicated “S.LVN” created the document on 8/22/2024 at 7:15 p.m. The Task Details Patient 4 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 8:21 p.m. During a concurrent observation and interview on 8/23/2024, at 2:11 p.m., a consultant (CT) arrived to the HHA. The CT stated her title was probably temporary consultant. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, office worker 2 (OW 2), and the CT. The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to ensure the Registered Nurse completed the initial assessment within 48 hours of the start of care for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This deficient practice had the potential to result in decline in health status by not assessing the patient’s needs. (Refer to G514). 2. The HHA failed to ensure a comprehensive assessment for ten of ten sample patients (Patient1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10), was completed within five days of admission in order to develop and implement an individualized plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services; also known as CMS form 485) to address the care needs of the patients. This failure had the potential to result in missed care to the patients which had the potential to place them at risk for hospitalizations and distress. (Refer to G520). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure home health care benefits are verified for eligibility to patients provided home health services.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a Registered Nurse completed the initial assessment within 48 hours of the start of care for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9 and Patient 10). This deficient practice had the potential to result in a decline in health status by not assessing the patient’s needs. 1. During a review of Patient 1’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). On 8/23/2024, at 8:30 a.m., an attempt was made to call Patient 1. Patient 1’s record titled, “Patient Information” did not have a phone number listed. The Patient Information did not indicate an emergency contact phone number. The surveyor was unable to look for a patient phone number in the Electronic Medical Record (EMR) because the HHA removed the access to the EMR. The access to the EMR resumed on 8/23/2024 at 12:15 p.m. During a review of Patient 1’s record titled, “OASIS-E Start of Care” dated 6/14/2024, indicated an RN had done the assessment on 6/14/2024. Continued review of the record did not indicate a signature to validate an RN had completed the assessment. During a review of Patient 1’s record titled, “Task Detail (an EMR form indicating who and when a document was created, updated, or revised), Patient 1's OASIS-E Start of Care,” printed on 8/23/2024, the Task Detail Patient 1 OASIS-E Start of Care indicated “S.LVN", Director of Patient Care Services (DPCS), and Director of Patient Care Services Designee (DD) did multiple revisions for the period 6/13/2024 to 8/22/2024. The Task Detail Patient 1 OASIS-E Start of Care, indicated the DPCS completed the document on 6/20/2024 and the DD completed the document on 8/22/2024. 2. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s record titled, “OASIS E-Start of Care,” dated 6/14/2024, the OASIS E-Start of Care indicated the assessment was by an RN on 6/14/2024. Continued review of the record did not indicate a signature to validate an RN had completed the assessment. During a review of Patient 2’s “Task Details Patient 2 OASIS E-Start of Care,” printed 8/22/2204 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN (License Vocational Nurse)” created the document on 5/31/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DPCS completed the document on 6/17/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DD completed and signed the document on 8/22/2024. 3. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a review of Patient 3’s record titled, “OASIS E-Start of Care,” dated 6/8/2024, the OASIS E-Start of Care indicated the assessment was by an RN on 6/8/2024. Continued review of the record did not indicate a signature to validate an RN had completed the assessment. During a review of Patient 3’s “Task Details Patient 3 OASIS E-Start of Care,” printed 8/22/2024 from the EMR, the Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 3 OASIS E-Start of Care indicated the DPCS completed the document on 6/13/2024. The Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” reopened and updated tasks on 8/22/2024 and the DD completed and signed the document on 8/22/2024. 4. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. Continued review of the record indicated Medical Director 2 (MD 2) was the primary doctor of Patient 4. During an interview at the home visit on 8/23/2024, at 10:55 a.m., Patient 4 stated MD 2 was not his primary care doctor. Patient 4 stated he has not met or spoken to MD 2. Patient 4 stated he had been seeing his primary care doctor for the last 20 years, with an upcoming appointment this month. During a review of Patient 4’s record titled, “OASIS E-Start of Care,” dated 6/20/2024, the OASIS E-Start of Care indicated the assessment was by an RN on 6/20/2024. Continued review of the record did not indicate a signature to validate an RN had completed the assessment. During a review of Patient 4’s “Task Details Patient 4 OASIS E-Start of Care,” printed 8/23/2204 from the EMR, the Task Details Patient 4 OASIS E-Start of Care, indicated “S.LVN” completed the document on 6/21/2024. The Task Details Patient 4 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 8/22/2024. 5. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s record titled, “OASIS E-Start of Care,” dated 5/30/2024, the OASIS E-Start of Care indicated the assessment was by an RN on 5/30/2024. Continued review of the record did not indicate a signature to validate an RN had completed the assessment. During a review of Patient 5’s “Task Details Patient 5 OASIS E-Start of Care”, printed 8/22/2204 the EMR, the Task Details Patient 5 OASIS E-Start of Care, indicated “S.LVN” created the document on 5/24/2024. The Task Details Patient 5 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 7/30/2024 and on 8/22/2024. 6. During a review of Patient 6’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 6’s medical record form titled “OASIS-E Start of Care,” dated 6/14/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated there was no listed phone number for the patient. The OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 6/14/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the person who completed the form. During a review of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, the Task Details indicated “Task-OASIS-E Start of Care." The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated user “(DD)” updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” completed and signed the form on 8/22/2024. The Task Details indicated LVN 2 updated task on 8/22/2024. During survey dates 8/21/2024 - 8/23/2024 at 5 p.m., the HHA did not provide Patient 6’s physical paper chart for review. 7. During a review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 7’s primary physician. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care” dated 5/22/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 5/22/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care” dated 5/22/2024 provided by the ADM on 8/23/2024, the OASIS-E Start of Care indicated the form was signed by the DPCS on 5/22/2024. During a review of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – OASIS-E Start of Care”, the Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. User “(DPCS)” reopened, updated, completed, and signed the form on 8/22/2024. On 8/23/2024, at 12:28 p.m., a call was made to Patient 7 and a female (unidentified) picked up the call and then hanged phone up after the surveyor introduced herself. 8. During a review of Patient 8’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 3/5/2024. The form indicated there was no documentation under sections primary and secondary diagnosis. On 8/23/2024, at 12:12 p.m. Patient 8 was called, with no answer. Message with call back number left. During a review of Patient 8’s medical record form titled “OASIS-E Start of Care” dated 3/5/2024, provided by OW1 on 8/22/2024, indicated a Registered Nurse (RN) was the discipline who completed the assessment on 3/5/2024. The form does not indicate who the author of the assessment was, and it did not have a signature. During a review of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, indicated “Task – OASIS-E Start of Care”, the form indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The form indicated LNV1 updated the task details on 8/22/2024. The form indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. 9. During a record review of Patient 9’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024 provided by the ADM on 8/23/2024, indicated the form was signed by the DPCS on 6/15/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 6/15/2024, indicated “Task – OASIS-E Start of Care,” the form indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. User “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “OASIS-E Discharge” dated 8/3/2024, indicated it was signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, indicated “Task – OASIS-E Discharge”. The form indicated user “S.LVN” reopened and updated the task details on 8/22/2024. User “(DPCS)” updated, completed, and signed the form on 8/22/2024. 10. During a record review of Patient 10’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. During a review of Patient 10’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024, indicated a RN was the discipline who completed the assessment on 6/15/2024. The form did not indicate who the author of the assessment was, and it did not have a signature. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, indicated “Task – OASIS-E Start of Care," the form indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. The form indicated LNV1 updated the task details on 8/22/2024. The form indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. The form indicated LVN2 updated task on 8/22/2024. During a concurrent observation and interview on 8/23/2024, at 2:11 p.m., a consultant (CT) arrived to the HHA. The CT stated her title was probably temporary consultant. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the CT. The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a comprehensive assessment for ten of ten sample patients (Patient1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9 and Patient 10), was completed within five days of admission in order to develop and implement an individualized plan of care (POC, an individualized plan of care that summarizes the patients’ health condition, specific care needs, current treatments, and the disciplines providing the services; also known as CMS form 485) to address the care needs of the patients. This failure had the potential to result in missed care to the patients which had the potential to place them at risk for hospitalizations and distress. 1. During a review of Patient 1’s record titled, “Patient Information,” the “Patient Information,” indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During a review of Patient 1’s record titled, “Task Detail (an EMR form indicating who and when a document was created, updated, or revised) Patient 1 OASIS-E Start of Care,” printed on 8/23/2024, the Task Detail Patient 1 OASIS-E Start of Care indicated “S.LVN”, Director of Patient Care Services (DPCS), and Director of Patient Care Services Designee (DD) did multiple revision for the period 6/13/2024 to 8/22/2024. The Task Detail Patient 1 OASIS-E Start of Care indicated the DPCS completed the document on 6/20/2024 and the DD completed the document on 8/22/2024. 2. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s “Task Details Patient 2 OASIS E-Start of Care,” printed 8/22/2204 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN (License Vocational Nurse)” created the document on 5/31/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DPCS completed the document on 6/17/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DD completed and signed the document on 8/22/2024. 3. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a review of Patient 3’s “Task Details Patient 3 OASIS E-Start of Care,” printed 8/22/2024 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 3 OASIS E-Start of Care indicated the DPCS completed the document on 6/13/2024. The Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” reopened and updated tasks on 8/22/2024 and the DD completed and signed the document on 8/22/2024. 4. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s “Task Details Patient 4 OASIS E-Start of Care,” printed 8/23/2204 from the EMR, the Task Details Patient 4 OASIS E-Start of Care, indicated “S.LVN” completed the document on 6/21/2024. The Task Details Patient 4 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 8/22/2024. 5. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s “Task Details Patient 5 OASIS E-Start of Care” printed 8/22/2204 the EMR, the Task Details Patient 5 OASIS E-Start of Care, indicated “S.LVN” created the document on 5/24/2024. The Task Details Patient 5 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 7/30/2024 and on 8/22/2024. 6. During a review of Patient 6’s medical record form titled, “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (the CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 6’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/14/2024, on 8/22/2024 at 3:36 p.m. the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were blank: “phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form listed the Director of Patient Care Services Designee (DD) as Patient 6’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. 7. During a record review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 7’s primary physician. During a concurrent observation, interview, and review of Patient 7’s EMR on 8/22/2024 at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 7’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 7’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated from 5/22/2024 to 7/20/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review on 8/22/2024 at 3:34 p.m. of Patient 7’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 5/22/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: email, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The form listed the Director of Patient Care Services (DPCS) as Patient 7’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review of Patient 7’s physical paper chart medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, which was provided on 8/23/2024 at 12:18 p.m., by the Administrator (ADM), the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS and MD 1 on 5/22/2024. 8. During a record review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. There was nothing documented under sections primary and secondary diagnosis. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review on 8/22/2024, at 3:37 p.m., of Patient 8’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The Home Health Certification and Plan of Care form listed the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The Home Health Certification and Plan of Care form did not indicate who the author was, and it did not have a nurse or physician’s signature. 9. During a record review of Patient 9’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024 provided by the ADM on 8/23/2024, indicated the form was signed by the DPCS on 6/15/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 6/15/2024, indicated the “Task – OASIS-E Start of Care” form indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. User “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “OASIS-E Discharge” dated 8/3/2024, indicated it was signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, the “Task – OASIS-E Discharge " form indicated user “S.LVN” reopened and updated the task details on 8/22/2024. User “(DPCS)” updated, completed, and signed the form on 8/22/2024. 10. During a review of Patient 10’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. During a concurrent observation, interview, and review of Patient 10’s EMR on 8/22/2024, at 3:12 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 10’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 10’s electronic medical record and click on the tab titled “Orders. After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not in the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 10’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/15/2024 to 8/13/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a record review on 8/22/2024 at 3:38 p.m. of Patient 10’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/15/2024, indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a record review of Patient 10’s medical record form titled, “Home Health Certification and Plan of Care” (the CMS 485 form) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: email, primary language, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The form listed the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: 1. The HHA failed to ensure the Plan of Care (POC – also known as CMS form 485) was developed for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10). This failure had the potential to result in the physician not being aware of the services being provided or not provided to the patient by the HHA. This failure had the potential to result in delay in care and services and a delay in healing that could lead to hospitalization and/or death. (Refer to G572). 2. The HHA failed to include complete medication lists in the Plan of Care (POC) for two of ten sampled patients (Patient 6 and Patient 8). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. (Refer to G574). 3. The HHA failed to ensure physician medical orders were received/transcribed for five of ten sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure resulted in patients receiving HHA services without a doctor’s order, which had the potential to result in providing the wrong care for the patients. (Refer to G584). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

