Every finding on record at Beneficial Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during the concurrent Emergency Preparedness and Partial Extended Recertification surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN; and 39210, HFEN. The survey team entered the Home Health Agency on 10/24/23 at 0900 hours. Glossary of Abbreviations: HHA: Home Health Agency P&P: Policy and Procedure

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the HHA failed to ensure the emergency preparedness P&P included the procedures to inform State and local emergency preparedness officials about homebound hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's psychiatric condition. This posed the potential risk for not providing the necessary care and services to the patients during the emergency disaster events. Findings: Review of the agency's emergency preparedness P&P was conducted on 10/27/23, and showed the P&P did not include the procedures to inform State and local emergency preparedness officials about the homebound patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's psychiatric condition. On 10/31/23 at 1435 hours, the Administrator was informed of the findings. The Administrator reviewed the P&P and acknowledged the findings.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the initial training in the emergency preparedness program for all new and existing staff, individuals providing services under arrangement and volunteers consistent with their expected role, maintain documentation of all emergency preparedness training, demonstrate staff knowledge of emergency procedures and if the emergency policies and procedures are significantly updated, the home health must conduct training on the updated procedures. This failure created the risk of the HHA's staff not knowing what to do in case of emergency. Findings: Review of the agency's emergency preparedness P&P was conducted on 10/27/23. The agency's emergency preparedness P&P included the initial training in the emergency preparedness program for all new and existing staff, individuals providing services under arrangement and volunteers consistent with their expected role, maintain documentation of all emergency preparedness training, demonstrate staff knowledge of emergency procedures and if the emergency policies and procedures are significantly updated, the home health must conduct training on the updated procedures. However, review of the agency emergency preparedness binder failed to show documented evidenced of the training and testing was provided to all the new and existing staff, individuals providing services under arrangement and volunteers consistent with their expected role. On 10/31/23 at 1525 hours, the Administrator was informed of the findings. The Administrator reviewed the P&P and emergency binder and acknowledged the findings.

The following reflects the findings of the California Department of Public Health during the concurrent Partial Extended Recertification and Emergency Preparedness surveys. Representing the California Department of Public Health: Surveyors 39796, HFEN and 39210, HFEN. The survey team entered the HHA on 10/24/23 at 0900 hours. The survey team conducted 3 home visits and reviewed 4 active and 2 closed clinical records. Glossary of Abbreviations and Brief Definitions: ADL: activity of daily living BID: Twice a Day BIMS: Brief Interview for Mental Status BP: Blood Pressure BS: Blood Sugar CHHA: Certified Home Health Aide cm: centimeter(s) dl: deciliter(s) DME: Durable Medical Equipment DPCS: Director of Patient Care Safety FBS: Fasting Blood Sugar HHA: home health agency HTN: hypertension (high blood pressure) Hyperglycemic: high blood sugar level Hypoglycemic: low blood sugar level LVN: Licensed Vocational Nurse mg: milligram(s) mmHg: milliliter(s) of mercury P&P: Policy and Procedure PCG: Primary Caregiver PO: By mouth POC: Plan of Care PRN: As Needed PT: Physical Therapy/Therapist Q: Every QD: Daily SBP: Systolic Blood Pressure (top number of the blood pressure reading) SN: Skilled Nursing/Nurse SOC: Start of Care Stage 2 pressure injury: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising Stage 3 pressure injury: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough may be visible. Unstageable Pressure injury: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar UTD: unable to determine W: week

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the RN conducted the initial assessment visit within 48 hours of the referral for one of nine sampled patients (Patient 1), creating the risk of not identifying and addressing the care needs in a timely manner for this patient. Findings: Review of the agency's P&P titled Initial and Comprehensive Assessment revised 5/23 showed the initial assessment visit must be performed wither within 48 hours of the referral, within 48 hours of the patient's return home, on the start of care date ordered by the physician or at the patient/family's request for approval of the physician. Review of Patient 1's clinical record was initiated on 1/14/23. The clinical record showed the referral date was 8/23/23, and the SOC was 8/30/23. The patient was certified for home health services during the certification period from 8/30/23 to 10/28/23. Further review of the clinical record showed the initial assessment visit was conducted by the RN on 8/30/23, seven days after the referral date. There was no documented evidence explaining why the initial assessment visit was not conducted within 48 hours of the referral date. On 10/31/23 at 1217 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 verified the above findings.

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 HHA failed to ensure the initial comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for eight of nine sampled patients (Patients 1, 3, 4, 5, 6, 7, 8, and 9). These failures created the risk of not identifying and addressing the care needs timely for these patients. X. Review of Patient 9's closed clinical record was initiated on 10/24/23. The clinical record showed the SOC was 1/14/23. The patient was certified for home health services from 1/14/23 to 3/14/23 and 3/15/23 to 5/13/23. Review of the SOC OASIS dated 1/16/23, showed no documented evidence the patient's hand grips, oxygen saturation, or blood glucose was completed. Review of the ROC OASIS dated 1/30/23, showed no documentation of oxygen saturation, blood glucose, hand grips, sleep rest, appetite, and capillary refill. Further review of the clinical records showed checked goals for compliance with medications, stabilization of cardiovascular pulmonary condition, and competence in the medical regime. However, further review of the clinical record failed to include dates the identified goals will be achieved by. On 10/31/23 at 1330 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. X. Review of Patient 1's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 8/30/23. The patient was certified for home health services from 8/30/23 to 10/28/23. Review of the SOC OASIS dated 9/8/23, showed no documented evidence the patient's hand grips, number of hours of sleep, ability of family to care for patient, and emergency preparedness was completed. In addition, further review of the clinical record failed to include dates the identified goals will be achieved by. On 10/31/23 at 1217 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. X. Review of Patient 4's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. Review of the SOC OASIS dated 7/27/23, showed no documented evidence the patient's hours of sleep, emergency preparedness, and dates of identified goals will be achieved by was completed. On 10/31/23 at 1247 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. X. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. Review of the SOC OASIS dated 7/27/23, showed no documented evidence the patient's hand grips, sleep/ rest and hours of sleep, date the Foley catheter was last changed, diet, blood glucose ranges, frequency of monitoring and competency on use of the glucometer, and dates of identified goals will be achieved by was completed. On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. 1. Revie of the agency P&P titled Initial and Comprehensive Assessment revised 5/2023, showed the comprehensive patient assessment will be completed within five calendar days of the patients start of care. The assessment will be patient-specific and comprehensive to include the patients need for home health care, rehabilitative care, social services and discharge planning. The assessment will also include the exact use of the current versions of the Outcome and Assessment Information Set (OASIS). This assessment will measure patient outcomes from data collected at the start of care and the following defined intervals thereafter. For recertification within the last five days of every 60 day episode, beginning with the start of care. During the comprehensive assessment the clinician will assign the patient a risk categorization for the emergency preparedness plan. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. Review of the SOC OASIS dated 7/21/23, showed the Musculoskeletal was assessed. The SN assessed patient to have weakness on upper and lower extremities and decrease range of motion. However, the hand grips were left blank. Further review of the SOC OASIS dated 7/21/23, showed the Emergency Preparedness Care Planning was assessed. However, the emergency priority code assigned to the patient was left blank. In addition, there was a check mark documented for a written materials to restate/reinforce the emergency preparedness procedures. However, the section where the emergency preparedness materials were given to was left blank. On 10/31/23 at 1205 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 9/8/23. The patient was certified for home health services during the certification period from 9/8/23 to 11/6/23. Review of the SOC OASIS dated 9/8/23, showed the Section for Emergency Preparedness priority code was left blank. In addition, the section for the Emergency Contact Information was left blank. Moreover, the section for Emergency Preparedness Care Planning was assessed. However, the emergency priority code assigned to the patient was left blank. On 10/31/23 at 1320 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 9/15/23. The patient was certified for home health services during the certification period from 9/15/23 to 11/3/23. Review of the SOC OASIS dated 9/15/23, showed the Section for Emergency Preparedness priority code was left blank. Further review of the SOC OASIS dated 9/15/23, showed the Emergency Preparedness Care Planning was assessed. However, the emergency priority code assigned to the patient was left blank. In addition, there was a check mark documented for a written materials to restate/reinforce the emergency preparedness procedures. However, the section where the emergency preparedness materials were given to was left blank. On 10/31/23 at 1442 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 4. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. Review of the SOC OASIS dated 9/15/23, showed the following section was left blank: - Emergency Contact Information, - Immunizations, - Endocrine/Hematology, showed patient had a type 2 Diabetes, on oral medications. However on the section as to "on medication since " was left blank. - The section for the time, date and type of testing for the blood sugar level, - The assessment for pedal pulses, loss of sense of and neuropathy, -The section for actual or reported height and weight, -The Musculoskeletal assessment for hand grips and -The Emergency Preparedness Care Planning.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the medication profiles were updated to reflect the current medications, include all the medication side effects, actual or potential drug interactions, and duplicate drug therapy for six of nine sampled patients (Patients 2, 3, 5, 6, 7, and 8). These failures created the risk for the patients not receiving the appropriate care and services necessary to improve the patients' health conditions. 1a. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. On 10/25/23 at 0951 hours, a joint home visit was conducted with LVN 2 to Patient 6’s home. Review of patient’s medications with LVN 2 showed the patient was taking Hydrocodone- Acetaminophen 7.5-325 mg 1/2 tablet, PO Q12hours PRN; Ferrous Sulfate 325mg 1 tab PO, daily; and clonidine 0.1mg (a medication used to treat high blood pressure) PO for SBP greater than 185. Further review of the medications showed the patient was no longer taking Tamsulosin 0.4mg PO QD; Modafinil 100mg PO QD; Multivitamin 1 tablet PO QD; Ocular lubricant to both eyes for dry eyes; Petrolatum Zinc Oxide TOP BID; Saccharomyces boulardii 1 table BID; Sodium Chloride PO BID; Tramadol 50mg PO PRN Pain; Valacyclovir 500mg PO Q8hours; The patient was also taking amlodipine 10mg PO Daily instead of 2.5mg; and Docusate Senna in the morning and night instead of 2 tablets PO at bedtime; as written in the medication profile. In addition, review of the medication profile in Patient 6's home failed to show an updated medication list with the new medications. Further review of the Medication Profiles for both certification periods showed the medications were appraised for possible adverse effects and reactions, including cogent drug interactions, ineffectual drug therapy, redundant drug therapy, serious side effects, and non-compliance with drug therapy. However, there was no documented evidence showing which adverse effects, drug interactions, and side effects were identified. On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledge the finding. Review of the agency’s P&P titled Medication Profile revised 5/2023, showed patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after a patient has been placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy omissions and unclear information. 1. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. On 10/26/23 at 1000 hours, a joint home visit was conducted with CHHA to Patient 7’s home. Review of the patient’s medications with CHHA showed the patient was on hydrocortisone 5 mg 3 tablets PO in the morning and two tablets in the evening instead of hydrocortisone 5 mg 1 tablet PO in the morning and two tablets in the evening as written in the medication profile. On 10/26/23 at 1145 hours, the CHHA verified and acknowledged the findings. Further review of the Medication Profile for certification period 9/19/23 to 11/17/23 showed the medication listed have been reviewed for the potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. However, review of the Medication Profile failed to include the medications potential adverse effects , drug reactions including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. On 10/31/23 at 1134 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 9/8/23. The patient was certified for home health services during the certification periods from 9/8/23 to 11/6/23. On 10/25/23 at 1100 hours, a joint home visit was conducted with DPCS to Patient 5’s home. Review of the patient’s medications with the DPCS showed the patient was on the following medications: -Norco 5/325 mg one tablet PO every 6 hours PRN, -Tylenol 325 mg one tablet in morning and one tablet in afternoon and -cetirizine 10 mg one tablet PO daily. However, the patient stated that she was not taking the medications that was listed on the medication profile as it was stopped. On 10/25/23 at 1134 hours, the DPCS was asked if the medication profile is updated. The DPCS