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 interview and record review, the Home Health Agency (HHA) failed to ensure the Plan of Care (POC – also known as CMS form 485) was developed for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 10). This failure had the potential to result in the physician not being aware of the services being provided or not provided to the patient by the HHA. This failure had the potential to result in delay in care and services and a delay in healing that could lead to hospitalization and/or death. 1. During a review of Patient 1’s record titled, “Patient Information,” the “Patient Information,” indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During an observation, on 8/22/2024, at 3:18 p.m., (Office Worker 1 (OW 1) was in front of the computer and a plan of care (POC) print out for Patient 1 was requested. OW 1 selected the “Orders” tab on Patient 1’s Electronic Medical Record (EMR), and the screen was blank. The OW 1 made many clicks, very quickly, refreshed the screen and a “CMS 485” (the Home Health Certification and Plan of Care [POC] form) appeared on the screen. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., OW 1 reviewed Patient 1’s record titled, “Task Details” Patient 1, “CMS 485”. The document indicated “S.LVN (License Vocational Nurse)” had created the document on 8/22/2024 at 3:18 p.m. The OW 1 stated, “I just created it right now. Everything, I put in.” The OW 1 stated she created the document because she did not know where the CMS 485 (the Home Health Certification and Plan of Care [POC]) was, and the surveyor asked for it. During an interview on 8/22/2024, at 3:40 p.m., with the ADM, the ADM stated OW 1 was not a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN). The ADM stated OW 1 could create patients’ plan of care but not able to go over it or sign it. The ADM stated she did not have an RN or an LVN available for interview “today.” During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care,” (the CMS 485) for certification period 6/14/2024 to 8/12/2024, the “Home Health Certification and Plan of Care,” did not have a signature under section “Nurse Signature and Date of Verbal SOC Where Applicable.” There was no date indicated under section “Date.” 2. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a concurrent interview and record review on 8/22/2024, at 3:24 p.m., OW 1 reviewed Patient 2’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 2’s record titled, “Task Details Patient 2 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 CMS 485 indicated “S.LVN” created the document on 8/22/2024, at 11:31 p.m. and the DPCS completed the record on 8/22/2024, at 11:50 p.m. During an interview on 8/23/2024, at 9:30 a.m., Patient 2 stated the last time a nurse from the HHA visited him was in the month of July 2024. Patient 2 stated he had brain surgery about three and a half years ago and had not been well ever since. Patient 2 stated his speech was not good, he was unable to speak well, and he needed to receive speech therapy. Patient 2 stated the only services he was receiving was speech therapy (ST), which began two weeks ago. Patient 2 stated the ST did not come this week and the HHA told him the ST would be off next week. Patient 2 stated he had not received any notice that he was being discharged or transferred to another HHA. Patient 2 stated, “I’m not going anywhere, I need the speech therapist.” Patient 2 stated what he knows is, he is still a current patient of the HHA. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 2. The paper chart included Patient 2’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/14/2024 to 8/12/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/14/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/20/2024. 3. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a concurrent interview and record review on 8/22/2024, at 3:35 p.m., OW 1 reviewed Patient 3’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 3’s record titled, “Task Details Patient 3 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 10:35 p.m. and the DPCS completed the record on 8/22/2024, at 11:22 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 3. The paper chart included Patient 3’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/8/2024 to 8/6/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/8/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 8/1/2024. 4. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s “Home Health Certification and Plan of Care,” for certification period 6/20/2024 to 8/18/2024, the Home Health Certification and Plan of Care indicated the document was digitally signed by DPCS, with a date of 6/20/2024. During a review of Patient 4’s “Task Details Patient 4 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 4 CMS 485 indicated the DPCS created the document on 8/6/2024. The record indicated “S.LVN” completed the document on 8/19/2024. During a review of Patient 4’s record titled, “Skilled Nursing Visit”, dated 6/24/2024, 7/2/2024, 7/12/2024, 7/17/2024, 7/25/2024, 7/29/2024, 8/8/2024, the Skilled Nursing Visit indicated visits were made to Patient 4. During an interview at Patient 4’s home on 8/23/2024, at 10:40 a.m., Patient 4 stated he was receiving nursing and physical therapy (PT) services. Patient 4 stated his last PT and nursing visit was two days ago (8/20/2024). 5. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent interview and record review on 8/22/2024, at 3:42 p.m., OW 1 reviewed Patient 5’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 5’s record titled, “Task Details Patient 5 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 8:43 p.m. and the DPCS completed the record on 8/22/2024, at 9:15 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 5. The paper chart included Patient 5’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 5/30/2024 to 7/28/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 5/30/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/3/2024. 6. During a review of Patient 6’s medical record form titled, “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). The Patient Information also indicated Patient 6’s primary physician was Medical Doctor 2 (MD2). During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with Office Worker 1 (OW 1), OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (the CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were blank: phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The form listed the Director of Patient Care Services Designee (DD) as Patient 6’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review of Patient 6’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/14/2024, on 8/22/2024 at 3:36 p.m., the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. Lastly, the form did not indicate MD2 accessed the form. During the survey process from 8/21/2024 to 8/23/2024, the Administrator (ADM) did not provide a paper chart for Patient 6. 7. During a record review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 7’s primary physician. During a concurrent observation, interview, and review of Patient 7’s EMR on 8/22/2024 at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 7’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 7’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated from 5/22/2024 to 7/20/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: email, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The form listed the Director of Patient Care Services (DPCS) as Patient 7’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review of Patient 7’s physical paper chart medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, which was provided on 8/23/2024 at 12:15 p.m., by the Administrator (ADM), the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS and MD 1 on 5/22/2024. During a review on 8/22/2024 at 3:34 p.m. of Patient 7’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 5/22/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. Lastly, the form did not indicate MD1 accessed the form. 8. During a record review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. There was nothing documented under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 8’s primary physician. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care form listed the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The Home Health Certification and Plan of Care form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024, at 3:37 p.m., of Patient 8’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. Lastly, the form did not indicate MD1 accessed the form. During the survey process from 8/21/2024 to 8/23/2024, the Administrator (ADM) did not provide a paper chart for Patient 8. 10. During a review of Patient 10’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 10’s primary physician. During a concurrent observation, interview, and review of Patient 10’s EMR on 8/22/2024, at 3:12 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 10’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 10’s electronic medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not in the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 10’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/15/2024 to 8/13/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a record review of Patient 10’s medical record form titled, “Home Health Certification and Plan of Care” (the CMS 485 form) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, primary language, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form listed the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a record review on 8/22/2024 at 3:38 p.m. of Patient 10’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/15/2024, indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. Lastly, the form did not indicate MD1 accessed the form. During the survey process from 8/21/2024 to 8/23/2024, the Administrator (ADM) did not provide a paper chart for Patient 10. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview, and record review the Home Health Agency (HHA) failed to include a complete medication lists in the Plan of Care (POC) for two of ten sampled patients (Patient 6 and Patient 8). This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. 1. During a review of Patient 6’s medical record form titled, “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (the CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were blank: “phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review of Patient 6’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/14/2024, on 8/22/2024 at 3:36 p.m. the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. 2. During a record review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. There was nothing documented under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 8’s primary physician. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed. The Home Health Certification and Plan of Care form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024, at 3:37 p.m., of Patient 8’s medical record form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. Lastly, the form did not indicate MD1 accessed the form. During the survey process from 8/21/2024 to 8/23/2024, the Administrator (ADM) did not provide a paper chart for Patient 8. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the physician medical orders were received and transcribed for five of ten sampled patients (Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure resulted in patients receiving HHA services without a doctor’s order, which had the potential to result in providing the wrong care for the patients. 1. During a review of Patient 6’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). The Patient Information indicated Medical Doctor 2 (MD2) was listed as Patient 6’s primary physician. During a review on 8/23/2024 at 1:46 p.m. of Patient 6’s electronic medical record (EMR) form titled “Episode Manager – Order” dated 6/14/2024 to 7/26/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 6/14/2024 and 7/26/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 6/14/2024, the Physician Order indicated Patient 6 was being admitted for HHA services. The form indicated it was digitally signed by the Director of Patient Care Services (DPCS) on 6/14/2024. Lastly, the form indicated it was not signed by MD2. During a review 8/23/2024 at 1:47 p.m. of Patient 6’s EMR form titled “Task Details” dated 6/14/2024, indicated “Task – Physician Order." The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD2. During a review of Patient 6’s medical record form title “Physician Order” dated 7/26/2024, the Physician Order indicated Patient 6 reached his goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/26/2024. Lastly, the form indicated it was not signed by MD2. During a review on 8/23/2024, at 1:48 p.m. of Patient 6’s EMR, medical record form titled “Task Details” dated 7/26/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent the form to the quality assurance manager on 8/22/2024. The Task Details indicate user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD2. During survey dates 8/21/2024 - 8/23/2024 at 5 p.m., the HHA did not provide Patient 6’s physical paper chart for review. 2. During a review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 7’s primary physician. On 8/23/2024, at 12:28 p.m., a call was made to Patient 7 and a female (unidentified) picked up the call and then hanged phone up after the surveyor introduced herself. During a review on 8/23/2024 at 1:50 p.m. of Patient 7’s EMR, medical record form titled “Episode Manager – Order” dated 5/22/2024 to 7/18/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 5/22/2024 and 7/18/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 5/22/2024, the Physician Order indicated “HCFA 485” (former name of the form CMS 485). The Physician Order indicated it was digitally signed by the DPCS on 5/22/2024. Lastly, the form indicated it was not signed by MD1. During a review 8/23/2024 at 1:51 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During a review of Patient 7’s medical record form titled, “Physician Order” dated 7/18/2024, the Physician Order indicated Patient 7 reached her goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/18/2024. Lastly, the form indicated it was not signed by MD1. During a review of Patient 7’s medical record form provided on 8/23/2024 by ADM titled, “Physician Order” dated 7/18/2024, the Physician Order indicated signed the form on 7/18/2024. The Physician Order indicated it was signed by MD 1 on 7/24/2024. During a review on 8/23/2024 at 1:52 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 7/18/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. 3. During a review of Patient 8’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 3/5/2024. The form indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 8’s primary physician. On 8/23/2024, at 12:12 p.m. Patient 8 was called, with no answer. Message with call back number left. During a review on 8/23/2024, at 1:53 p.m. of Patient 8’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “F2F Encounter. 2. CMS 485” and 3rd Physician Order.” During a review of Patient 8’s medical record form titled “Physician Order” dated 4/23/2024 indicated Patient 8 was transferred to a hospital due to shortness of breath. The form indicated it was digitally signed by the DPCS on 4/23/2024. Lastly, the form indicated it was not signed by MD1. During a review on 8/23/2024, at 1:53 p.m., of Patient 8’s EMR, medical record form titled “Task Details” dated 4/23/2024, indicated “Task – Physician Order." The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated LVN1 updated the task details on 8/22/2024. The form indicates user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During survey dates 8/21/2024 - 8/23/2024 at 5 p.m., Patient 8’s physical paper chart was not provided for review. 4. During a record review of Patient 9’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). The form indicated Medical Doctor 1 (MD1) was listed as Patient 9’s primary physician. During a record review on 8/22/2024 at 3:38 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, indicated there were no entries made under task. During a review on 8/23/2024 at 1:57 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Order” dated 6/15/2024 to 8/3/2024, indicated there were three tasks listed. The 1st “CMS 485”, the 2nd and 3rd task were physician orders dated 6/15/2024 and 8/3/2024. During a review of Patient 9’s medical record form title “Physician Order” dated 6/15/2024, indicated Patient 9 was being admitted for HHA services. The form indicated MD1 was noted as the physician. The form indicated it was digitally signed by the DPCS on 6/15/2024. Lastly, the form indicated it was not signed by MD1. During a review of Patient 9’s medical record form title “Physician Order” dated 6/15/2024 received on 8/23/2024 by the ADM, indicated Patient 9 was being admitted for HHA services. The form indicated MD1 was noted as the physician. The form indicated it was digitally signed by the DPCS on 6/15/2023. The form indicated it was signed by MD1 on 6/21/2024. During a review 8/23/2024, at 1:58 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order." The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During a review of Patient 9’s medical record form title “Physician Order” dated 8/3/2024, indicated Patient 9 was being discharged from HHA services. The form indicated MD1 was noted as the physician. The form indicated it was digitally signed by the DPCS on 8/3/2024. Lastly, the form indicated it was not signed by MD1. During a review of Patient 9’s medical record form titled “Physician Order” dated 8/3/2024, received on 8/23/2024 by the ADM, indicated Patient 9 was being discharged from HHA services. The form indicated MD1 was noted as the physician. The form indicated it was digitally signed by the DPCS on 8/3/2024. The form indicated it was signed by MD1 on 8/12/2024. During a review on 8/23/2024 at 1:59 p.m. of Patient 9’s EMR, medical record form titled “Tas Details” dated 8/3/2024, indicated “Task – Physician Order”. The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. 5. During a record review of Patient 10’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 10’s primary physician. During a review on 8/23/2024, at 2 p.m., of Patient 10’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician order dated 6/15/2024 and 8/6/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 6/15/2024 indicated “HCFA 485” and indicated MD1 was the physician. The form indicated it was digitally signed by the DPCS on 6/15/2024. Lastly, the form indicated it was not signed by MD1. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order." The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicates user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During a review of Patient 10’s medical record form titled “Physician Order” dated 8/6/2024 indicated Patient 10 was being discharged from receiving HHA services and indicated MD1 was the physician. The form indicated it was digitally signed by the DPCS on 8/6/2024. Lastly, the form indicated it was not signed by MD1. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, indicated “Task – Physician Order." The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicates user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During survey dates 8/21/2024 - 8/23/2024 at 5 p.m., Patient 10’s physical paper chart was not provided for review. During a concurrent observation and interview on 8/23/2024, at 2:11 p.m., a consultant (CT) arrived to the HHA. The CT stated her title was probably temporary consultant. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the CT. The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/22/2024, at 5:01 p.m., a call was made to LVN 1 based on the employee list of phone numbers provided by the HHA. There was no answer to the call. A message was left to return the call of the survey team. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Skilled Professional Services as follows: 1. The HHA failed to ensure the health care professionals providing direct patient care met the qualifications to be able provide safe and therapeutic care to ten of ten sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in patients receiving improper care that can result in injury. (Refer to G702). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