replied, no it was not. The DPCS was informed and acknowledged the findings. In addition review of the Medication Profile for the certification period 9/8/23 to 11/6/23, showed the medication listed have been reviewed for the potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. However, review of the Medication Profile failed to include the potential adverse effects, drug reactions including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. On 10/31/23 at 1320 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 3's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 9/15/23. The patient was certified for home health services during the certification periods from 9/15/23 to 11/3/23. Review of the Medication Profile for the certification periods from 9/15/23 to 11/3/23, showed the medication listed have been reviewed for the potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. However, review of the Medication Profile failed to include the medications potential adverse effects including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. On 10/31/23 at 1442 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 4. Review of Patient 2's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/13/23 and 9/20/23 to 11/18/23. Review of the Medication Profile for the certification periods from 9/15/23 to 11/18/23 and 9/20/23 to 11/18/23 , showed the medication listed have been reviewed for the potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. However, review of the Medication Profile failed to include the medications potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. On 10/31/23 at 1302 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 5. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. Review of the Medication Profile for the certification periods from 11/25/22 to 1/23/23, showed the medication listed have been reviewed for the potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. However, review of the Medication Profile failed to include the medications potential adverse effects and drug reactions, including ineffective therapy, significant side effects and drug interactions, duplicate therapy and non-compliance with drug therapy. On 10/31/23 at 1419 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the updated comprehensive assessments were completed accurately and consistently with the patients’ immediate needs for six of nine sampled patients (Patients 2, 4, 6, 7, 8, and 9). These failures created the risk of not identifying and addressing the care needs timely for these patients. 1. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. Review of the Recertification OASIS dated 9/16/23, showed the psychosocial section was left blank. Further review of the Recertification OASIS dated 9/16/23, showed the fall risk assessment was performed. The total points score was 40. Implement fall precautions for a total score of 15 or greater. However, the section for the plan/comment was left blank. On 10/31/23 at 1134 hours an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if psychosocial and plan for fall should be assessed and documented. The DPCS Designee replied, it was missed and should have been documented. The plan for fall was missed and should have been written on the narrative notes. The DPCS Designee further stated the agencies electronic system for the Recertification OASIS was changed at the beginning of this year, only provides six categories and the body system assessment were incomplete. The DPCS Designee was informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. Review of the Recertification OASIS dated 9/15/23, showed the section for Emergency Preparedness, priority code was left blank. In addition the patient Emergency Contact Information was left blank. Moreover on the section of Fall Risk Assessment, showed the total points score was 50. Implement fall precautions for a total score of 15 or greater. However, the section for the plan/comment was left blank. On 10/31/23 at 1237 hours an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. Review of the Recertification OASIS dated 1/21/23, showed the following sections were left blank: - Emergency Preparedness, priority code, - Emergency Contact Information, -The Fall Risk assessment plan, -Musculoskeletal, hand grips and -Integumentary. On 10/31/23 at 1344 hours an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. Review of the agency's P&P titled Initial and Comprehensive Assessment, revised 5/23, showed a comprehensive patient assessment will be completed within five calendar days of the patient's start of care. The assessment will be patient specific and comprehensive to include the patient's need for home health care, rehabilitative care, social services, and discharge planning. The comprehensive assessment for each patient must be completed in its entirety by the same clinician. All baseline data to be used in measuring the patient's progress toward goal and other relevant information will be documented in the patient's clinical record, including at least the following, if applicable: a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, approximate height/ weight, nutritional status, and other relevant data pertinent physical findings; patient's functional status; medical and psychosocial history; psychosocial status; educational needs, an evaluation of the home environment and emergency preparedness; presence of any advance directives; wishes regarding end of life decisions; equipment in the home; symptoms of pain; medication history; patient and family caregiver and other available support systems; cultural and religious practices; involvement of family/ CG; laboratory results; medical, alcohol and other drug history; immunizations; specific individualized patient needs and problems pertinent to the care being provided; past medical and surgical care; and anticipated discharge needs. X. Review of Patient 9's closed clinical record was initiated on 10/24/23. The closed clinical record showed the SOC was 1/14/23. The patient was certified for home health services during the certification periods from 1/14/23 to 3/14/23 and 3/15/23 to 5/12/23. Review of the Recertification OASIS dated 3/14/23, failed to show documentation of a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, approximate height/ weight, nutritional status, and other relevant data pertinent physical findings; educational needs, an evaluation of the home environment and emergency preparedness; presence of any advance directives; wishes regarding end of life decisions; equipment in the home; symptoms of pain; medication history; patient and family caregiver and other available support systems; cultural and religious practices; involvement of family/ CG; laboratory results; medical, alcohol and other drug history; immunizations; specific individualized patient needs and problems pertinent to the care being provided; past medical and surgical care; and anticipated discharge needs as per P&P. On 10/31/23 at 1330 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. XX. Review of Patient 4's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. Review of the Recertification OASIS dated 10/6/23, failed to show documentation of a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, approximate height/ weight, nutritional status, and other relevant data pertinent physical findings; educational needs, an evaluation of the home environment and emergency preparedness; presence of any advance directives; wishes regarding end of life decisions; equipment in the home; symptoms of pain; medication history; patient and family caregiver and other available support systems; cultural and religious practices; involvement of family/ CG; laboratory results; medical, alcohol and other drug history; immunizations; specific individualized patient needs and problems pertinent to the care being provided; past medical and surgical care; and anticipated discharge needs as per P&P. On 10/31/23 at 1247 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. X. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. Review of the Recertification OASIS dated 10/6/23, failed to show documentation of a physical assessment, including blood pressure, temperature, pulse, respiration, skin, pain status, approximate height/ weight, nutritional status, and other relevant data pertinent physical findings; educational needs, an evaluation of the home environment and emergency preparedness; presence of any advance directives; wishes regarding end of life decisions; equipment in the home; symptoms of pain; medication history; patient and family caregiver and other available support systems; cultural and religious practices; involvement of family/ CG; laboratory results; medical, alcohol and other drug history; immunizations; specific individualized patient needs and problems pertinent to the care being provided; past medical and surgical care; and anticipated discharge needs as per P&P. On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the care and services were provided as ordered for six of nine sampled patients (Patients 2, 4, 6, 7, 8, and 9), creating the risk of not providing appropriate, consistent, and quality of care to these patients. X. Review of Patient 9's closed clinical record was initiated on 10/24/23. The clinical record showed the SOC was 1/14/23. The patient was certified for home health services during the certification periods from 1/14/23 to 3/13/23 and 3/14/23 to 5/13/23. The POC for the certification period from 1/14/23 to 3/13/23 and 3/14/23 to 5/13/23, cited SN visits 1W9. The POC includes SN to monitor overall body system will focus care on integumentary, endocrine, HTN, musculoskeletal, circulatory, mental, neuro, genitourinary, gastrointestinal systems competence level and comprehension level. In addition, the Sn to perform blood pressure and blood glucose monitoring weekly/ daily per SN visit. Review of the SN visit notes during certification periods showed there were multiple dates where the SN failed to document the patient's blood glucose level. For example, review of the SN note dated 1/19/23, showed the SN documented a check mark showing the patient had "normal findings". However, there was no evidence to show the patient's blood glucose level. On10/31/23 at 1330 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. XX. Review of Patient 4's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. The POC for the certification period from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23 cited SN visits 2w1, 1W8, then 1W9. The POC included the SN to observe/ assess pain level, control, and management. Review of the SN visit notes dated 9/29 to 10/18/23, failed to documentation of the patient's pain level. On 10/31/23 at 1247 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. X. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. the patient as certified for home health services during the certification periods from 7/26/26 to 9/23/23 and 9/24/23 to 11/22/23. The POC for the certification period from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23 cited SN visits 2w1, 1W8, then 1W9. The POC included the SN to observe/ assess overall body systems with focus on care including competence and comprehension level. Review of the SN visit notes dated 8/3 and 8/17, showed the SN had provided instruction to the patient and CG; however, further review of the clinical record failed to show the SN had assessed their competence and comprehension levels. On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. 1. The agency P&P titled Missed Visits revised 5/2023, showed missed visits will be communicated to the clinical supervisor and the patients physician. Document in the patients clinical record the physician notification including date, time, physician name, method of notification and the staff reporting the information. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. The POC for the certification period from 7/21/23 to 9/18/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. However, on Week 8 (from 9/3 to 9/9) and Week 9 (9/10 to 9/16) failed to show documented evidenced the SN visited the patient for as ordered in the POC. * The POC for the certification period from 7/21/23 to 9/18/23, cited CHHA visits 1W9 for personal care, assists with ADLs , meal preparation, assist in feeding and to make sure the clients take the right medication on schedule and monitor them for any concerning symptoms. However, on Weeks 2 (7/23/23 to 7/29/23) and Week 5 (8/13/23 to 8/19/23) failed to show documented evidenced the CHHA had visited the patient as ordered on the POC. * The POC for the certification period from 7/21/23 to 9/18/23, cited PT visits 1W1, 2W5 for evaluation and treatment. Review of the clinical record showed the PT visited the patient on Week 3 (7/30 to 8/8) on 8/1/23. However, the PT visited the patient once a week instead of two times a week as ordered. On 10/31/23 at 1205 hours, an interview with concurrent medical record review was conducted with the DPCS Designee. The DPCS Designee was asked if the physician was notified of the missed visits. The DPCS Designee replied, we notified the physician if there were three consecutive missed visits per policy. The DPCS Designee reviewed the P&P and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. * The POC for the certification period from 7/22/23 to 9/19/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. However, on Week 2 (7/23 to7/29/23), failed to show documented evidenced of the SN visit was provided as ordered. * The POC for the certification period from 9/20/23 to 11/18/23 cited SN visits 2W3,1W6. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. However, review of the clinical record failed to show the SN visited the patient on Week1 (9/20 to 9/23/23) as ordered by the physician. On 10/31/23 at 1302 hours, an interview with concurrent medical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the finding. 3. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. * The POC for certification periods from 11/25/22 to 1/23/23 cited SN visits 1W9 for SN observation, assessment, intervention and evaluation. Review of the clinical record showed SN missed visits on the following dates: -On Week 2 (11/17 to 12/3/23), -On Week 3 (12/4 to 12/10/23) and -On Week 8 (1/8 to 1/14/23) Review of the SN communication dated 12/9 and 11/28/22, showed the missed visit report. However, the missed visit report failed to show the physician was not notified of the missed visits. * The POC for certification periods from 11/25/22 to 1/23/23 cited SN visits 1W9 for SN observation, assessment, intervention and evaluation. Review of the clinical record showed an SN missed visits on the following dates: -On Week 4 (2/12 to 2/18/23), -On Week 5 (2/19 to 2/25/23) and -On Week 7 (3/5 to 3/11/23). Review of the SN communication dated 2/23, 2/16, 2/3, and 1/27/23 showed the missed visit report. However, the missed visit report failed to show the physician was not notified of the missed visits. * The POC for certification periods from 11/25/22 to 1/23/23 cited PT visits 1W1, 2W3 for observation, assessment, intervention and evaluation. Review of the clinical record showed the PT missed visits on the following dates: -On Week 2 (1/29 to 2/5/23), -On Week 4 (2/12 to 2/18/23. In addition, on Week 3 (2/5 to 2/11/23) showed the PT visits the patient on 2/10/23. However the PT visited the patient once a week instead of two times a week as ordered. On 10/31/23 at 1419 hours, an interview with concurrent medical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the finding.