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 observations, interviews, and record review, the Home Health Agency (HHA) failed to ensure the health care professionals providing direct patient care met the qualifications to be able provide safe and therapeutic care to ten of ten sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in patients receiving improper care that can result in injury. During an interview on 8/22/2024, at 3:16 p.m., the Office Worker (OW 1) stated she was not a licensed nurse. During an observation on 8/22/2024, at 3:16 p.m., OW 1 was sitting at a desk with a computer. The computer was on and OW 1 was using it. The electronic medical record (EMR) program was on the screen (computer monitor). The sampled patient list for the survey (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) was on the screen. On the right upper hand corner of the EMR, the user identification (ID) showed “S.LVN”. During a concurrent observation and interview on 8/22/2024, at 3:20 p.m., with the ADM, the ADM stood next to OW 1 and stated the user ID “S.LVN” belonged to Licensed Vocational Nurse (LVN) 1. The ADM stated LVN 1 had not been and was not in the office on 8/22/2024. During an interview on 8/22/2024, at 3:40 p.m., with the ADM, the ADM stated OW 1 was not a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN). The ADM stated OW 1 could create patients’ plan of care but not able to go over it or sign it. The ADM stated she did not have an RN or an LVN available for interview “today.” On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During a record review of HHA’s undated form titled “(HHA) Home Health, Inc.” indicated the Director of Patient Care Services Designee’s (DD’s) name was listed under section “DPCS (Director of Patient Care Services)/Designee RN Supervisor”. During an interview on 8/23/2024, at 3:02 p.m., with the Director of Patient Care Services Designee (DD), the DD stated that as of June 2024, she no longer worked at the HHA. The DD stated she never worked as the DD, a Registered Nurse (RN) Supervisor, or as any administrative staff. The DD stated her name should not be listed in the HHA’s organizational chart. The DD stated she worked for the HHA as a field RN, conducting patients start of care assessments and resumption of care assessments. During an interview on 8/23/2024, at 3:41 p.m., with License Vocational Nurse 2 (LVN 2), the LVN 2 stated she was an RN and not an LVN. LVN 2 stated she applied to another home health agency (HHA 2) owned by the ADM and she was told she was going to cover for other home health agencies owned by the ADM, if needed. LVN 2 stated she started working for HHA 2 about a month ago and she has not had any patients assigned to her from any home health agency. LVN2 stated she was asked to conduct two home visits last week to assist in a survey. LVN 2 stated she did not document the home visits conducted last week because she was not asked to. LVN 2 stated she did not have access to the HHA’s electronic medical record. On 8/23/2024, at 11:30 a.m., employee files were requested to the OW2 and not provided. On 8/23/2024, at 12:18 p.m., employee files were requested to the ADM and not provided. 1. During a review of Patient 1’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care,” for certification period 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care did not have a signature under section “Nurse Signature and Date of Verbal SOC Where Applicable”. There was no date indicated under section “Date.” During a review of Patient 1’s record titled, “Discharge Summary,” dated 7/26/2024, the Discharge Summary indicated Patient 1 was discharged due to goals met. The Discharge Summary indicated the Director of Patient Care Services (DPCS) signed the document with the date of 7/26/2024. During an observation on 8/22/2024, at 3:18 p.m., OW 1 was in front of the computer and a copy of Patient 1’s plan of care (POC) was requested. OW 1 selected the “Orders” tab on Patient 1’s EMR, and the screen was blank. The OW 1 made many clicks, very quickly, refreshed the screen and a “CMS 485” (the Home Health Certification and Plan of Care [POC] form) appeared on the screen. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., OW 1 reviewed Patient 1’s record titled, “Task Details” Patient 1, “CMS 485." The document indicated “S.LVN” had created the document on 8/22/2024 at 3:18 p.m. The OW 1 stated, “I just created it right now. Everything, I put in.” The OW 1 stated she created the document because she did not know where the CMS 485 (the Home Health Certification and Plan of Care [POC]) was, and the surveyor asked for it. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 1’s record titled, “Task Detail Patient 1 Discharge Summary,” the Task Detail Patient 1 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 9:16 p.m. The Task Detail Patient 1 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 9:39 p.m. During a review of Patient 1’s record titled, “Task Details Patient 1 CMS 485,” the Task Details Patient 1 CMS 485 indicated, the DPCS completed the document on 8/22/2024 at 9:44 p.m. During a review of Patient 1’s record titled, “Task Detail Patient 1 OASIS-E Discharge”, printed 8/23/2024, the Task Detail Patient 1 OASIS-E Discharge indicated the task was created by “S.LVN” on 8/20/2024. The Task Detail Patient 1 OASIS-E Discharge indicated the DPCS completed the document on 8/21/24. The Task Detail Patient 1 OASIS-E Discharge indicated the DD completed the document on 8/22/2024. 2. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s record titled, “OASIS E-Start of Care,” dated 6/14/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 2’s “Task Details Patient 2 OASIS E-Start of Care,” printed 8/22/2204 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DPCS completed the document on 6/17/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:24 p.m., OW 1 reviewed Patient 2’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 2’s record titled, “Task Details Patient 2 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 CMS 485 indicated “S.LVN” created the document on 8/22/2024, at 11:31 p.m. and the DPCS completed the record on 8/22/2024, at 11:50 p.m. During an interview on 8/23/2024, at 9:30 a.m., Patient 2 stated the last time a nurse from the HHA visited him was in the month of July 2024. Patient 2 stated he had brain surgery about three and a half years ago and had not been well ever since. Patient 2 stated his speech was not good, he was unable to speak well, and he needed to receive speech therapy. Patient 2 stated the only services he was receiving was speech therapy (ST), which began two weeks ago. Patient 2 stated the ST did not come this week and the HHA told him the ST would be off next week. Patient 2 stated he had not received any notice that he was being discharged or transferred to another HHA. Patient 2 stated, “I’m not going anywhere, I need the speech therapist.” Patient 2 stated what he knows is, he is still a current patient of the HHA. During a review of Patient 2’s EMR, on 8/23/2024, at 4:51 p.m., there were no ST notes. During a review of Patient 2’s EMR, on 8/23/2024, at 4:58 p.m., there was Physical Therapy visit dates (PT), dated 6/19/2024, 6/26/2024, 7/3/2024, 7/10/2024, 7/17/2024, 7/24/2024, 7/31/2024, and 8/7/2024. When selecting “PT Visit” for any date, there was no documentation. The “print view” (a function used to view and print the note) option was not available. During a review of Patient 2’s record titled, “Task Details Patient 2, PT visit for 6/26/24” the Task Details Patient 2, PT visit for 6/26/24 indicated “S.LVN” created and completed the document on 7/26/2024. 3. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a review of Patient 3’s record titled, “OASIS E-Start of Care,” dated 6/8/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 3’s “Task Details Patient 3 OASIS E-Start of Care,” printed 8/22/2024 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 3 OASIS E-Start of Care indicated the DPCS completed the document on 6/13/2024. The Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” reopened and updated tasks on 8/22/2024 and the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:35 p.m., OW 1 reviewed Patient 3’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 3’s record titled, “Task Details Patient 3 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 10:35 p.m. and the DPCS completed the record on 8/22/2024, at 11:22 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 3. The paper chart included Patient 3’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/8/2024 to 8/6/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/8/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 8/1/2024. 4. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s record titled, “OASIS E-Start of Care,” dated 6/20/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 4’s “Home Health Certification and Plan of Care,” for certification period 6/20/2024 to 8/18/2024, the Home Health Certification and Plan of Care indicated the document was digitally signed by DPCS, with a date of 6/20/2024. During a review of Patient 4’s “Task Details Patient 4 OASIS E-Start of Care,” printed 8/23/2204 from the EMR, the Task Details Patient 4 OASIS E-Start of Care, indicated “S.LVN” completed the document on 6/21/2024. The Task Details Patient 4 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s “Task Details Patient 4 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 4 CMS 485 indicated the DPCS created the document on 8/6/2024. The record indicated “S.LVN” completed the document on 8/19/2024. During a review of Patient 4’s record titled, “Skilled Nursing Visit” dated 6/24/2024, 7/2/2024, 7/12/2024, 7/17/2024, 7/25/2024, 7/29/2024, 8/8/2024, the Skilled Nursing Visit indicated visits were made to see Patient 4. During an interview at Patient 4’s home on 8/23/2024, at 10:40 a.m., Patient 4 stated he was receiving nursing and physical therapy (PT) services. Patient 4 stated his last PT and nursing visit was two days ago (8/20/2024). 5. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s record titled, “OASIS E-Start of Care,” dated 5/30/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 5’s “Task Details Patient 5 OASIS E-Start of Care”, printed 8/22/2204 the EMR, the Task Details Patient 5 OASIS E-Start of Care, indicated “S.LVN” created the document on 5/24/2024. The Task Details Patient 5 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 7/30/2024 and on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:42 p.m., OW 1 reviewed Patient 5’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 5’s record titled, “Task Details Patient 5 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 8:43 p.m. and the DPCS completed the record on 8/22/2024, at 9:15 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 5. The paper chart included Patient 5’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 5/30/2024 to 7/28/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 5/30/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/3/2024. During a review of Patient 5’s record titled, “Skilled Nursing Visit”, dated 6/3/2024, 6/12/2024, 6/19/2024, 6/26/2024, 7/2/2024, 7/11/2024, 7/17/2024, the Skilled Nursing Visit indicated visits were made to see the patient. 6. During a review of Patient 6’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). The Patient Information indicated Medical Doctor 2 (MD2) was listed as Patient 6’s primary physician. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the Director of Patient Care Services Designee (DD) was Patient 6’s clinical manager. The form also indicated Patient 6’s treatment orders included – skilled nurse visits 1w1 (once a week for one week), then 2w2, then once 1w6 & physical therapy (PT) evaluation. During a record review on 8/23/2024 at 2:06 p.m. of Patient 6’s Electronic Medical Record (EMR) medical record form titled “Episode Manger: View Therapy – All Therapy” indicated Patient 6 received PT services on: 6/19/2024, 6/26/2024, 7/3/2024, 7/10/2024, and 7/17/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 6/14/2024, the Physician Order indicated Patient 6 was being admitted for HHA services. The form indicated “skilled nursing visit frequency 1w 9 (Once a week for nine weeks) & PT evaluation.” During a review 8/23/2024 at 1:47 p.m. of Patient 6’s EMR form titled “Task Details (an EMR form indicating who and when a document was created, updated, or revised)” dated 6/14/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated the Director of Patient Care Services (DPCS) completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD2. During survey dates 8/21/2024 - 8/23/2024, the HHA did not provide Patient 6’s physical paper medical record for review. 7. During a review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 7’s primary physician. During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care (POC)” (the CMS 485) dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the Director of Patient Care Services (DPCS) was Patient 7’s clinical manager. The form also indicated Patient 7’s treatment orders included – skilled nurse visits 1w1 (once a week for one week), then 2w2, then once 1w6 & physical therapy (PT) evaluation. On 8/23/2024, at 12:28 p.m., a call was made to Patient 7 and a female (unidentified) picked up the call and then hanged phone up after the surveyor introduced herself. During a record review on 8/23/2024 at 2:07 p.m. of Patient 7’s Electronic Medical Record (EMR) medical record form titled “Episode Manger: View Therapy – All Therapy” indicated Patient 7 received PT services on: 5/24/2024, 5/31/2024, 6/7/2024, 6/14/2024, and 6/21/2024. During a record review on 8/23/2024 at 2:07 p.m. of Patient 7’s EMR, medical record form titled “Episode Manger: View HHA (Home Health Aide) – HHA” indicated Patient 7 received home health aide services on 5/26/2024, 6/9/2024, 6/16/2024, 6/23/2024, 6/30/2024, 7/7/2024, and 7/14/2024. During a record review on 8/23/2024 at 1:50 p.m. of Patient 7’s EMR medical record form titled “Episode Manager: View Orders – Orders” indicated there were four entries made. The 1st entry – F2F encounter, 2nd CMS 485 and the 3rd and 4th were physician orders dated 5/22/2024 and 7/18/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 5/22/2024 and 7/18/2024, the form did not indicate Patient 7’s order for visiting disciplines and their frequencies. During a record review on 8/23/2024 at 12:15 p.m. of Patient 7’s physical paper medical record provided by the ADM, the record did not indicate there was a physician order that specify Patient 7’s visiting disciplines and their frequency. 8. During a review of Patient 8’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 3/5/2024. The form indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 8’s primary physician. During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The form also indicated Patient 8’s treatment orders included – skilled nurse visits 2w2 (twice a week for two week) then once 1w7 & physical therapy (PT) evaluation. On 8/23/2024, at 12:12 p.m. Patient 8 was called, with no answer. Message with call back number left. During a review on 8/23/2024, at 1:53 p.m. of Patient 8’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “F2F Encounter. 2. CMS 485” and 3rd Physician Order dated 4/23/2024.” During a review of Patient 8’s medical record form titled “Physician Order” dated 4/23/2024, did not indicate Patient 8’s visiting disciplines and their frequencies. During survey dates 8/21/2024 - 8/23/2024, Patient 8’s physical paper medical record was not provided for review. 9. During a record review of Patient 9’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). The form indicated Medical Doctor 1 (MD1) was listed as Patient 9’s primary physician. During a record review on 8/23/2024 at 2:08 p.m. of Patient 9’s EMR, medical record form titled “Episode Manger: View Therapy – All Therapy” indicated Patient 9 received PT services on 6/17/2024, 6/24/2024, 7/1/2024, 7/8/2024, 7/15/2024, and 7/22/2024. During a record review on 8/22/2024 at 3:38 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, indicated there were no entries made under task. Patient 9 did not have a POC documented for review. During a review on 8/23/2024 at 1:57 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Order” dated 6/15/2024 to 8/3/2024, indicated there were three tasks listed. The 1st “CMS 485”, the 2nd and 3rd task were physician orders dated 6/15/2024 and 8/3/2024. During an observation, interview, and record review on 8/23/2024 at 12:15 p.m. with the ADM in the HHA of patients’ paper medical records. ADM was noted arriving to the HHA with seven patients’ medical records, one of the records belonged to Patient 9. Patient 9’s physical paper medical record indicated there was a POC and physician orders. During a review of Patient 9’s medical record form title “Physician Order” dated 6/15/2024 received on 8/23/2024 by the ADM, indicated Patient 9 was being admitted for HHA services. The form indicated “skilled nursing visit frequency 1w8 (Once a week for eight weeks) & PT evaluation.” The form indicated it was digitally signed by the DPCS on 6/15/2023. The form indicated it was signed by MD1 on 6/21/2024. During a review 8/23/2024, at 1:58 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order”. The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. 10. During a record review of Patient 10’s medical record form titled “Patient Information” indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 10’s primary physician. During a record review on 8/23/2024 at 2:08 p.m. of Patient 10’s EMR, medical record form titled “Episode Manger: View Therapy – All Therapy” indicated Patient 10 received PT services on 6/17/2024, 6/24/2024, 7/1/2024, 7/8/2024, 7/15/2024, and 7/22/2024. During a record review of Patient 10’s medical record form titled, “Home Health Certification and Plan of Care” (the CMS 485 form) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The form also indicated Patient 10’s treatment orders included – skilled nurse visits 1w1 (once a week for one week) then 2w2, then 1w6 & physical therapy (PT) evaluation. During a review on 8/23/2024, at 2 p.m., of Patient 10’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician order dated 6/15/2024 and 8/6/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 6/15/2024 indicated “HCFA 485” did not indicate Patient 10’s visiting disciplines and their frequencies. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order”. The form indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicates user “(DPCS)” completed the form on 8/22/2024. Lastly, the form indicated the physician order was not accessed by MD1. During survey dates 8/21/2024 - 8/23/2024, Patient 10’s physical paper medical record was not provided for review. On 8/23/2024 at 11:30 a.m. Office Worker 2 (OW2) was requested to provide all employee files. During an interview on 8/23/2024 at 12 p.m. with OW2, OW2 stated she spoke with the Administrator (ADM) and was told by her that the employee files were in a storage unit (SU). OW2 stated the ADM was going to provide the employee files today (8/23/2024). During an observation and interview on 8/23/2024 at 12:18 p.m. with ADM of files provided, ADM arrived to the HHA with seven files on hand. ADM stated she will go back to the SU for the requested employee files. During an interview on 8/23/2024, at 3:02 p.m., with the Director of Patient Care Services Designee (DD), the DD stated that as of June 2024, she no longer worked at the HHA. The DD stated she never worked as the DD, a Registered Nurse (RN) Supervisor, or as any administrative staff. The DD stated her name should not be listed in the HHA’s organizational chart. The DD stated she worked for the HHA as a field RN, conducting patients start of care assessments and resumption of care assessments. During survey dates 8/21/2024 - 8/23/2024, the HHA did not provide any employee files for review. There were no clinical staff available for interview regarding employee files. On 8/23/2024 at 5:14 p.m. a call was made to the HHA physical therapist with no answer. Message with call back number left. During a concurrent observation and interview on 8/23/2024, at 2:11 p.m., a consultant (CT) arrived to the HHA. The CT stated her title was probably temporary consultant. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the CT. The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. On 8/23/2024 at 12:15 p.m. MD1 was called with no answer. Message with call back number left.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure a governing body assume responsibility for the operations of the HHA, has an organizational structure with clear lines of authority, and the HHA was operating within all legal bounds by failing to: 1. Ensure Office Worker (OW) 1, who is not a licensed nurse, did not create the Home Health Certification and Plan of Care, also known as CMS 485 form (the plan of care that is paired with the home health certification that the physician signs to show or certify that the patient needs home health care) of five of ten sampled patients (Patient 1, Patient 6, Patient 7, Patient 8, Patient 10), using the credentials of an unidentified Licensed Vocational Nurse (LVN). 2. Ensure the electronic health records, which included the initial assessment, Home Health Certification and Plan of Care, physician orders, and discharge assessment and orders, of the ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10) were accurate, completed timely, and signed by the licensed nurse, who conducted the assessment and provided the care, and by the physician, who gave the orders. 3. Ensure there was a written agreement with the offsite storage unit (facility) that the health records of the ten of ten sampled discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10) were accessible on a 24-hour basis and readily available for review upon request of the surveyors, as authorized representatives of the Department. 4. Ensure a Director of Patient Care Services (DPCS) or a Director of Patient Care Services Designee (DD) was available during all operating hours to maintain a smooth functioning of the agency and maintain accurate and complete patient health records for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10). 5. Ensure the Administrator (ADM) performed her responsibilities to oversee and manage the agency, which included maintaining compliance with the federal regulations. These deficient practices had the potential to result in disruption of patient care and services and in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. (Refer to G942). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Organization and administration of services and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure a governing body assume responsibility for the operations of the HHA, has an organizational structure with clear lines of authority, and the HHA was operating within all legal bounds by failing to: 1. Ensure Office Worker (OW) 1, who is not a licensed nurse, did not create the Home Health Certification and Plan of Care, also known as CMS 485 form (the plan of care that is paired with the home health certification that the physician signs to show or certify that the patient needs home health care) of five of ten sampled patients (Patient 1, Patient 6, Patient 7, Patient 8, Patient 10), using the credentials of an unidentified Licensed Vocational Nurse (LVN). 2. Ensure the electronic health records, which included the initial assessment, Home Health Certification and Plan of Care, physician orders, and discharge assessment and orders, of the ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10) were accurate, completed timely, and signed by the licensed nurse, who conducted the assessment and provided the care, and by the physician, who gave the orders. 3. Ensure there was a written agreement with the offsite storage unit (facility) that the health records of the ten of ten sampled discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10) were accessible on a 24-hour basis and readily available for review upon request of the surveyors, as authorized representatives of the Department. 4. Ensure a Director of Patient Care Services (DPCS) or a Director of Patient Care Services Designee (DD) was available during all operating hours to maintain a smooth functioning of the agency and maintain accurate and complete patient health records for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10). 5. Ensure the Administrator (ADM) performed her responsibilities to oversee and manage the agency, which included maintaining compliance with the federal regulations. These deficient practices had the potential to result in disruption of patient care and services and in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:22 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Administrator Designee (AD) related to the HHA’s failure to ensure a governing body assume responsibility for the operations of the HHA, has an organizational structure with clear lines of authority, and the HHA was operating within all legal bounds. The noncompliance had the potential to result in disruption of patient care and services and in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:22 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and will no longer be opened. The HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. During an interview on 8/21/2024 at 4:25 p.m. with the ADM, ADM stated the physical health records (charts) of the discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) were in a storage unit (offsite storage facility). The ADM was made aware that the ten discharged sample patients’ physical charts were needed for review by 8/22/2024. During an interview on 8/22/2024 at 11:30 a.m. with the ADM, ADM was requested to provide the ten discharged sample patients’ physical chart for review. During an interview on 8/22/2024, at 3:16 p.m., the office worker (OW 1) stated she was not a licensed nurse. During an observation on 8/22/2024, at 3:16 p.m., OW 1 was sitting on a desk with a computer. The computer was on and OW 1 was using it. The electronic medical record (EMR) program was on the screen (computer monitor). The sampled patient list for the survey (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) was on the screen. On the right upper hand corner of the EMR, the user identification (ID) showed “S.LVN”. During a concurrent observation and interview on 8/22/2024, at 3:20 p.m., with the ADM, the ADM walked (arrived) into the office, stood next to OW 1, and stated the user ID “S.LVN” belonged to Licensed Vocational Nurse (LVN) 1. The ADM stated LVN 1 had not been and was not in the office on 8/22/2024. During an interview on 8/22/2024 at 3:40 p.m. with the ADM, the ADM stated that OW 1 was not a Registered Nurse (RN) or a License Vocational Nurse (LVN). ADM stated OW 1 can create patients plans of care but not able to go over it or sign it. ADM stated she did not have an RN or LVN available for interview “today”. During an interview on 8/22/2024 at 4:07 p.m. with the ADM, ADM stated the DPCS will be at HHA on 8/23/2024 for assistance with survey. During an interview on 8/22/2024 at 4:10 p.m. with the ADM, ADM was requested to provide the physical health records (chart) of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 for review. During a concurrent interview and review of a Storage Unit (SU) receipt dated 8/20/2024 with the Administrator Designee (AD), on 8/22/2024 at 4:38 p.m., the AD stated Office Worker 2 (OW 2) was sent to the storage unit where the physical paper charts of the ten discharged patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 ) were stored, but OW 2 was not able to bring the charts because the storage unit was closed. On 8/22/2024, at 5:01 p.m., a call was made to LVN 1 based on the employee list of phone numbers provided by the HHA. There was no answer to the call. A message was left to return the call of the surveyor. During an interview on 8/22/2024 at 5:20 p.m. with the ADM, ADM stated LVN 2 was going to assist with the three home visits scheduled for 8/23/2024. During a telephone call on 8/22/2024 at 8:01 p.m. was made to the number listed on the Storage Unit receipt. There was no answer, the automated message stated that the office is opened Monday to Friday from 9:30 a.m. to 6 p.m. and Saturday to Sunday from 9:30 a.m. to 5 p.m. During an interview on 8/23/2024 at 11:20 a.m. with OW 2, OW 2 was requested to provide the physical health records (chart) of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 for review. OW 2 stated she would inform the ADM of the request. During an observation and interview on 8/23/2024 at 12:18 p.m. with ADM, ADM was noted arriving to the HHA at 12:18 p.m. with the physical paper charts of the seven patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, and Patient 9). ADM stated she needed to return to the Storage Unit for the other patient records (Patient 6, Patient 8, and Patient 10). The ADM was requested to also provide all her staff employee files. ADM stated the Administrator Designee (AD) was going to bring the DPCS to the HHA today for assistance with survey. During an interview on 8/23/2024 at 1 p.m. with the AD, the AD stated the DPCS did not answer her phone or home door. The AD stated there was an RN (HHA Consultant) on her way to the HHA for assistance. During a concurrent interview and record review on 8/23/2024 at 1:50 p.m., OW 1 reviewed the HHA’s EMR record titled, “Edit User Profile” for “S.LVN”, printed on 8/23/2024. The document indicated the last name of the user was “LVN” and the first name was “SN”. The document did not indicate any other information except “Email”. The “Email” address of “S.LVN” had the full name of the ADM and an email address domain of @yahoo.com. OW 1 stated she could not explain the information on the form. During a concurrent interview and record review on 8/23/2024, at 1:50 p.m., OW 1 reviewed the HHA’s EMR record titled, “Edit User Profile” for LVN 1, printed on 8/23/2024. The Edit User Profile indicated the last and first name of LVN 1 and LVN 1’s phone number, as documented in the HHA’s employee list. The Edit User Profile did not show any words or information matching “S.LVN” information with LVN 1’s profile. LVN 1’s email address domain was @gmail.com. OW 1 stated she could not explain the information on the form. During a concurrent observation and interview on 8/23/2024, at 2:31 p.m., the ADM was not at the HHA. OW 1 used her personal phone to call the ADM. The ADM answered the call and stated she was gone for the day because she had to pack to leave the country. The ADM stated her mother was very sick and she had to leave to see her in Germany. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the employee list of phone number provided by the HHA. There was no answer to the call. A message was left to return the call of the survey team. During a telephone interview on 8/23/2024 at 3:02 p.m. with the Director of Patient Care Services Designee (DD), the DD stated that as of June 2024 she was no longer worked at the HHA. The DD stated she never worked as the DD, a Registered Nurse (RN) Supervisor, or as any administrative staff. The DD stated her name should not be listed in the HHA’s organizational chart. The DD stated she worked for the HHA as a field RN, conducting patients start of care assessments and resumption of care assessments. The DD was not physically present in the agency since the start of the survey on 8/21/2024. During an interview on 8/23/2024 at 3:41 p.m. with License Vocational Nurse 2 (LVN 2), LVN 2 stated she is an RN and not an LVN. LVN 2 stated she applied to another home health agency (HHA 2) owned by the ADM and was told she was going to cover for other home health agencies (not identified) owned by the ADM if needed. LVN 2 stated she started working for HHA 2 about a month ago and had not had any patients assigned to her from any home health agency. LVN 2 stated she was asked to conduct two home visits last week (dates not specified) to assist in a survey. LVN 2 stated she did not document the home visits conducted last week because she was not asked to. LVN 2 stated she does not have access to the HHA’s electronic medical record. During a review of HHA’s form titled “(HHA) Home Health, Inc.” undated, indicated DDs name was listed under section “DPCS/Designee RN Supervisor”. On 8/23/2024 at 5 p.m., the HHA did not provide the physical paper charts of the discharged patients, Patient 6, Patient 8, and Patient 10, for review. The DPCS was not reachable and not physically present in the agency since the start of the survey on 8/21/2024. a. During a review of Patient 1’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During an observation on 8/22/2024, at 3:18 p.m., OW 1 was in front of the computer and a copy of Patient 1’s plan of care (POC) was requested. OW 1 selected the “Orders” tab on Patient 1’s EMR, and the screen was blank. The OW 1 made many clicks, very quickly, refreshed the screen and a “CMS 485” (the Home Health Certification and Plan of Care [POC] form) appeared on the screen. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., OW 1 reviewed Patient 1’s record titled, “Task Details” Patient 1, “CMS 485”. The document indicated “S.LVN” had created the document on 8/22/2024 at 3:18 p.m. The OW 1 stated, “I just created it right now. Everything, I put in.” The OW 1 stated she created the document because she did not know where the CMS 485 (the Home Health Certification and Plan of Care [POC]) was, and the surveyor asked for it. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care,” (also known as CMS 485) for certification period 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care did not have a signature under section “Nurse Signature and Date of Verbal SOC Where Applicable”. There was no date indicated under section “Date.” During a review of Patient 1’s record titled, “Task Details Patient 1 CMS 485,” the Task Details Patient 1 CMS 485 indicated the DPCS completed the document on 8/22/2024 at 9:44 p.m. On 8/23/2024, at 8:30 a.m., an attempt was made to call Patient 1. Patient 1’s record titled, “Patient Information” did not have a phone number listed. The Patient Information did not indicate an emergency contact phone number. The surveyor was unable to look for a patient phone number in the EMR because the HHA removed the access to the EMR. The access to the EMR resumed on 8/23/2024 at 12:15 p.m. During a review of Patient 1’s record titled, “Task Detail Patient 1 OASIS-E Start of Care,” printed on 8/23/2024, the Task Detail Patient 1 OASIS-E Start of Care indicated “S.LVN”, DPCS, and DD did multiple revision for the period 6/13/2024 to 8/22/2024. The Task Detail Patient 1 OASIS-E Start of Care indicated the DPCS completed the document o 6/20/2024 and the DD completed the document on 8/22/2024. During a review of Patient 1’s record titled, “Notice of Medicare Non-Coverage,” dated 7/26/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services, Services will End: 7/26/2024.” The Notice of Medicare Non-Coverage indicated Patient 1’s signature. The Notice of Medicare Non-Coverage did not indicate Patient 1 was discharged from the HHA. During a review of Patient 1’s record titled, “OASIS-E Discharge”, dated 7/26/2024, the OASIS-E Discharge indicated the assessment was being completed for the reason of being discharged from agency. During a review of Patient 1’s record titled, “Task Detail Patient 1 OASIS-E Discharge”, printed 8/23/2024, the Task Detail Patient 1 OASIS-E Discharge indicated the task was created by “S.LVN” on 8/20/2024. The Task Detail Patient 1 OASIS-E Discharge indicated the DPCS completed the document on 8/21/24. The Task Detail Patient 1 OASIS-E Discharge indicated the DD completed the document on 8/22/2024. During a review of Patient 1’s record titled, “Discharge Summary,” dated 7/26/2024, the Discharge Summary indicated Patient 1 was discharged due to goals met. The Discharge Summary indicated the Director of Patient Care Services (DPCS) signed the document with the date of 7/26/2024. During a review of Patient 1’s record titled, “Task Detail Patient 1 Discharge Summary,” the Task Detail Patient 1 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 9:16 p.m. The Task Detail Patient 1 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 9:39 p.m. b. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s record titled, “OASIS E-Start of Care,” dated 6/14/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 2’s “Task Details Patient 2 OASIS E-Start of Care,” printed 8/22/2204 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DPCS completed the document on 6/17/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:24 p.m., OW 1 reviewed Patient 2’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 2’s record titled, “Task Details Patient 2 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 CMS 485 indicated “S.LVN” created the document on 8/22/2024, at 11:31 p.m. and the DPCS completed the record on 8/22/2024, at 11:50 p.m. During an interview on 8/23/2024, at 9:30 a.m., Patient 2 stated the last time a nurse from the HHA visited him was in the month of July 2024. Patient 2 stated he had brain surgery about three and a half years ago and had not been well ever since. Patient 2 stated his speech was not good, he was unable to speak well, and he needed to receive speech therapy. Patient 2 stated the only services he was receiving was speech therapy (ST), which began two weeks ago. Patient 2 stated the ST did not come this week and the HHA told him the ST would be off next week. Patient 2 stated he had not received any notice that he was being discharged or transferred to another HHA. Patient 2 stated, “I’m not going anywhere, I need the speech therapist.” Patient 2 stated what he knows is, he is still a current patient of the HHA. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 2. The paper chart included Patient 2’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/14/2024 to 8/12/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/14/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/20/2024. During a review of Patient 2’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the ADM, the paper chart included Patient 2’s printed EMR record titled, “Discharge Summary,” dated 8/9/2024. The Discharge Summary indicated the patient was discharged for the reason of goals met. The Discharge Summary indicated the DPCS signed the document digitally, with a date of 8/9/2024. During a review of Patient 2’s EMR, on 8/23/2024, at 4:51 p.m., there were no ST notes. During a review of Patient 2’s EMR, on 8/23/2024, at 4:58 p.m., there was Physical Therapy visit dates (PT), dated 6/19/2024, 6/26/2024, 7/3/2024, 7/10/2024, 7/17/2024, 7/24/2024, 7/31/2024, and 8/7/2024. When selecting “PT Visit” for any date, there was no documentation. The “print view” (a function used to view and print the note) option was not available. During a review of Patient 2’s record titled, “Task Details Patient 2, PT visit for 6/26/24” the Task Details Patient 2, PT visit for 6/26/24 indicated “S.LVN” created and completed the document on 7/26/2024. During a review of Patient 2’s record titled, “Notice of Medicare Non-Coverage,” dated 8/9/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/9/2024.” The Notice of Medicare Non-Coverage had Patient 2’s signature. The form did not indicate Patient 2 was discharged from the HHA. During a review of Patient 2’s record titled, “OASIS-E Discharge,” dated 8/9/2024, the OASIS-E Discharge indicated the assessment was done for the reason of discharged from agency. During a review of Patient 2’s record titled, “Task Details Patient 2 OASIS-E Discharge,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the record on 8/20/24. The Task Details Patient 2 OASIS-E Discharge indicated, “S.LVN” reopened and updated tasks on 8/22/2024. The DD signed and completed the document on 8/22/2024. During a review of Patient 2’s records titled, “Task Details Patient 2 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 11:29 p.m. The Task Details Patient 2 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 11:54 p.m. c. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a review of Patient 3’s record titled, “OASIS E-Start of Care,” dated 6/8/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 3’s “Task Details Patient 3 OASIS E-Start of Care,” printed 8/22/2024 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 3 OASIS E-Start of Care indicated the DPCS completed the document on 6/13/2024. The Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” reopened and updated tasks on 8/22/2024 and the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:35 p.m., OW 1 reviewed Patient 3’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 3’s record titled, “Task Details Patient 3 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 10:35 p.m. and the DPCS completed the record on 8/22/2024, at 11:22 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 3. The paper chart included Patient 3’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/8/2024 to 8/6/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/8/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 8/1/2024. During a review of Patient 3’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the chart included Patient 3’s printed EMR record titled, “Discharge Summary,” dated 7/30/2024. The Discharge Summary indicated the patient was discharged for the reason of goals met. The record indicated the DPCS signed the document digitally, with a date of 7/30/2024. During a review of Patient 3’s record titled, “Notice of Medicare Non-Coverage”, dated 7/30/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 7/30/2024. The Notice of Medicare Non-Coverage had Patient 3’s signature. The Notice of Medicare Non-Coverage did not indicate Patient 3 was discharged from the HHA. During a review of Patient 3’s record titled, “OASIS-E Discharge”, dated 7/30/2024, the OASIS-E Discharge indicated the assessment was done for the reason of discharged from agency. During a review of Patient 3’s record titled, “Task Details Patient 3 OASIS-E Discharge,” printed on 8/23/2204 from the EMR, the Task Details Patient 3 OASIS-E Discharge indicated “S.LVN” created the document on 7/30/2024. The Task Details Patient 3 OASIS-E Discharge indicated the DPCS completed the record on 8/6/24. The Task Details Patient 2 OASIS-E Discharge indicated “S.LVN” reopened, updated tasks, and completed the document on 8/22/2024. The DD signed and completed the document on 8/22/2024. During a review of Patient 3’s records titled, “Task Details Patient 3 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 Discharge Summary indicated S.LVN created the document on 8/22/2024 at 10:31 p.m. The Task Details Patient 3 Discharge Summary indicated the DPCS completed the document on 8/22/24 at 11:20 p.m. d. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s record titled, “OASIS E-Start of Care,” dated 6/20/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 4’s “Task Details Patient 4 OASIS E-Start of Care,” printed 8/23/2204 from the EMR, the Task Details Patient 4 OASIS E-Start of Care, indicated “S.LVN” completed the document on 6/21/2024. The Task Details Patient 4 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s “Home Health Certification and Plan of Care,” (also known as CMS 485) for certification period 6/20/2024 to 8/18/2024, the Home Health Certification and Plan of Care indicated the document was digitally signed by DPCS, with a date of 6/20/2024. During a review of Patient 4’s “Task Details Patient 4 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 4 CMS 485 indicated the DPCS created the document on 8/6/2024. The record indicated “S.LVN” completed the document on 8/19/2024. During an interview on 8/22/2024, at 3:40 p.m., OW 1 stated there was no discharge summary in Patient 4’s EMR. During an interview at Patient 4’s home on 8/23/2024, at 10:40 a.m., Patient 4 stated he was receiving nursing and physical therapy (PT) services. Patient 4 stated his last PT and nursing visit was two days ago (8/20/2024). During an interview, on 8/23/2024, at 10:51 a.m., Patient 4 stated he was not informed that HHA services were stopped or that he was discharged from the HHA. During a concurrent interview and record review on 8/23/2024, at 10:52 a.m., Patient 4 had a document titled, “Notice of Medicare Non-Coverage”, dated 8/13/2024. The Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/13/2024.” Patient 4 stated a nurse came two days ago and had him sign the papers (the Notice of Medicare Non-Coverage), but he did not know what they were for. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 4. The chart included Patient 4’s printed EMR record titled, “Discharge Summary,” dated 8/13/2024. The Discharge Summary indicated Patient 4 was discharged for the reason of goals met. The record indicated the DPCS signed the document digitally with a date of 8/13/2024. During a review of Patient 4’s record titled, “OASIS-E Discharge,” dated 8/13/2024. the OASIS-E Discharge indicated assessment done for reason of discharged of agency. During a review of Patient 4’s record titled, “Task Details Patient 4 OASIS-E Discharge”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the document on 8/19/2024. The Task Details Patient 2 OASIS-E Discharge indicated “S. LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s record titled, “Task Details Patient 4 Discharge Summary”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 Discharge Summary indicated “S.LVN” created the document on 8/22/2024 at 7:15 p.m. The Task Details Patient 4 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 8:21 p.m. e. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s record titled, “OASIS E-Start of Care,” dated 5/30/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 5’s “Task Details Patient 5 OASIS E-Start of Care”, printed 8/22/2204 the EMR, the Task Details Patient 5 OASIS E-Start of Care, indicated “S.LVN” created the document on 5/24/2024. The Task Details Patient 5 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 7/30/2024 and on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:42 p.m., OW 1 reviewed Patient 5’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 5. The paper chart included Patient 5’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 5/30/2024 to 7/28/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 5/30/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/3/2024. During a review of Patient 5’s record titled, “Task Details Patient 5 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 8:43 p.m. and the DPCS completed the record on 8/22/2024, at 9:15 p.m. During a review of Patient 5’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the chart included Patient 5’s printed EMR record titled, “Discharge Summary,” dated 7/25/2024. The Discharge Summary indicated the patient was discharged from the agency because the goals were met. The Discharge Summary was signed by the DPCS with a date of 7/25/2024. During a review of Patient 5’s record titled, “Notice of Medicare Non-Coverage”, dated 7/25/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services, Services will End: 7/25/2024.” During a review of Patient 5’s record titled, “OASIS-E Discharge,” dated 7/25/2024, the OASIS-E Discharge indicated assessment done for reason of discharged of agency. During a review of Patient 5’s record titled, “Task Details Patient 5 OASIS-E Discharge,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 5 OASIS-E Discharge indicated “S.LVN” completed the document on 7/30/2024 and reopened to update the document on 8/22/2024. During a review of Patient 5’s record titled, “Task Details Patient 5 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 Discharge Summary indicated “S.LVN” created the document on 8/22/2024 at 8:41 p.m. The Task Details Patient 5 Discharge Summary indicated DPCS completed the document on 8/22/2024 at 9:17 p.m. f. During a review of Patient 6’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (also known as CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (also knowns as CMS 485), dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 6’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024, at 3:36 p.m., of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 6’s medical record form titled “OASIS-E Start of Care,” dated 6/14/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated there was no listed phone number for the patient. The OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 6/14/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the person who completed the form. During a review of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated user “(DD)” updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” completed and signed the form on 8/22/2024. The Task Details indicated LVN 2 updated task on 8/22/2024. During a review on 8/23/2024 at 1:46 p.m. of Patient 6’s electronic medical record (EMR) form titled “Episode Manager – Order” dated 6/14/2024 to 7/26/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 6/14/2024 and 7/26/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 6/14/2024, the Physician Order indicated Patient 6 was being admitted for HHA services. The form indicated it was digitally signed by the DPCS on 6/14/2024. During a review 8/23/2024 at 1:47 p.m. of Patient 6’s EMR form titled “Task Details” dated 6/14/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 7/26/2024, the Physician Order indicated Patient 6 reached his goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/26/2024. During a review on 8/23/2024, at 1:48 p.m. of Patient 6’s EMR, medical record form titled “Task Details” dated 7/26/2024, The Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to quality assurance manager on 8/22/2024. The Task Details indicate user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 6’s record titled “OASIS-E Discharge” dated 7/26/2024, provided by OW 1 on 8/22/2024, the OASIS-E Discharge indicated an RN was the discipline who completed the assessment on 7/26/2024. The form does not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 6’s medical record form titled “Task Details” dated 7/26/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated user “S.LVN” created the form on 8/20/2024 and revised the form on 8/21/2024 and 8/22/2024. The Task Details indicated user “(DPCS)” signed, submitted, and completed the form on 8/21/2024. During a review of Patient 6’s medical record form titled “Task Details” dated 7/26/2024, The Task Details indicated user indicated “Task – Discharge Summary.” The Task Details indicated user “S.LVN” created, submitted, and sent form to quality assurance manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. g. During a review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 7’s primary physician. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care”, dated 5/22/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 5/22/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care”, dated 5/22/2024 provided by the ADM on 8/23/2024, the OASIS-E Start of Care indicated the form was signed by the DPCS on 5/22/2024. During a review of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. User “(DPCS)” reopened, updated, completed, and signed the form on 8/22/2024. During a concurrent observation, interview, and review of Patient 7’s EMR on 8/22/2024 at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 7’s medical record form titled Home Health Certification and Plan of Care (also known as CMS 485 form). OW 1 proceeded to log into Patient 7’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated from 5/22/2024 to 7/20/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485), dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services (DPCS) as Patient 7’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:34 p.m. of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated user “S. LVN,” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 7’s physical paper chart medical record form titled “Home Health Certification and Plan of Care,” dated 5/22/2024 to 7/20/2024, provided by the ADM on 8/23/2024 at 12:18 p.m., the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS and Medical Doctor 1 (MD 1) on 5/22/2024. On 8/23/2024, at 12:28 p.m., a call was made to Patient 7 and a female (unidentified) picked up the call and then hung the phone up after the surveyor introduced herself. During a review on 8/23/2024 at 1:50 p.m. of Patient 7’s EMR, medical record form titled “Episode Manager – Order” dated 5/22/2024 to 7/18/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 5/22/2024 and 7/18/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 5/22/2024, the Physician Order indicated “HCFA 485” (former name of the form CMS 485). The Physician Order indicated it was digitally signed by the DPCS on 5/22/2024. During a review 8/23/2024 at 1:51 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 7/18/2024, the Physician Order indicated Patient 7 reached her goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/18/2024. During a review of Patient 7’s medical record form provided on 8/23/2024 by ADM titled, “Physician Order” dated 7/18/2024, the Physician Order indicated user “(DPCS)” completed the form on 8/22/2024. The Physician Order indicated it was signed by MD 1 on 7/24/2024. During a review on 8/23/2024 at 1:52 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 7/18/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 7’s medical record form provided on 8/23/2024 by the ADM titled “Discharge Summary” dated 7/18/2024, the Discharge Summary indicated Patient 7 was discharge from the HHA on 7/17/2024. The Discharge Summary indicated it was digitally signed by the DPCS on 7/18/2024. During a review on 8/23/2024 at 12:44 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 7/18/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. h. During a review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. During a review of Patient 8’s medical record form titled “OASIS-E Start of Care”, dated 3/5/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 3/5/2024. The OASIS-E Start of Care does not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated LVN 1 updated the task details on 8/22/2024. The Task Details indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:37 p.m. of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. On 8/23/2024, at 12:12 p.m., a call was made to Patient 8 and Patient 8 did not answer the call. Left a message return the call. During a review of Patient 8’s medical record form titled “Physician Order” dated 4/23/2024, the Physician Order indicated Patient 8 was transferred to a hospital due to shortness of breath. The Physician Order indicated it was digitally signed by the DPCS on 4/23/2024. During a review on 8/23/2024, at 1:53 p.m., of Patient 8’s EMR, medical record form titled “Task Details,” dated 4/23/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated LVN 1 updated the task details on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review on 8/23/2024, at 12:45 p.m. of Patient 8’s EMR, medical record form titled “Task Details” dated 4/23/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. i. During a record review of Patient 9’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). During a record review on 8/22/2024 at 3:38 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, the Episode Manager – Orders indicated there were no entries made under task. During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 6/15/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024 provided by the ADM on 8/23/2024, the OASIS-E Start of Care indicated the form was signed by the DPCS on 6/15/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated 6/15/2024 to 8/13/2024, provided by the OW 1 on 8/23/2024 at 12 p.m. the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, and primary language”. The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 9’s clinical manager and MD 1 as her primary physician. The Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS on 6/15/2024. The form indicated it was not signed by MD 1. During a review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” dated 6/15/2024 to 8/13/2024, provided by the ADM on 8/23/2024 at 12:18 p.m., the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS on 6/15/2024. The Home Health Certification and Plan of Care indicated it was signed by MD 1 on 6/21/2024. During a review on 8/23/2024 at 1:57 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, the Episode Manager – Orders indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician orders dated 6/15/2024 and 8/3/2024. During a review of Patient 9’s medical record form title “Physician Order” dated 6/15/2024 received on 8/23/2024 from the ADM, the Physician Order indicated Patient 9 was being admitted for HHA services. The form indicated MD 1 was noted as the physician. The Physician Order indicated it was digitally signed by the DPCS on 6/15/2023. The Physician Order indicated it was signed by MD 1 on 6/21/2024. During a review 8/23/2024, at 1:58 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “Physician Order” dated 8/3/2024, the Physician Order indicated Patient 9 was being discharged from HHA services. The Physician Order indicated MD 1 was noted as the physician. The Physician Order indicated it was digitally signed by the DPCS on 8/3/2024. The Physician Order indicated it was signed by MD 1 on 8/12/2024. During a review on 8/23/2024 at 1:59 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 8/3/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “OASIS-E Discharge” dated 8/3/2024, the OASIS-E Discharge indicated it was signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form provided on 8/23/2024 by the ADM titled “Discharge Summary” dated 8/3/2024, the Discharge Summary indicated Patient 9 was discharge from the HHA on 8/3/2024. The Discharge Summary form indicated it was digitally signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, the Task Details indicated “Task – Discharge Summary”. The Task – Discharge Summary indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task – Discharge Summary indicated user “(DPCS)” completed the form on 8/22/2024. j. During a review of Patient 10’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. During a review of Patient 10’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024, the OASIS-E Start of Care indicated an RN was the discipline who completed the assessment on 6/15/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. The Task Details indicated LNV 1 updated the task details on 8/22/2024. The Task Details indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. The form indicated LVN 2 updated task on 8/22/2024. During a concurrent observation, interview, and review of Patient 10’s EMR on 8/22/2024, at 3:12 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 10’s medical record form titled Home Health Certification and Plan of Care (also known as CMS 485 form). OW 1 proceeded to log into Patient 10’s electronic medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not in the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 10’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/15/2024 to 8/13/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 10’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, primary language, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:38 p.m. of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review on 8/23/2024 at 2 p.m., of Patient 10’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician orders dated 6/15/2024 and 8/6/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 6/15/2024, the Physician Order indicated “HCFA 485” (former name of the form CMS 485) and MD 1 was the physician. The Physician Order indicated it was digitally signed by the DPCS on 6/15/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 8/6/2024, the Physician Order indicated Patient 10 was being discharged from receiving HHA services and indicated MD 1 was the physician. The Physician Order indicated it was digitally signed by the DPCS on 8/6/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “OASIS-E Discharge” dated 8/6/2024, the OASIS-E Discharge indicated an RN was the discipline that completed Patient 10’s discharge assessment on 8/6/2024. The OASIS-E Discharge did not indicate who the author was, and it was not signed. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated “S.LVN” created, submitted, and sent form to the case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “(DPCS)” completed and signed the form on 8/22/2024. On 8/23/2024 at 5 p.m., the HHA did not provide Patient 10’s physical paper chart for review. The HHA did not provide the physical paper chart of Patient 10 since the start of the survey on 8/21/2024. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey were OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1. The Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the clinical records, including the comprehensive assessment (an assessment conducted by a registered nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records), plans of care (documents the process of identifying a patient's needs and facilitating holistic care [caring for the whole person by providing physical mental, spiritual, and social needs] and ensures collaboration among nurses, patients, and other healthcare providers), physician admission, and discharge orders were accurately completed, accessible, and available for review for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). These failures had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. (Refer to G1012). 2. The Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a licensed nurse (in general) authenticated the notes in the clinical records for five of ten sampled patients (Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10) by failing to: 1. Ensure Office Worker 1 (OW 1), who was not a licensed nurse, did not create a plan of care for Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10 on 8/22/2024. 2. Ensure OW 1 did not use Licensed Vocational Nurse 1’s (LVN 1’s) nursing credentials to create Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s Home Health Certification and Plan of Care (the CMS 485 form) on 8/22/2024. These failures resulted in unauthorized patient information entries that did not reflect Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s current medical condition and needs, which is likely to result in inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the clinical records, including the comprehensive assessment (an assessment conducted by a registered nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records), plans of care (documents the process of identifying a patient's needs and facilitating holistic care [caring for the whole person by providing physical mental, spiritual, and social needs] and ensures collaboration among nurses, patients, and other healthcare providers), physician admission, and discharge orders were accurately completed, accessible, and available for review for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10). These failures had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024, at 5:22 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the HHA’s Administrator Designee (AD) related to the HHA failure to ensure clinical records for ten of ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) included their plan of care (POC), initial assessments, comprehensive assessment, clinical notes and physician admission and discharge orders that reflected the patients’ current health status, correct and updated assessments. The noncompliance had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10 receiving inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:22 p.m., the Administrator Designee (AD) told the survey team the agency would be closed (for business) and will no longer be opened. The HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. Findings: During an interview on 8/21/2024, at 4:25 p.m., with the Administrator (ADM), the ADM stated the discharge physical charts of the ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) were in a storage unit. The survey team informed the ADM the survey team needed the discharged physical charts of the ten sampled patients for review by 8/22/2024. During an interview on 8/22/2024 at 11:30 a.m., with the ADM, the survey team requested for the ADM to provide the discharge physical charts of the ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) for review. During an interview on 8/22/2024, at 3:16 p.m., the Office Worker (OW 1) stated she was not a licensed nurse. During an observation on 8/22/2024, at 3:16 p.m., OW 1 was sitting on a desk with a computer. The computer was on and OW 1 was using it. The electronic medical record (EMR) program was on the screen (computer monitor). The sampled patient list for the survey (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) was on the screen. On the right upper hand corner of the EMR, the user identification (ID) showed “S.LVN”. During a concurrent observation and interview on 8/22/2024, at 3:20 p.m., with the ADM, the ADM stood next to OW 1 and stated the user ID “S.LVN” belonged to Licensed Vocational Nurse (LVN) 1. The ADM stated LVN 1 had not been and was not in the office on 8/22/2024. During an interview on 8/22/2024, at 3:40 p.m., with the ADM, the ADM stated OW 1 was not a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN). The ADM stated OW 1 could create patients’ plan of care but not able to go over it or sign it. The ADM stated she did not have an RN or an LVN available for interview “today.” During an interview on 8/22/2024, at 4:10 p.m., with the ADM, the survey team requested the ADM to provide the discharge physical charts of the ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) for review. During a concurrent interview and review of a Storage Unit (SU) receipt dated 8/20/2024 with the AD, on 8/22/2024 at 4:38 p.m., the AD stated Office Worker 2 (OW 2) went to the storage unit where the discharge physical charts of the ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) were, but OW 2 was not able to bring them because the storage unit was closed. On 8/22/2024, at 5:01 p.m., a call was made to LVN 1 based on the employee list of phone numbers provided by the HHA. There was no answer to the call. A message was left to return the call of the surveyor. During an interview on 8/23/2024, at 11:20 a.m., with OW 2, the survey team asked OW 2 to provide the discharge physical charts of the ten sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) for review. OW 2 stated she would inform the ADM of the request. During an observation and interview on 8/23/2024, at 12:18 p.m., with the ADM at the HHA, the ADM arrived at the HHA at 12:18 p.m., with physical paper charts of the seven patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, and Patient 9). The ADM stated she needed to return to the Storage Unit for the other patient records. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During a record review of HHA’s form titled “(HHA) Home Health, Inc.” undated, indicated the Director of Patient Care Services Designee’s (DD’s) name was listed under section “DPCS (Director of Patient Care Services)/Designee RN Supervisor”. During an interview on 8/23/2024, at 3:02 p.m., with the DD, the DD stated that as of June 2024, she no longer worked at the HHA. The DD stated she never worked as the DD, a Registered Nurse (RN) Supervisor, or as any administrative staff. The DD stated her name should not be listed in the HHA’s organizational chart. The DD stated she worked for the HHA as a field RN, conducting patients start of care assessments and resumption of care assessments. During an interview on 8/23/2024, at 3:41 p.m., with License Vocational Nurse 2 (LVN 2), the LVN 2 stated she was an RN and not an LVN. LVN 2 stated she applied to another home health agency (HHA 2) owned by the ADM, and she was told she was going to cover for other home health agencies owned by the ADM if needed. LVN 2 stated she started working for HHA 2 about a month ago and she has not had any patients assigned to her from any home health agency. LVN 2 stated she was asked to conduct two home visits (the recipients of the home visits were not identified) last week to assist in a survey. LVN 2 stated she did not document the home visits conducted last week because she was not asked to. LVN 2 stated she did not have access to the HHA’s electronic medical record. On 8/23/2024 at 5 p.m., the HHA did not provide the discharge physical paper charts of Patient 6, Patient 8, and Patient 10 for review. a. During a review of Patient 1’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During an observation on 8/22/2024, at 3:18 p.m., OW 1 was in front of the computer and a copy of Patient 1’s plan of care (POC) was requested. OW 1 selected the “Orders” tab on Patient 1’s EMR, and the screen was blank. The OW 1 made many clicks, very quickly, refreshed the screen and a “CMS 485” (the Home Health Certification and Plan of Care [POC] form) appeared on the screen. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., OW 1 reviewed Patient 1’s record titled, “Task Details” Patient 1, “CMS 485”. The document indicated “S.LVN” had created the document on 8/22/2024 at 3:18 p.m. The OW 1 stated, “I just created it right now. Everything, I put in.” The OW 1 stated she created the document because she did not know where the CMS 485 (the Home Health Certification and Plan of Care [POC]) was, and the surveyor asked for it. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care,” (also known as CMS 485) for certification period 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care did not have a signature under section “Nurse Signature and Date of Verbal SOC Where Applicable”. There was no date indicated under section “Date.” During a review of Patient 1’s record titled, “Task Details Patient 1 CMS 485,” the Task Details Patient 1 CMS 485 indicated the DPCS completed the document on 8/22/2024 at 9:44 p.m. On 8/23/2024, at 8:30 a.m., an attempt was made to call Patient 1. Patient 1’s record titled, “Patient Information” did not have a phone number listed. The Patient Information did not indicate an emergency contact phone number. The surveyor was unable to look for a patient phone number in the EMR because the HHA removed the access to the EMR. The access to the EMR resumed on 8/23/2024 at 12:15 p.m. During a review of Patient 1’s record titled, “Task Detail Patient 1 OASIS-E Start of Care,” printed on 8/23/2024, the Task Detail Patient 1 OASIS-E Start of Care indicated “S.LVN”, DPCS, and DD did multiple revision for the period 6/13/2024 to 8/22/2024. The Task Detail Patient 1 OASIS-E Start of Care indicated the DPCS completed the document o 6/20/2024 and the DD completed the document on 8/22/2024. During a review of Patient 1’s record titled, “Notice of Medicare Non-Coverage,” dated 7/26/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services, Services will End: 7/26/2024.” The Notice of Medicare Non-Coverage indicated Patient 1’s signature. The Notice of Medicare Non-Coverage did not indicate Patient 1 was discharged from the HHA. During a review of Patient 1’s record titled, “OASIS-E Discharge”, dated 7/26/2024, the OASIS-E Discharge indicated the assessment was being completed for the reason of being discharged from agency. During a review of Patient 1’s record titled, “Task Detail Patient 1 OASIS-E Discharge”, printed 8/23/2024, the Task Detail Patient 1 OASIS-E Discharge indicated the task was created by “S.LVN” on 8/20/2024. The Task Detail Patient 1 OASIS-E Discharge indicated the DPCS completed the document on 8/21/24. The Task Detail Patient 1 OASIS-E Discharge indicated the DD completed the document on 8/22/2024. During a review of Patient 1’s record titled, “Discharge Summary,” dated 7/26/2024, the Discharge Summary indicated Patient 1 was discharged due to goals met. The Discharge Summary indicated the Director of Patient Care Services (DPCS) signed the document with the date of 7/26/2024. During a review of Patient 1’s record titled, “Task Detail Patient 1 Discharge Summary,” the Task Detail Patient 1 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 9:16 p.m. The Task Detail Patient 1 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 9:39 p.m. b. During a review of Patient 2’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/14/2024, with a primary diagnosis of hypothyroidism (the thyroid does not produce enough hormones). During a review of Patient 2’s record titled, “OASIS E-Start of Care,” dated 6/14/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 2’s “Task Details Patient 2 OASIS E-Start of Care,” printed 8/22/2204 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DPCS completed the document on 6/17/2024. The Task Details Patient 2 OASIS E-Start of Care indicated the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:24 p.m., OW 1 reviewed Patient 2’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 2’s record titled, “Task Details Patient 2 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 CMS 485 indicated “S.LVN” created the document on 8/22/2024, at 11:31 p.m. and the DPCS completed the record on 8/22/2024, at 11:50 p.m. During an interview on 8/23/2024, at 9:30 a.m., Patient 2 stated the last time a nurse from the HHA visited him was in the month of July 2024. Patient 2 stated he had brain surgery about three and a half years ago and had not been well ever since. Patient 2 stated his speech was not good, he was unable to speak well, and he needed to receive speech therapy. Patient 2 stated the only services he was receiving was speech therapy (ST), which began two weeks ago. Patient 2 stated the ST did not come this week and the HHA told him the ST would be off next week. Patient 2 stated he had not received any notice that he was being discharged or transferred to another HHA. Patient 2 stated, “I’m not going anywhere, I need the speech therapist.” Patient 2 stated what he knows is, he is still a current patient of the HHA. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 2. The paper chart included Patient 2’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/14/2024 to 8/12/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/14/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/20/2024. During a review of Patient 2’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the ADM, the paper chart included Patient 2’s printed EMR record titled, “Discharge Summary,” dated 8/9/2024. The Discharge Summary indicated the patient was discharged for the reason of goals met. The Discharge Summary indicated the DPCS signed the document digitally, with a date of 8/9/2024. During a review of Patient 2’s EMR, on 8/23/2024, at 4:51 p.m., there were no ST notes. During a review of Patient 2’s EMR, on 8/23/2024, at 4:58 p.m., there was Physical Therapy visit dates (PT), dated 6/19/2024, 6/26/2024, 7/3/2024, 7/10/2024, 7/17/2024, 7/24/2024, 7/31/2024, and 8/7/2024. When selecting “PT Visit” for any date, there was no documentation. The “print view” (a function used to view and print the note) option was not available. During a review of Patient 2’s record titled, “Task Details Patient 2, PT visit for 6/26/24” the Task Details Patient 2, PT visit for 6/26/24 indicated “S.LVN” created and completed the document on 7/26/2024. During a review of Patient 2’s record titled, “Notice of Medicare Non-Coverage,” dated 8/9/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/9/2024.” The Notice of Medicare Non-Coverage had Patient 2’s signature. The form did not indicate Patient 2 was discharged from the HHA. During a review of Patient 2’s record titled, “OASIS-E Discharge,” dated 8/9/2024, the OASIS-E Discharge indicated the assessment was done for the reason of discharged from agency. During a review of Patient 2’s record titled, “Task Details Patient 2 OASIS-E Discharge,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the record on 8/20/24. The Task Details Patient 2 OASIS-E Discharge indicated, “S.LVN” reopened and updated tasks on 8/22/2024. The DD signed and completed the document on 8/22/2024. During a review of Patient 2’s records titled, “Task Details Patient 2 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 2 Discharge Summary indicated “S.LVN” created the document on 8/22/2024, at 11:29 p.m. The Task Details Patient 2 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 11:54 p.m. c. During a review of Patient 3’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/8/2024, with a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia. During a review of Patient 3’s record titled, “OASIS E-Start of Care,” dated 6/8/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 3’s “Task Details Patient 3 OASIS E-Start of Care,” printed 8/22/2024 from the EMR, the Task Details Patient 2 OASIS E-Start of Care indicated “S.LVN” created the document on 5/31/2024. The Task Details Patient 3 OASIS E-Start of Care indicated the DPCS completed the document on 6/13/2024. The Task Details Patient 3 OASIS E-Start of Care indicated “S.LVN” reopened and updated tasks on 8/22/2024 and the DD completed and signed the document on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:35 p.m., OW 1 reviewed Patient 3’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. During a review of Patient 3’s record titled, “Task Details Patient 3 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 10:35 p.m. and the DPCS completed the record on 8/22/2024, at 11:22 p.m. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 3. The paper chart included Patient 3’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 6/8/2024 to 8/6/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 6/8/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 8/1/2024. During a review of Patient 3’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the chart included Patient 3’s printed EMR record titled, “Discharge Summary,” dated 7/30/2024. The Discharge Summary indicated the patient was discharged for the reason of goals met. The record indicated the DPCS signed the document digitally, with a date of 7/30/2024. During a review of Patient 3’s record titled, “Notice of Medicare Non-Coverage”, dated 7/30/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 7/30/2024. The Notice of Medicare Non-Coverage had Patient 3’s signature. The Notice of Medicare Non-Coverage did not indicate Patient 3 was discharged from the HHA. During a review of Patient 3’s record titled, “OASIS-E Discharge”, dated 7/30/2024, the OASIS-E Discharge indicated the assessment was done for the reason of discharged from agency. During a review of Patient 3’s record titled, “Task Details Patient 3 OASIS-E Discharge,” printed on 8/23/2204 from the EMR, the Task Details Patient 3 OASIS-E Discharge indicated “S.LVN” created the document on 7/30/2024. The Task Details Patient 3 OASIS-E Discharge indicated the DPCS completed the record on 8/6/24. The Task Details Patient 2 OASIS-E Discharge indicated “S.LVN” reopened, updated tasks, and completed the document on 8/22/2024. The DD signed and completed the document on 8/22/2024. During a review of Patient 3’s records titled, “Task Details Patient 3 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 3 Discharge Summary indicated S.LVN created the document on 8/22/2024 at 10:31 p.m. The Task Details Patient 3 Discharge Summary indicated the DPCS completed the document on 8/22/24 at 11:20 p.m. d. During a review of Patient 4’s record titled, “Patient Information,” the Patient Information indicated a start of care on 6/20/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 4’s record titled, “OASIS E-Start of Care,” dated 6/20/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 4’s “Task Details Patient 4 OASIS E-Start of Care,” printed 8/23/2204 from the EMR, the Task Details Patient 4 OASIS E-Start of Care, indicated “S.LVN” completed the document on 6/21/2024. The Task Details Patient 4 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s “Home Health Certification and Plan of Care,” (also known as CMS 485) for certification period 6/20/2024 to 8/18/2024, the Home Health Certification and Plan of Care indicated the document was digitally signed by DPCS, with a date of 6/20/2024. During a review of Patient 4’s “Task Details Patient 4 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 4 CMS 485 indicated the DPCS created the document on 8/6/2024. The record indicated “S.LVN” completed the document on 8/19/2024. During an interview on 8/22/2024, at 3:40 p.m., OW 1 stated there was no discharge summary in Patient 4’s EMR. During an interview at Patient 4’s home on 8/23/2024, at 10:40 a.m., Patient 4 stated he was receiving nursing and physical therapy (PT) services. Patient 4 stated his last PT and nursing visit was two days ago (8/20/2024). During an interview, on 8/23/2024, at 10:51 a.m., Patient 4 stated he was not informed that HHA services were stopped or that he was discharged from the HHA. During a concurrent interview and record review on 8/23/2024, at 10:52 a.m., Patient 4 had a document titled, “Notice of Medicare Non-Coverage”, dated 8/13/2024. The Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services will End: 8/13/2024.” Patient 4 stated a nurse came two days ago and had him sign the papers (the Notice of Medicare Non-Coverage), but he did not know what they were for. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 4. The chart included Patient 4’s printed EMR record titled, “Discharge Summary,” dated 8/13/2024. The Discharge Summary indicated Patient 4 was discharged for the reason of goals met. The record indicated the DPCS signed the document digitally with a date of 8/13/2024. During a review of Patient 4’s record titled, “OASIS-E Discharge,” dated 8/13/2024. the OASIS-E Discharge indicated assessment done for reason of discharged of agency. During a review of Patient 4’s record titled, “Task Details Patient 4 OASIS-E Discharge”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 2 OASIS-E Discharge indicated the DPCS completed the document on 8/19/2024. The Task Details Patient 2 OASIS-E Discharge indicated “S. LVN” reopened and updated the document on 8/22/2024. During a review of Patient 4’s record titled, “Task Details Patient 4 Discharge Summary”, printed on 8/23/2024 from the EMR, the Task Details Patient 4 Discharge Summary indicated “S.LVN” created the document on 8/22/2024 at 7:15 p.m. The Task Details Patient 4 Discharge Summary indicated the DPCS completed the document on 8/22/2024 at 8:21 p.m. e. During a review of Patient 5’s record titled, “Patient Information,” the Patient Information indicated a start of care on 5/30/2024, with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a review of Patient 5’s record titled, “OASIS E-Start of Care,” dated 5/30/2024, the OASIS E-Start of Care indicated the assessment was done for the reason of start of care. During a review of Patient 5’s “Task Details Patient 5 OASIS E-Start of Care”, printed 8/22/2204 the EMR, the Task Details Patient 5 OASIS E-Start of Care, indicated “S.LVN” created the document on 5/24/2024. The Task Details Patient 5 OASIS E-Start of Care indicated “S.LVN” reopened and updated the document on 7/30/2024 and on 8/22/2024. During a concurrent interview and record review on 8/22/2024, at 3:42 p.m., OW 1 reviewed Patient 5’s EMR and stated the patient did not have a POC (the Home Health Certification and Plan of Care, also known as CMS 485) and did not have a discharge summary in his records. On 8/23/2024, at 12:15 p.m., the ADM provided a paper chart for Patient 5. The paper chart included Patient 5’s printed EMR record titled, “Home Health Certification and Plan of Care,” dated 5/30/2024 to 7/28/2024. The Home Health Certification and Plan of Care indicated a digital signature by the DPCS, with a date of 5/30/2024. The Home Health Certification and Plan of Care indicated a manual doctor’s signature with a manual date of 6/3/2024. During a review of Patient 5’s record titled, “Task Details Patient 5 CMS 485,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 CMS 485 indicated “S.LVN” created the document on 8/22/2024 at 8:43 p.m. and the DPCS completed the record on 8/22/2024, at 9:15 p.m. During a review of Patient 5’s paper chart provided by ADM on 8/23/2024, at 12:15 p.m., the chart included Patient 5’s printed EMR record titled, “Discharge Summary,” dated 7/25/2024. The Discharge Summary indicated the patient was discharged from the agency because the goals were met. The Discharge Summary was signed by the DPCS with a date of 7/25/2024. During a review of Patient 5’s record titled, “Notice of Medicare Non-Coverage”, dated 7/25/2024, the Notice of Medicare Non-Coverage indicated, “The effective Date Coverage of Your Current Skilled Nursing Services, Services will End: 7/25/2024.” During a review of Patient 5’s record titled, “OASIS-E Discharge,” dated 7/25/2024, the OASIS-E Discharge indicated assessment done for reason of discharged of agency. During a review of Patient 5’s record titled, “Task Details Patient 5 OASIS-E Discharge,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 OASIS-E Discharge indicated “S.LVN” created the document on 7/29/2024. The Task Details Patient 5 OASIS-E Discharge indicated “S.LVN” completed the document on 7/30/2024 and reopened to update the document on 8/22/2024. During a review of Patient 5’s record titled, “Task Details Patient 5 Discharge Summary,” printed on 8/23/2024 from the EMR, the Task Details Patient 5 Discharge Summary indicated “S.LVN” created the document on 8/22/2024 at 8:41 p.m. The Task Details Patient 5 Discharge Summary indicated DPCS completed the document on 8/22/2024 at 9:17 p.m. f. During a review of Patient 6’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (also known as CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (also knowns as CMS 485), dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 6’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024, at 3:36 p.m., of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 6’s medical record form titled “OASIS-E Start of Care,” dated 6/14/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated there was no listed phone number for the patient. The OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 6/14/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the person who completed the form. During a review of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated user “(DD)” updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” completed and signed the form on 8/22/2024. The Task Details indicated LVN 2 updated task on 8/22/2024. During a review on 8/23/2024 at 1:46 p.m. of Patient 6’s electronic medical record (EMR) form titled “Episode Manager – Order” dated 6/14/2024 to 7/26/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 6/14/2024 and 7/26/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 6/14/2024, the Physician Order indicated Patient 6 was being admitted for HHA services. The form indicated it was digitally signed by the DPCS on 6/14/2024. During a review 8/23/2024 at 1:47 p.m. of Patient 6’s EMR form titled “Task Details” dated 6/14/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The form indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 6’s medical record form title “Physician Order” dated 7/26/2024, the Physician Order indicated Patient 6 reached his goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/26/2024. During a review on 8/23/2024, at 1:48 p.m. of Patient 6’s EMR, medical record form titled “Task Details” dated 7/26/2024, The Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to quality assurance manager on 8/22/2024. The Task Details indicate user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 6’s record titled “OASIS-E Discharge” dated 7/26/2024, provided by OW 1 on 8/22/2024, the OASIS-E Discharge indicated an RN was the discipline who completed the assessment on 7/26/2024. The form does not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 6’s medical record form titled “Task Details” dated 7/26/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated user “S.LVN” created the form on 8/20/2024 and revised the form on 8/21/2024 and 8/22/2024. The Task Details indicated user “(DPCS)” signed, submitted, and completed the form on 8/21/2024. During a review of Patient 6’s medical record form titled “Task Details” dated 7/26/2024, The Task Details indicated user indicated “Task – Discharge Summary.” The Task Details indicated user “S.LVN” created, submitted, and sent form to quality assurance manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. g. During a review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The form indicated Medical Doctor 1 (MD1) was listed as Patient 7’s primary physician. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care”, dated 5/22/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 5/22/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 7’s medical record form titled “OASIS-E Start of Care”, dated 5/22/2024 provided by the ADM on 8/23/2024, the OASIS-E Start of Care indicated the form was signed by the DPCS on 5/22/2024. During a review of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. User “(DPCS)” reopened, updated, completed, and signed the form on 8/22/2024. During a concurrent observation, interview, and review of Patient 7’s EMR on 8/22/2024 at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 7’s medical record form titled Home Health Certification and Plan of Care (also known as CMS 485 form). OW 1 proceeded to log into Patient 7’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated from 5/22/2024 to 7/20/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485), dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services (DPCS) as Patient 7’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:34 p.m. of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated user “S. LVN,” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 7’s physical paper chart medical record form titled “Home Health Certification and Plan of Care,” dated 5/22/2024 to 7/20/2024, provided by the ADM on 8/23/2024 at 12:18 p.m., the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS and Medical Doctor 1 (MD 1) on 5/22/2024. On 8/23/2024, at 12:28 p.m., a call was made to Patient 7 and a female (unidentified) picked up the call and then hung the phone up after the surveyor introduced herself. During a review on 8/23/2024 at 1:50 p.m. of Patient 7’s EMR, medical record form titled “Episode Manager – Order” dated 5/22/2024 to 7/18/2024, the Episode Manager – Order indicated there were four tasks listed. The 1st “F2F Encounter. 2nd “CMS 485”. 3rd and 4th task were physician orders dated 5/22/2024 and 7/18/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 5/22/2024, the Physician Order indicated “HCFA 485” (former name of the form CMS 485). The Physician Order indicated it was digitally signed by the DPCS on 5/22/2024. During a review 8/23/2024 at 1:51 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 7’s medical record form titled, “Physician Order” dated 7/18/2024, the Physician Order indicated Patient 7 reached her goals and was being discharged from HHA’s services. The Physician Order indicated it was digitally signed by the DPCS on 7/18/2024. During a review of Patient 7’s medical record form provided on 8/23/2024 by ADM titled, “Physician Order” dated 7/18/2024, the Physician Order indicated user “(DPCS)” completed the form on 8/22/2024. The Physician Order indicated it was signed by MD 1 on 7/24/2024. During a review on 8/23/2024 at 1:52 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 7/18/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 7’s medical record form provided on 8/23/2024 by the ADM titled “Discharge Summary” dated 7/18/2024, the Discharge Summary indicated Patient 7 was discharge from the HHA on 7/17/2024. The Discharge Summary indicated it was digitally signed by the DPCS on 7/18/2024. During a review on 8/23/2024 at 12:44 p.m. of Patient 7’s EMR, medical record form titled “Task Details” dated 7/18/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. h. During a review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. During a review of Patient 8’s medical record form titled “OASIS-E Start of Care”, dated 3/5/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 3/5/2024. The OASIS-E Start of Care does not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated LVN 1 updated the task details on 8/22/2024. The Task Details indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:37 p.m. of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. On 8/23/2024, at 12:12 p.m., a call was made to Patient 8 and Patient 8 did not answer the call. Left a message return the call. During a review of Patient 8’s medical record form titled “Physician Order” dated 4/23/2024, the Physician Order indicated Patient 8 was transferred to a hospital due to shortness of breath. The Physician Order indicated it was digitally signed by the DPCS on 4/23/2024. During a review on 8/23/2024, at 1:53 p.m., of Patient 8’s EMR, medical record form titled “Task Details,” dated 4/23/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated LVN 1 updated the task details on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review on 8/23/2024, at 12:45 p.m. of Patient 8’s EMR, medical record form titled “Task Details” dated 4/23/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. i. During a record review of Patient 9’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024 with a primary diagnosis of myalgia (muscle pain). During a record review on 8/22/2024 at 3:38 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, the Episode Manager – Orders indicated there were no entries made under task. During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024, provided by OW 1 on 8/22/2024, the OASIS-E Start of Care indicated a Registered Nurse (RN) was the discipline who completed the assessment on 