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 HHA failed to ensure the POCs included pertinent information for three of the nine sampled patients (Patients 2, 3, and 8) creating the risk of not addressing the care needs of these patients. Findings: The agency's P&P titled Care Planning Process revised 5/2023, showed the definition of individualized plan of care. The specific clinical plan of care includes all pertinent information related to types of services/equipment and nutritional requirements. Based on the assessment and conclusions the plan of care will include, but not limited to patient specific interventions, nutritional requirements and equipment and supplies 1. Review of Patient 3's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 9/15/23. The patient was certified for home health services during the certification periods from 9/15/23 to 11/3/23. Review of the POC, for the certification periods from 9/15/23 to 11/3/23, showed the POC did not include the patient's DME, supplies, and nutritional requirements in the individualized plan of care. On 10/31/21 at 1442 hours, an interview and concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if the POC included an assessment for nutritional requirements and DME and supplies. The DPCS Designee replied it should have been filled out. The DPCS Designee was informed acknowledged the findings. 2. Review of Patient 2 's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. * The POC, for the certification period 7/22/23 to 9/19/23, cited SN visits 1W9 for observation, assessment, intervention, and evaluation. The POC also included blood sugar monitoring per SN visit. Review of the SN notes dated 8/3, 8/12, 8/18, 9/1, and 9/8/23, showed there was a check next to monitoring by self. However, review of the POC did not include the patient to perform the blood sugar monitoring. * The POC, for the certification period 9/20/23 to 11/18/23, cited SN visits 2W3 and 1W6 for observation, assessment, intervention, and evaluation. The POC also included blood sugar monitoring per SN visit. Review of the SN notes dated 10/5, 9/28/23 showed there was a check next to monitoring by self. However, review of the POC did not include the patient to perform blood sugar monitoring. On 10/31/21 at 1302 hours, an interview and concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. * Review of the POC, for the certification period from 11/25/22 to 1/23/23, showed the POC did not include the nutritional requirements. On 10/31/21 at 1419 hours, an interview and concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. * The POC, for the certification period from 1/24/23 to 3/24/23, cited SN visits 1W9 for observation, assessment, intervention, and evaluation. The POC also included blood sugar monitoring per SN visit. However, review of the POC showed the POC did not include who will check the patients' blood sugar on non-SN visit days. On 10/31/21 at 1344 hours, an interview and concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed acknowledged the findings.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure effective coordination of care and services for one of nine sampled patients (Patient 6), creating the risk of not providing necessary care and services to this patient. Findings: Review of the agency's P&P titled Monitoring Patient's Response/Reporting to Physician, (undated), showed the patient's physician will be contacted on the same day including changes to the patient's condition, changes that have occurred regarding diagnoses, prognosis or treatment, changes in the patient's expected response to treatment or medications. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23, and 9/27/23 to 11/22/23. Review of the SOC OASIS dated 7/27/23, showed the patient was assessed to have a skin lesion on her sacrococcyx and did not have an unhealed pressure ulcer/injury at Stage 2 or higher or designated as unstageable. Further review of the clinical record showed the wound was a skin irritation, raised pink area. No wound measurements were documented. Review of the physician's order dated 7/26/23, showed wound care to unstageable sacrococcyx pressure injury as follows: cleanse with normal saline, pat dry, apply Venelex ointment (topical use in the management of chronic and acute wounds, and dermal ulcers) to wound bed, Phytoplex (used to treat and prevent diaper rash and other minor skin irritation) so periwound, cover with ABD (abdominal pad) pad, and secure with tape, daily for 21 days. Review of the SN visit notes for August 2023 showed the following: - The SN note dated 8/3/23, showed a documentation the patient was to be referred for wound specialist evaluation. Further review of the clinical record showed the wound was measured and assessed as an unstageable pressure injury, 2.5 cm (length) x 4.8 cm (width) x UTD with 100% dead tissue with small clear drainage. In addition, the clinical record showed the patient was to be referred for wound specialists evaluation. Further review of the clinical record failed to show the physician was notified of the change in condition. - The SN note dated 8/10/23, showed the wound measurements, 2.4 cm X 4.7 cm x UTD. The wound was cleansed with normal saline, pat dried, applied Venelex ointment to wound bed, Phytoplex to periwound, and covered with an ABD pad and secure with tape. - The SN note dated 8/17/23, showed the wound measurements, 5.0 cm X 4.2 cm x UTD; with dead tissue. The wound was cleansed with normal saline, pat dried, applied Venelex ointment to wound bed, Phytoplex to periwound, and covered with an ABD pad, and secure with tape. * However, further review of the clinical record failed to show a physician's order for the wound specialist evaluation after LVN 3's visit on 8/3/23. Review of Patient 6's clinical record showed a wound care note with Wound Consultants 1's name dated 8/8/23, showing an unstageable pressure injury to the coccyx, measuring 2.4 cm x 4.6 cm x unknown. The recommended treatment order was to cleanse the wound with NS, pat dry gently, apply Santyl (wound debriding ointment), cover with a dry dressing, and secure with a foam dressing or island dressing daily. The SN was to provide wound care on Thursday and Saturday and to provide training to the caregiver on other days. Review of Patient 6's Wound Consultant 2 Referral Form dated 8/17/23, showed a request for a wound consultation for one wound on the sacral area. Another physician's order dated 8/22/23, showed to refer to a wound consultant for evaluation and recommendation of treatment for collaboration of care and treatment plan. Review of the wound consultation note by Wound Consultant 2 dated 8/23/23, showed the patient was seen for an initial wound evaluation, Stage 3 pressure injury on the left medial sacrococcyx. The recommended wound treatment showed to cleanse the wound with dermal wound cleanser, pat dry with gauze, apply tetracyte to the wound bed, followed by Cuticerin (multipurpose, impregnated gauze dressing designed to help treat abrasions, burns and skin grafts), and dress with Replicare dressing (Hydrocolloid Dressing is indicated for the management of partial- to full-thickness wounds). On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1 and the Assistant Administrator/Office Manager. When asked, the Assistant Administrator/Office Manager stated the wound care note dated 8/8/23, was completed and sent by the agency to Wound Consultant 1 for consult. The Administrator Designee stated after sending the request for service, they did not follow up with Wound Consultant 1 until it was discovered on 8/17/23, after the SN visit. The Administrator Designee stated there was a miscommunication leading to the delay for the wound consultation (until 8/23/23). LVN 1 and the Administrator Designee was informed and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to provide the written instructions on the SN visit schedule for two of nine sampled patients (Patients 5 and 6), creating the risk of not providing the necessary information to these patients. X Review of Patient 6 's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification period from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. The POC, for the certification period from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23, cited SN visits 1W9 and 3W9 for observation, assessment, intervention and evaluation. On 10/25/23 at 0950 hours, a joint home visit was conducted in Patient 5's home with LVN 2. LVN 2 was asked for the written instructions on the SN visit schedule provided on the patient chart. LVN 2 stated we call ahead of time prior to the visit and, before the actual visit to confirm . Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 10/26/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the finding. 1. Review of the agency's P&P titled Care Planning Process revised 5/2023, showed the procedures includes the organization shall provide the patient and caregiver with a copy of written instructions outlining visit schedule, including the frequency of visits by personnel and personnel acting on behalf of the organization. Review of Patient 5's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 9/8/23. The patient was certified for home health services during the certification period from 9/8/23 to 11/6/23. The POC, for the certification period from 9/8/23 to 11/6/23, cited SN visits 1W9 for observation, assessment, intervention and evaluation. On 10/26/22 at 1100 hours, a joint home visit with the DPCS was conducted to Patient 5's home. The DPCS was asked for the written instructions on the SN visit schedule provided on the patient chart. The DPCS replied, no. The DPCS was further asked as to how does the patient knew if they are coming. The DPCS replied we have an agreement with the patient and we will call ahead of time prior to the visit, we call them 30 minutes before the actual visit to confirm. Review of the patient's admission packet provided by the HHA showed no documented evidence of the written instructions outlining the SN visit schedule. On 10/26/23 at 1138 hours, an interview and concurrent clinical record review was conducted with the DPCS. The DPCS was informed and acknowledged the finding.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the SN provided care and services in accordance with the POC for three of nine sampled patients (Patients 5, 7, and 9), creating the risk of not providing appropriate, consistent, and quality care to these patients. X. Review of Patient 9's closed clinical record was initiated on 10/26/23. The clinical record showed the SOC was 1/14/23. The patient was certified for home health services during the certification periods from 1/14/23 to 3/14/23 and 3/15/23 to 5/13/23. The POC for the certification period from 3/15/23 to 5/13/23, cited SN visits 1W9. The POC includes SN to assess overall body system with focus on care on integumentary/ endocrine/ HTN/ musculoskeletal/ Mental/ neuro/ Genito-urinary/ gastrointestinal systems/ competence level/ comprehensive level, including blood glucose monitoring weekly/ daily per SN visit. However, review of the SN notes dated 1/19/23 to 3/12/23, 3/31/23 failed to show the blood glucose were assessed On 10/31/23 at 1330 hours, an interview and concurrent closed clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. 1. Review of the agency's P&P titled Ongoing Assessments revised 5/2023, showed the ongoing assessments will be determined by the patients' diagnoses, condition, desire for care, response to previous care, and the care setting. The procedure includes during each visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visit. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. The POC showed the patient primary diagnosis was age related osteoporosis. Other diagnoses includes difficulty in walking. The POC for the certification period from 9/19/23 to 11/17/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. Review of the SN notes dated 9/29 and 10/4/23, showed the SN had performed body system assessment. However, the musculoskeletal system was left blank. On 10/31/23 at 1134 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if they needed to assess the musculoskeletal system. The DPCS Designee replied, yes but the assessment was missed. The DPCS Designee was further asked if they followed the POC. The DPCS Designee replied, no, the POC was not followed. The DPCS Designee was informed and acknowledged the findings. 2. Review of Patient 5's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 9/8/23. The patient was certified for home health services during the certification periods from 9/8/23 to 11/6/23. The POC for the certification period from 9/8/23 to 11/6/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. Review of the Resumption of Care Assessment dated 9/18/23 showed the reason for admission includes right total hip replacement. Review of the SN notes dated 9/20, 9/27,10/4 and 10/18/23 showed the SN assessed the patients Integumentary system. However, the section for surgical incision was left blank. On 10/31/23 at 1320 hours, the DPCS Designee was asked if they needed to assess the the patients surgical incision site. The DPCS Designee replied, yes, we need to assess the skin integrity but not documented. The DPCS Designee was informed and acknowledged the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the agency's skilled staff prepared accurate and complete clinical notes for five of nine sampled patients (Patients 1, 2, 6, 7, and 8). This failure created the increased risk of substandard healthcare outcomes to these patients. 1. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. The POC for the certification period from 9/19/23 to 11/17/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. The POC includes a diagnoses of unsteadiness of feet. Review of the Recertification OASIS dated 9/16/23, showed under the section of musculoskeletal system showed patient was unsteady ambulating and weakness in the upper and lower extremities. However, review of the SN notes dated 10/18 and 10/13/23, showed the SN had performed body system assessment. The musculoskeletal system was assessed to have a normal findings which was inaccurate. On 10/31/23 at 1134 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if the musculoskeletal assessment was accurate. The DPCS Designee replied, no. The DPCS Designee was informed and acknowledged the findings. 2. Review of Patient 2's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. The POC for the certification period from 7/22/23 to 9/19/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. SN to monitor blood sugar every visit. Review of SN notes dated 8/18/23 under Endocrine section showed the blood sugar result. There was a checked next to self for monitoring. However, the section for FBS, Before meal, Postprandial and Random was left blank. Further review of the SN notes dated 8/25/23 under the Endocrine section showed the blood sugar result. However, on the section of monitored by self, caregiver and nurse was left blank. On 10/31/23 at 1302 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. * Review of SN notes dated 12/29/22 and 1/5/23, showed the patient blood sugar level was 1157 mg/dl. On 10/31/23 at 1419 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if the blood sugar level was re-checked . The DPCS Designee replied, no, it was a typographical error. The DPCS Designee was informed and acknowledged the findings. * Review of the Recertification OASIS dated 1/21/23, showed the patient was assessed to have allergy to medications. The medication includes "seroel". *Review of the Discharge OASIS dated 3/24/23, showed the patient BIMS was coded as zero (0) = patient is rarely/never understood. However, the patient Cognitive Functioning was coded as zero (0) = alert/oriented, able to focus and shift attention, comprehends and recalls task directed independently which was inconsistent. On 10/31/23 at 1344 hours, an interview with concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. X. Review of Patient 1's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 8/30/23. The patient was certified for home health services during the certification periods from 8/30/23 to 10/28/23. The POC for the certification period from 8/30/23 to 10/28/23, cited SN visits 1W9. The POC includes SN to perform assessment of all body systems as appropriate and response to treatment. Review of the SN notes dated 9/1 to 10/20/23, showed the patient's weight was "000". Review of the SN note dated 9/7/23, showed the patient's respirations were "000", and oxygen saturation was left blank. On 10/31/23 at 1217 hours, an interview with concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings. X. Review of Patient 