6/15/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 9’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024 provided by the ADM on 8/23/2024, the OASIS-E Start of Care indicated the form was signed by the DPCS on 6/15/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” (also known as CMS 485) dated 6/15/2024 to 8/13/2024, provided by the OW 1 on 8/23/2024 at 12 p.m. the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, and primary language”. The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 9’s clinical manager and MD 1 as her primary physician. The Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS on 6/15/2024. The form indicated it was not signed by MD 1. During a review of Patient 9’s medical record form titled “Home Health Certification and Plan of Care” dated 6/15/2024 to 8/13/2024, provided by the ADM on 8/23/2024 at 12:18 p.m., the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS on 6/15/2024. The Home Health Certification and Plan of Care indicated it was signed by MD 1 on 6/21/2024. During a review on 8/23/2024 at 1:57 p.m. of Patient 9’s EMR, medical record form titled “Episode Manager – Orders” dated from 6/15/2024 to 8/3/2024, the Episode Manager – Orders indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician orders dated 6/15/2024 and 8/3/2024. During a review of Patient 9’s medical record form title “Physician Order” dated 6/15/2024 received on 8/23/2024 from the ADM, the Physician Order indicated Patient 9 was being admitted for HHA services. The form indicated MD 1 was noted as the physician. The Physician Order indicated it was digitally signed by the DPCS on 6/15/2023. The Physician Order indicated it was signed by MD 1 on 6/21/2024. During a review 8/23/2024, at 1:58 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 6/15/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “Physician Order” dated 8/3/2024, the Physician Order indicated Patient 9 was being discharged from HHA services. The Physician Order indicated MD 1 was noted as the physician. The Physician Order indicated it was digitally signed by the DPCS on 8/3/2024. The Physician Order indicated it was signed by MD 1 on 8/12/2024. During a review on 8/23/2024 at 1:59 p.m. of Patient 9’s EMR, medical record form titled “Task Details” dated 8/3/2024, indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 9’s medical record form titled “OASIS-E Discharge” dated 8/3/2024, the OASIS-E Discharge indicated it was signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated user “S.LVN” reopened and updated the task details on 8/22/2024. The Task Details indicated user “(DPCS)” updated, completed, and signed the form on 8/22/2024. During a review of Patient 9’s medical record form provided on 8/23/2024 by the ADM titled “Discharge Summary” dated 8/3/2024, the Discharge Summary indicated Patient 9 was discharge from the HHA on 8/3/2024. The Discharge Summary form indicated it was digitally signed by the DPCS on 8/3/2024. During a review of Patient 9’s medical record form titled “Task Details” dated 8/3/2024, the Task Details indicated “Task – Discharge Summary”. The Task – Discharge Summary indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task – Discharge Summary indicated user “(DPCS)” completed the form on 8/22/2024. j. During a review of Patient 10’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. During a review of Patient 10’s medical record form titled “OASIS-E Start of Care”, dated 6/15/2024, the OASIS-E Start of Care indicated an RN was the discipline who completed the assessment on 6/15/2024. The OASIS-E Start of Care did not indicate who the author of the assessment was, and it did not have a signature of the author. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – OASIS-E Start of Care”. The Task Details indicated user “S.LVN” exported, reopened, and updated the task details on 8/22/2024. The Task Details indicated LNV 1 updated the task details on 8/22/2024. The Task Details indicated, user “(DPCS)” completed, and signed the form on 8/22/2024. The form indicated LVN 2 updated task on 8/22/2024. During a concurrent observation, interview, and review of Patient 10’s EMR on 8/22/2024, at 3:12 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 10’s medical record form titled Home Health Certification and Plan of Care (also known as CMS 485 form). OW 1 proceeded to log into Patient 10’s electronic medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not in the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 10’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/15/2024 to 8/13/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 10’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, primary language, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care listed the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review on 8/22/2024 at 3:38 p.m. of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review on 8/23/2024 at 2 p.m., of Patient 10’s EMR, medical record form titled “Episode Manager - Orders” indicated there were three entries made. The 1st “CMS 485”, the 2nd and 3rd were physician orders dated 6/15/2024 and 8/6/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 6/15/2024, the Physician Order indicated “HCFA 485” (former name of the form CMS 485) and MD 1 was the physician. The Physician Order indicated it was digitally signed by the DPCS on 6/15/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “Physician Order” dated 8/6/2024, the Physician Order indicated Patient 10 was being discharged from receiving HHA services and indicated MD 1 was the physician. The Physician Order indicated it was digitally signed by the DPCS on 8/6/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – Physician Order”. The Task Details indicated user “S.LVN” created, submitted, and sent form to case manager on 8/22/2024. The Task Details indicates user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “OASIS-E Discharge” dated 8/6/2024, the OASIS-E Discharge indicated an RN was the discipline that completed Patient 10’s discharge assessment on 8/6/2024. The OASIS-E Discharge did not indicate who the author was, and it was not signed. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – OASIS-E Discharge”. The Task Details indicated “S.LVN” created, submitted, and sent form to the case manager on 8/22/2024. The Task Details indicated user “(DPCS)” completed the form on 8/22/2024. During a review of Patient 10’s medical record form titled “Task Details” dated 8/6/2024, the Task Details indicated “Task – Discharge Summary”. The Task Details indicated user “(DPCS)” completed and signed the form on 8/22/2024. On 8/23/2024 at 5 p.m., the HHA did not provide Patient 10’s physical paper chart for review. The HHA did not provide the physical paper chart of Patient 10 since the start of the survey on 8/21/2024. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey were OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures. <span class="EOP SCXW46083820 BCX8" data-ccp-props="{"201341983":0,"3355

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 observation, interview, and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure a licensed nurse (in general) authenticated the notes in the clinical records for five of ten sampled patients (Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10) by failing to: 1. Ensure Office Worker 1 (OW 1), who was not a licensed nurse, did not create a plan of care for Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10 on 8/22/2024. 2. Ensure OW 1 did not use Licensed Vocational Nurse 1’s (LVN 1’s) nursing credentials to create Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s Home Health Certification and Plan of Care (the CMS 485 form) on 8/22/2024. These failures resulted in unauthorized patient information entries that did not reflect Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s current medical condition and needs, which is likely to result in inappropriate treatment, delayed or incorrect diagnoses, and medical errors that can lead to serious injury, harm, impairment, or death. On 8/22/2024, at 5:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Administrator (ADM) related to the HHA failure to ensure a licensed nurse (in general) authenticated the notes in the clinical records for Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10. The non-compliance resulted in unauthorized patient information entries that did not reflect Patient 1’s, Patient 6’s, Patient 7’s, Patient 8’s, and Patient 10’s current medical condition and needs, which is likely to result in inappropriate treatment, delayed or incorrect diagnoses, and fatal medical errors that can lead to serious injury, harm, impairment, or death. On 8/23/2024 at 5:25 pm, the Administrator Designee (AD) told the survey team the agency would be closed (for business) and would no longer be opened. HHA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The survey team was not able to complete the survey tasks and could not exit (end) the survey. Findings: During an interview on 8/22/2024, at 3:16 p.m., with OW 1, OW 1 stated she was not a licensed nurse. During an observation on 8/22/2024, at 3:16 p.m., OW 1 was sitting on a desk with a computer. The computer was on and OW 1 was using it. The electronic medical record (EMR) program was on the screen (computer monitor). The sampled patient list for the survey, which included Patient 1, Patient 6, Patient 7, Patient 8, and Patient 10, was on the screen. On the right upper hand corner of the EMR, the user identification (ID) showed “S.LVN.” a. During a review of Patient 1’s record titled, “Patient Information,” the “Patient Information,” indicated a start of care on 6/14/2024, with a primary diagnosis of type 2 diabetes mellitus (a medical condition characterized by the body's inability to regulate blood sugar levels) with hyperglycemia (high blood sugar). During an observation, on 8/22/2024, at 3:18 p.m., OW 1 was in front of the computer and a plan of care (POC) print out for Patient 1 was requested. OW 1 selected the “Orders” tab on Patient 1’s EMR, and the screen was blank. The OW 1 made many clicks, very quickly, refreshed the screen and a “CMS 485” (the Home Health Certification and Plan of Care [POC] form) appeared on the screen. During a concurrent interview and record review on 8/22/2024, at 3:19 p.m., OW 1 reviewed Patient 1’s record titled, “Task Details” Patient 1, “CMS 485”. The document indicated “S.LVN” had created the document on 8/22/2024 at 3:18 p.m. The OW 1 stated, “I just created it right now. Everything, I put in.” The OW 1 stated she created the document because she did not know where the CMS 485 (the Home Health Certification and Plan of Care [POC]) was and the surveyor asked for it. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a concurrent observation and interview on 8/22/2024, at 3:20 p.m., with the ADM, the ADM stood next to OW 1 and stated the user ID “S.LVN” belonged to LVN 1. The ADM stated LVN 1 had not been and was not in the office on 8/22/2024. During an interview on 8/22/2024, at 3:40 p.m., with the ADM, the ADM stated OW 1 was not a Registered Nurse (RN) or a Licensed Vocational Nurse (LVN). The ADM stated OW 1 could create patients’ plan of care but not able to go over it or sign it. The ADM stated she did not have an RN or an LVN available for interview “today.” On 8/22/2024, at 5:01 p.m., a call was made to LVN 1 based on the employee list of phone numbers provided by the HHA. There was no answer to the call. A message was left to return the call of the survey team. During a review of Patient 1’s record titled, “Home Health Certification and Plan of Care,” (the CMS 485) for certification period 6/14/2024 to 8/12/2024, the “Home Health Certification and Plan of Care,” did not have a signature under section “Nurse Signature and Date of Verbal SOC Where Applicable.” There was no date indicated under section “Date.” b. During a review of Patient 6’s medical record form titled, “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/14/2024 with a primary diagnosis of type 2 diabetes mellitus with hyperglycemia. During a concurrent observation, interview, and review of Patient 6’s EMR on 8/22/2024, at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 6’s Home Health Certification and Plan of Care form (the CMS 485). OW 1 logged into the EMR system and clicked on a pre saved log in information for HHA. OW 1 proceeded to log into Patient 6’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485 (the Home Health Certification and Plan of Care) was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 6’s CMS 485 (Home Health Certification and Plan of Care) dated from 6/14/2024 to 8/12/2024. OW 1 stated Patient 6’s plan of care was not created by the admitting nurse (unidentified). OW 1 stated she auto populated Patient 6’s assessment information from the admitting nurse’s admission assessment to be able to create Patient 6’s plan of care. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review of Patient 6’s medical record form titled “Task Details” dated 6/14/2024, on 8/22/2024 at 3:36 p.m. the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 6’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 6/14/2024 to 8/12/2024, the Home Health Certification and Plan of Care indicated the following sections were blank: “phone number, email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form listed the Director of Patient Care Services Designee (DD) as Patient 6’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. c. During a record review of Patient 7’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 5/22/2024. The Patient Information indicated there was no documentation under sections primary and secondary diagnosis. The Patient Information indicated Medical Doctor 1 (MD 1) was listed as Patient 7’s primary physician. During a concurrent observation, interview, and review of Patient 7’s EMR on 8/22/2024 at 3:10 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 7’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 7’s medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated from 5/22/2024 to 7/20/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review on 8/22/2024 at 3:34 p.m. of Patient 7’s medical record form titled “Task Details” dated 5/22/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a review of Patient 7’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form listed the Director of Patient Care Services (DPCS) as Patient 7’s clinical manager. The form did not indicate who the author was, and it did not have a nurse or physician’s signature. During a review of Patient 7’s physical paper chart medical record form titled “Home Health Certification and Plan of Care” (the CMS 485) dated 5/22/2024 to 7/20/2024, which was provided on 8/23/2024 at 12:18 p.m., by the Administrator (ADM), the Home Health Certification and Plan of Care indicated it was digitally signed by the DPCS and MD 1 on 5/22/2024. d. During a record review of Patient 8’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 3/5/2024. There was nothing documented under sections primary and secondary diagnosis. During a concurrent observation, interview, and review of Patient 8’s EMR on 8/22/2024 at 3:11 p.m. with OW 1, OW1 was asked to provide a copy of Patient 8’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 8’s medical record and click on the tab titled “Orders.” After OW1 clicked on the tab “Orders,” it was noted that “CMS 485” was not on the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated from 3/5/2024 to 5/3/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a review on 8/22/2024, at 3:37 p.m., of Patient 8’s medical record form titled “Task Details” dated 3/5/2024, the Task Details indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a record review of Patient 8’s medical record form titled “Home Health Certification and Plan of Care” (the CMS 485 form) dated 3/5/2024 to 5/3/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, medications, allergies, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The Home Health Certification and Plan of Care form listed the Director of Patient Care Services Designee (DD) as Patient 8’s clinical manager. The Home Health Certification and Plan of Care form did not indicate who the author was, and it did not have a nurse or physician’s signature. e. During a review of Patient 10’s medical record form titled “Patient Information,” the Patient Information indicated a start of care date (SOC) of 6/15/2024. There was nothing documented under sections primary and secondary diagnosis. During a concurrent observation, interview, and review of Patient 10’s EMR on 8/22/2024, at 3:12 p.m. with OW 1, OW 1 was asked to provide a copy of Patient 10’s medical record form titled Home Health Certification and Plan of Care (the CMS 485 form). OW 1 proceeded to log into Patient 10’s electronic medical record and click on the tab titled “Orders.” After OW 1 clicked on the tab “Orders,” it was noted that “CMS 485” was not in the list of orders. OW 1 rapidly clicked on the keyboard a couple of times which allowed her to list “CMS 485” under the “Orders” tab. OW 1 proceeded to print Patient 10’s medical record form titled “Home Health Certification and Plan of Care” dated from 6/15/2024 to 8/13/2024. During an interview on 8/22/2024, at 3:20 p.m., OW 1 stated, “Yes,” she was logged in as LVN 1. The OW 1 stated, “Just now I called her. She said it was okay to use her username and password.” The OW 1 stated, “You needed the 485, so I put in the basic 485.” During a record review on 8/22/2024 at 3:38 p.m. of Patient 10’s medical record form titled “Task Details” dated 6/15/2024, indicated user “S. LVN” created, sent to quality manager, and submitted the task “CMS 485” on 8/22/2024. During a record review of Patient 10’s medical record form titled, “Home Health Certification and Plan of Care” (the CMS 485 form) dated 6/15/2024 to 8/13/2024, the Home Health Certification and Plan of Care indicated the following sections were left blank: “email, primary language, nurse signature and date of verbal SOC where applicable, and attending physician’s signature and date signed.” The form listed the Director of Patient Care Services Designee (DD) as Patient 10’s clinical manager. The Home Health Certification and Plan of Care did not indicate who the author was, and it did not have a nurse or physician’s signature. During a concurrent observation and interview on 8/23/2024, at 2:50 p.m., the HHA staff present during the survey was OW 1, OW 2, and the consultant (CT). The survey team asked for policies and procedures. The CT stated she would find someone to help the survey team. On 8/23/2024, at 2:55 p.m., a second call was made to LVN 1 based on the phone number in the HHA employee list. There was no answer to the call. A message was left to return the call of the survey team. During an interview on 8/23/2024, at 4:45 p.m., the CT stated cabinets at the HHA were empty and she did not know where the HHA kept their policies and procedures.