6's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/26/23. The patient was certified for home health services during the certification periods from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23. The POC for the certification period from 7/26/23 to 9/23/23 and 9/24/23 to 11/22/23, cited SN visits 1W9 and 3W9, respectively. The POC includes SN to observe and assess overall body system with focus care on integumentary, endocrine, HTN, musculoskeletal systems, competence and comprehension level; SN to perform blood glucose monitoring per SN visit; and Sn to observe and assess pain level, control and management. Review of the SN notes dated 8/3 to 10/16/23, showed the patient was noted with dyspnea on exertion; however, the patient's oxygen saturation as left blank. Review of the SN notes dated 8/17, 8/24, 9/4, 9/18, 9/25, 9/29, 10/2, 10/9, 10/13, 10/16 and 10/20/23, failed to show documented evidence the patient's blood glucose was assessed. Review of the SN notes dated 9/11, 9/18, 9/25, 9/29, 10/2, 10/6, 10/9, 10/13, 10/16, and 10/20/23 failed to show the patient's pain level was documented. On 10/31/23 at 1340 hours, an interview and concurrent clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the CHHA failed to follow the plan of care for one of the nine sampled patients (Patient 7), creating the risk of not providing necessary care and services to this patient. Review of the agency's P&P titled Home Health Aide Plan of Care revised 5/2023 showed each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. Review of Patient 7's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 7/21/23. The patient was certified for home health services during the certification periods from 7/21/23 to 9/18/23 and 9/19/23 to 11/17/23. The POC, for the certification period from 9/19/23 to 11/17/23, cited CHHA visits 1W9 for providing personal care, assistance with ADL care, meal preparation, assistance in feeding and make sure clients take the right medications on schedule and monitor them for any concerning symptoms. Review of the Home Health Aide Care Plan dated 9/16/23, showed the orders for services and treatment were included. The orders did not include to obtain BP, Temperature, pulse and respiration every visit. Review of the CHHA visit notes dated 10/9, 10/4, 9/27, and 9/23/23, showed the CHHA provided care to the patient as ordered by the physician. On 10/26/23 at 1000 hours, a visit with the CHHA was conducted to the patient's home. The CHHA was asked regarding the plan for the patient. The CHHA stated would give the patient bath and check if bed linens needed to be changed. However, the CHHA was observed checking the patient's vital signs which was not included in the care plan. On 10/31/23 at 1134 hours, an interview and concurrent clinical record review was conducted with the DPCS Designee. The DPCS Designee was asked if the CHHA was assigned to take the patients vital signs (BP, Heart rate, temperature, and respiratory rate) every visit. The DPCS Designee replied there should be written as needed if with symptoms. The DPCS was informed of the CHHA taking the patient's vital signs during the home visit. The DPCS Designee was also asked if the CHHA followed the plan of care as ordered by the physician. The DPCS Designee replied no, it was a mistake by the CHHA. The DPCS Designee was informed and acknowledged the findings. However, the POC did not include the instructions for the CHHA to take the patient's vital signs during the CHHA visits. On 1/11/22 at 1130 hours, an interview and concurrent clinical record review was conducted with LVN 1/Case Manager. LVN 1/ Case Manager was asked if the CHHA should take the patient's vital signs during the CHHA visit. LVN 1/Case manager stated the POC did not provide the instructions for the CHHA to take the patient's vital signs during the CHHA. LVN 1/Case manager was informed and acknowledged the findings.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the CLIA waiver certificate was current when conducting the blood glucose testing for two of nine sampled resident (Patients 2 and 8) creating the risk of not meeting the regulatory standards related to laboratory testing. Findings: On 10/24/23 at 1200 hours, during the entrance conference conducted with the Administrator and DPCS Designee, they were asked to provide the agency's CLIA certificate of waiver. Review of the agency's CLIA certificate of waiver showed the effective date was 11/14/19, and the expiration date was on 11/13/21. On 10/24/23 at 1315 hours, an interview was conducted with the Administrator. The Administrator stated the agency's CLIA certificate of waiver had expired. The Administrator was asked when they filed for the renewal. The Administrator replied before it expired in October of 2021 and until present, I do not have the certificate yet. On 10/27/23 at 1554 hours, a follow-up interview with the Administrator, the Administrator stated they resubmitted the application and the payment was received on 10/26/23. The Administrator stated it would be five to ten days from the application date to receive the CLIA certificate. On 10/31/23 at 1510 hours, an interview was conducted with the Administrator. The Administrator stated they had not received the CLIA certificate. The Administrator was informed and acknowledged the findings. Review of two clinical records for Patients 2 and 8 showed an order to perform the blood glucose monitoring. However, the agency's CLIA waiver certificate was not current. For example: a. Review of Patient 2 's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. The POC, for the certification periods from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23, showed SN to perform blood sugar monitoring every visit. b. Review of Patient 8 's closed clinical record was initiated on 10/24/23. The closed clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 611/25/22 to 1/23/22 and 1/24/23 to 3/24/23. The POC, for the certification period from 1/24/23 to 3/24/23, showed SN to monitor blood sugar level every visit and instruct for hypo and hyperglycemia and any sign/symptoms of hypo/hyperglycemia. The POC showed to report the BS readings below 60 mg/dl and above 400 mg/dl to the physician, symptomatic of hypo and hyperglycemia. Review of the SN notes dated 3/2, 2/9, and 3/16/23, showed the SN checked the patient's blood sugar as ordered by the physician. On 10/31/23 at 1510 hours, an interview and concurrent clinical record review was conducted with the Administrator and DPCS. They were informed and acknowledged the findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the responsibility for the day-to-day operations by not implementing the agency's P&P as evidenced by: * The agency failed to ensure the written agreements for one of the two contractors (Contractor 1) included the required elements in the contracts as per Title 22. * The agency failed to ensure the competencies for one LVN and two RNs were completed as per the agency's P&P. These failures had the potential to negatively impact the agency’s operational performance. Findings: 1. Review of the agency’s Job Description Summary for the Executive Director/Administrator revised dated 5/2023 showed the Executive Director/Administrator is responsible for planning, coordinating, managing, and directing all activities and programs of the HHA. According to Title 22, Section 74719, when any service offered by the agency is not provided by employees, there shall be a written agreement meeting the requirements of this section. The agreement shall include at least the following: - The rights and responsibilities of the agency or individual providing services and of the contraction agency in the coordination, supervision, and evaluation of care and services provided. - The role, if any, of the agency and the contracted individual or agency in the admission process; patient assessment; development, review, and revision of the plan of care or treatment; patient care conferences; scheduling of visits or hours, discharge planning, submission to the agency of documentation of services provided, and responsibility of the contractor to applicable agency policies, including personnel qualifications, Review of the written agreement between the agency and Contractor 1 providing therapy was initiated on 10/30/23. The written agreement did not include the role, if any, of the agency and the contracted individual or agency in the development, review, and revision of the plan of care or treatment; scheduling of visits or hours, discharge planning, submission to the agency of documentation of services provided, and responsibility of the contractor to applicable agency policies, including personnel qualifications. Review of the written agreement between the agency and Contractor 2 providing therapy, nutritional, and social services was initiated on 10/30/23. The written agreement did not include the role, if any, of the agency and the contracted individual or agency in the patient care conferences. Review of the written agreement between the agency and Contractor 3 providing medical social services was initiated on 10/30/23. The written agreement did not include the rights and responsibilities of the agency or individual providing services and of the contraction agency in the coordination, supervision, and evaluation of care and services provided. In addition, the written agreement did not include the role, if any, of the agency and the contracted individual or agency in the admission process; patient assessment; development, review, and revision of the plan of care or treatment; patient care conferences; scheduling of visits or hours, discharge planning, or the responsibility of the contractor to applicable agency policies, including personnel qualifications, On 10/30/23 at 1507 hours, an interview and concurrent agency document review was conducted with the Administrator. The Administrator was informed and acknowledged the findings. 2. Review of the agency's P&P titled Competency Assessment revised 5/23 showed the staff will be assessed during orientation, probationary period, and periodically throughout the course of the year. Upon completion of the checklist, the new staff will end initial orientation. Competency assessments will be completed at least one time per year. Review of the DPCS's competency checklist showed the date of hire was 10/1/22, and the competency checklist was completed on 10/3/22. Further review of the checklist failed to show documented evidence the DPCS' competency was completed annually as per the agency's P&P. Review of the DPCS designee's competency checklist showed the date of hire was 4/2/22, and the competency checklist was completed on 4/3/22. Further review of the checklist failed to show documented evidence the DPCS Designee's competency was completed annually as per the agency's P&P. Review of the LVN 3's competency checklist showed the date of hire was 1/24/22, and the competency checklist was completed on 1/26/22. Further review of the checklist failed to show documented evidence the LVN 3's competency was completed annually as per the agency's P&P. On 10/31/23, an interview and concurrent agency's document record review was conducted with the Administrator. The Administrator was informed and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to send the discharge and transfer summaries for two of nine sampled patients (Patients 8 and 9) to their primary care physicians. This failure created the risk for these patients to not receive continuity in care and medical treatment. Review of Patient 8 's clinical record was initiated on 10/25/23. The clinical record showed the SOC was 11/25/22. The patient was certified for home health services during the certification periods from 11/25/22 to 1/23/23 and 1/24/23 to 3/24/23. Review of the Physicians Order dated 3/24/23, showed an order for discharge. Review of the OASIS Discharge dated 3/24/23 under the section of Discharge Instructions, showed the patient was unavailable for a discharge visit. The discharge was made thru telephone call. However, review of the Summary section showed the following were left blank: -Disciplines involved during the admission, -Verbal order obtained, -Emergency contact, -Diagnoses, -Summary for the certification period, -Condition at the time of discharge, -Medication reconciliation, -Written copy of discharge instructions given and -Patient/caregiver verbalized understanding of the discharge instructions. In addition, review of the medical record failed to show a discharge summary was provided to the physician. On 10/31/23 at 1344 hours, an interview with concurrent closed medical record review was conducted with the DPCS Designee. The DPCS Designee was informed and acknowledged the findings. Findings: 1a. Review of Patient 9's closed clinical record showed the SOC was 1/14/23. The closed clinical record showed the patient received home health services during the certification periods from 1/14/23 to 3/14/23 and 3/15/23 to 5/13/23. Review of the physician orders dated 4/2/23, showed to hold home health services until discharged from hospital. Review of the Transfer OASIS dated 1/24/23 and 4/3/23, showed the patient was admitted to the hospital. However, further review of the clinical record failed to show documented evidence a copy of the transfer summary, plan of care, and medication list was sent to the physician. b. Review of the Discharge Oasis dated 4/17/23 showed the discharge date of 4/17/23. However, further review of the clinical record failed to show the reason for admission to home health, type of services provided and frequency of services, medications, discharge condition, or patient outcomes in meeting the goals in the plan of care. On 10/31/23 at 1330 hours, an interview and concurrent closed clinical record review was conducted with LVN 1. LVN 1 was informed and acknowledged the findings.

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 interview and record review, the HHA failed to ensure the entries on the clinical record included the credential of the staff who completed the documents for three of nine sampled patients (Patients 1, 2, and 5), creating the risk of not having the complete and accurate information. Findings: Review of the agency’s P&P titled Entries Into The Clinical Record- Clinical Service Data Collection, revised 5/23 showed the clinical/service note will include the signature of the clinician/technician and his/her credential. Signature authorization of the clinical/service documentation will include the staff member's name and credentials (as specified on professional licenses and/or certification documents). Review of Patient 1's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 8/30/23. The patient was certified for home health services during the period from 8/30/23 to 10/28/23. The SN notes dated 9/1/23 to 10/20/23 showed the notes were electronically signed by Clinician 1. Documentation showed that Clinician 1 was identified as "SN." However, the clinician's credential was not included. Review of the employee file showed Clinician 1 was a LVN. On 10/31/23 at 1217 hours, an interview and concurrent clinical record review was conducted with LVN1. LVN 1 informed of the findings. 2. Review of Patient 5's clinical record was initiated on 10/26/23. The clinical record showed the SOC was 8/30/23. The patient was certified for home health services during the period from 9/8/23 to 11/6/23. The SOC OASIS dated 9/8/23, showed the notes were electronically signed by the Administrator Designee/DPCS Designee. However, on 10/24/23 at 1050 hours an entrance conference was conducted with the Administrator and DPCS Designee. The name of the DPCS was verified. In addition, on 10/25/23 at 1059 hours, a joint home visit was conducted with the DPCS. The DPCS verified the job title. On 10/31/23 at 1320 hours, the DPCS Designee was asked if the job title on the electronic signature of the DPCS Designee was accurate. The DPCS Designee replied, no it was incorrect, should be DPCS. The DPCS Designee was informed and acknowledged the findings. 3. Review of Patient 2's clinical record was initiated on 10/27/23. The clinical record showed the SOC was 7/22/23. The patient was certified for home health services during the period from 7/22/23 to 9/19/23 and 9/20/23 to 11/18/23. The SOC OASIS dated 7/22/23, showed the notes were electronically signed by the Administrator Designee/DPCS Designee. The Recertification OASIS dated 9/25/23, showed the notes were electronically signed by the Administrator Designee/DPCS Designee. On 10/31/23 at 1237 hours, the DPCS Designee was asked if the job title on the electronic signature of the DPCS Designee was accurate. The DPCS Designee replied, no it was incorrect. The DPCS Designee was informed and acknowledged the findings.